# De-escalation, escalation and response-adapted therapy

Source: https://onco.cc/terms/de-escalation/  
OnCo record `de-escalation` (Term). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Giving less treatment to patients who are doing well and more to those who are not, using a marker such as scan response, ctDNA or MRD to decide. The aim is to cure the same number of people with less harm.

## Summary

Examples: omitting chemotherapy in low-risk HR-positive breast cancer by genomic assays (TAILORx, MINDACT) or in HER2-positive disease by PET response (PHERGain); shortening adjuvant FOLFOX to 3 months (IDEA); ctDNA-guided omission or escalation of adjuvant chemotherapy in colon cancer (DYNAMIC, CIRCULATE); PET-guided omission of radiotherapy or bleomycin in lymphoma; 12 versus 6 months of trastuzumab (PERSEPHONE); radiotherapy dose reduction in HPV-positive oropharynx cancer (which has repeatedly failed); and MRD-guided stopping in CLL and myeloma. De-escalation trials need non-inferiority designs and large numbers, and are rarely funded by industry. Escalation trials add drugs to non-responders (KEYNOTE-522 residual disease, CheckMate 577).

## Fields

- Kind: Term
- Last checked: 2026-09-09
- Also known as: de-escalation; de-escalate; de-escalated; de-escalating; de-intensification; de-intensify; treatment de-escalation; treatment intensification; intensification; response-adapted; response-guided; risk-adapted; risk-adapted therapy; biomarker-guided; ctDNA-guided; MRD-guided; PET-adapted; omission of chemotherapy; chemotherapy omission; chemotherapy-free; chemo-free; less is more; treatment omission

## Sources

- ClinicalTrials.gov NCT03036488: KEYNOTE-522: https://clinicaltrials.gov/study/NCT03036488
- ClinicalTrials.gov NCT02743494: CheckMate 577: https://clinicaltrials.gov/study/NCT02743494

## Connected records

- terms: [ABVD, BEACOPP and BrECADD (Hodgkin lymphoma regimens)](https://onco.cc/terms/abvd-beacopp/), [Backbone, add-on and monotherapy](https://onco.cc/terms/backbone-add-on/), [Circulating tumour DNA (ctDNA)](https://onco.cc/terms/ctdna/), [Deauville score and PET-adapted therapy](https://onco.cc/terms/deauville/), [Late effects and survivorship toxicity](https://onco.cc/terms/late-effects/), [Non-inferiority margin and equivalence trials](https://onco.cc/terms/non-inferiority-margin/), [Non-inferiority trial](https://onco.cc/terms/non-inferiority/), [Organ preservation (watch-and-wait, bladder-sparing, larynx preservation)](https://onco.cc/terms/organ-preservation/), [Residual disease after neoadjuvant therapy in triple-negative breast cancer: the decision point](https://onco.cc/terms/tnbc-residual-disease-decision/), [SMART design (sequential multiple assignment randomised trial)](https://onco.cc/terms/smart-design/), [Stepped-wedge design](https://onco.cc/terms/stepped-wedge-design/), [Triple-negative breast cancer trials open today (registry snapshot and UK sites)](https://onco.cc/terms/tnbc-trials-open-today/), [Undetectable MRD (uMRD / MRD-negative)](https://onco.cc/terms/umrd/)
- fronts: [Chemotherapy](https://onco.cc/fronts/chemotherapy/)
- trials: [CheckMate 577](https://onco.cc/trials/checkmate-577/), [CIRCULATE-Japan (GALAXY / VEGA / ALTAIR)](https://onco.cc/trials/circulate-japan/), [CIRCULATE-US](https://onco.cc/trials/circulate-us/), [COG ACNS0331](https://onco.cc/trials/acns0331/), [COG AREN0533](https://onco.cc/trials/aren0533/), [DYNAMIC](https://onco.cc/trials/dynamic/), [DYNAMIC-III](https://onco.cc/trials/dynamic-iii/), [IDEA collaboration](https://onco.cc/trials/idea-collaboration/), [KEYNOTE-522](https://onco.cc/trials/keynote-522/), [NeoPACT](https://onco.cc/trials/neopact/), [SCOT](https://onco.cc/trials/scot/)
- cancers: [Triple-negative breast cancer (TNBC)](https://onco.cc/cancers/tnbc/)
- key papers: [Tailoring treatment to cancer risk and patient preference: the 2025 St Gallen International Breast Cancer Consensus Statement on individualizing therapy for patients with early breast cancer](https://onco.cc/key-papers/paper-st-gallen-2025-consensus-ann-oncol-2025/), [Tumor-Infiltrating Lymphocytes in Triple-Negative Breast Cancer](https://onco.cc/key-papers/paper-leon-ferre-tils-tnbc-no-chemotherapy-jama-2024/), [Understanding breast cancer complexity to improve patient outcomes: The St Gallen International Consensus Conference for the Primary Therapy of Individuals with Early Breast Cancer 2023](https://onco.cc/key-papers/paper-st-gallen-2023-consensus-ann-oncol-2023/)
- roadmaps: [ctDNA tests roadmap: from a curiosity in plasma to blood tests that decide treatment](https://onco.cc/roadmaps/ctdna-tests/), [Triple-negative breast cancer roadmap: from a remainder defined by three negative tests to immunotherapy, antibody-drug conjugates and the residual disease problem](https://onco.cc/roadmaps/tnbc-roadmap/)
- ideas: [A ctDNA residual disease-guided adjuvant trial after gallbladder cancer resection](https://onco.cc/ideas/idea-gbc-ctdna-residual-disease-guided-adjuvant-trial/), [A trial of sparing the liver resection in peritoneal-side (T2a) gallbladder cancer](https://onco.cc/ideas/idea-gbc-t2a-spare-liver-resection-trial/), [Give exceptional responders less: pembrolizumab omission after complete response, anthracycline-free regimens and chemotherapy omission in lymphocyte-rich stage I disease](https://onco.cc/ideas/idea-tnbc-de-escalation-for-exceptional-responders/), [Test whether T1b gallbladder cancer needs the second operation at all](https://onco.cc/ideas/idea-gbc-t1b-simple-cholecystectomy-prospective-study/)
- people: [David A. Palma](https://onco.cc/people/david-palma/), [Jeffrey S. Dome](https://onco.cc/people/jeffrey-dome/)
- journals: [JAMA Internal Medicine](https://onco.cc/journals/jama-internal-medicine/)

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