De-escalator.

Top Line: What inevitably follows major improvements in outcomes with cancer treatment? The search for de-escalated therapies in selected populations.

The Study: Here is an excellent review on just that for nasopharyngeal cancers. A lot hinges on the Will Rogers effect of more advanced PET and MR imaging, leading to cancers of all stages harboring inherently better biology. One area of contention is concurrent chemo for stage II disease where you’ll find quite the grab bag of both primary and nodal tumor extent, with an ongoing trial assessing omission of chemo with low pre-treatment EBV titers. While the role of concurrent platinum chemo is cemented for locally-advanced disease, there may be options to de-escalate from the standard three tri-weekly doses of cisplatin to two doses, to lower dosing weekly, or to another agent nedaplatin (not yet approved in the US). Finally, when it comes to radiation de-escalation, a reduced dose (~60 Gy) may prove sufficient for T1-2 primary tumors or those that respond well to induction chemo, and a reduced volume (without elective nodal coverage of IB, VB or maybe even IV) may prove the best balance of risk and reward.

TBL: With greater patient selection via advanced imaging and biomarkers, individualized treatment de-escalation is on the horizon for nasopharyngeal cancers. | Lee, JAMA Oncol 2020