# Payer-funded trials that omit surgery or radiotherapy in low-risk patients

Source: https://onco.cc/ideas/idea-fund-omission-deescalation-trials/  
OnCo record `idea-fund-omission-deescalation-trials` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Low-risk patients often receive operations and radiotherapy they may not need, for example sentinel node biopsy in older women with favourable breast cancer or radiotherapy after breast-conserving surgery in genomically low-risk disease. Because no company will sponsor trials of leaving treatment out, health systems should fund them and keep the savings.

## Summary

Payers and public funders sponsor randomised trials of omission or de-escalation of local therapy: omitting sentinel node biopsy in older women with favourable breast cancer (as SOUND and INSEMA tested), omitting radiotherapy after breast-conserving surgery in genomically low-risk disease, active surveillance instead of surgery in low-risk thyroid and prostate cancer, and shorter or lower-dose regimens. These trials save money, reduce harm and address overdiagnosis, but have no commercial sponsor. Genomic and imaging biomarkers now allow risk-adapted selection that makes omission trials ethically and statistically feasible.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: A payer-funded omission programme produces at least four practice-changing results within six years, each reducing the number of procedures or radiotherapy courses in the target population by a fifth or more with non-inferior recurrence.
- Rationale: SOUND, INSEMA, PRIME II and the low-risk DCIS trials have shown omission is safe in defined groups and changed guidelines; each was funded with difficulty by academic grants. Payers are the natural sponsors because the savings accrue to them directly.
- Proposed test: A payer trials fund launches two omission trials and pre-registers projected savings; audit realised savings and outcome non-inferiority at trial completion.
- Maturity: being-tested-at-scale
- Actor: payer

## Sources

- Bottleneck evidence (Surgery and radiotherapy cure most, get least): Sullivan et al., Global cancer surgery (Lancet Oncology Commission 2015): https://doi.org/10.1016/S1470-2045(15)00223-5

## Connected records

- ideas: [A funded programme of organ-preservation trials to avoid radical surgery](https://onco.cc/ideas/idea-fund-organ-preservation-programme/), [Payers fund trials of cheaper, shorter or lower-dose versions of expensive treatments](https://onco.cc/ideas/idea-fund-payer-funded-pragmatic-trials/), [TIL-based omission of chemotherapy in stage I TNBC](https://onco.cc/ideas/idea-til-guided-deescalation/)
- cancers: [HR-positive / HER2-negative breast cancer](https://onco.cc/cancers/breast-hr-positive/), [Prostate cancer](https://onco.cc/cancers/prostate/), [Thyroid cancer](https://onco.cc/cancers/thyroid/)
- technologies: [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/), [Sentinel lymph node biopsy](https://onco.cc/technologies/sentinel-node/)
- drugs: [Oncotype DX](https://onco.cc/drugs/oncotype-dx/)
- bottlenecks: [Overdiagnosis and false alarms](https://onco.cc/bottlenecks/b-overdiagnosis/), [Surgery and radiotherapy cure most, get least](https://onco.cc/bottlenecks/b-surgery-radiation-innovation/), [Toxicity and quality of life are undervalued](https://onco.cc/bottlenecks/b-toxicity-qol/)
- key papers: [Global cancer surgery: delivering safe, affordable, and timely cancer surgery](https://onco.cc/key-papers/paper-sullivan-lancet-oncol/)

---
JSON: https://onco.cc/api/v1/entities/idea-fund-omission-deescalation-trials.json