Treatment deintensification: Gastrointestinal cancers

Over the past decade, therapeutic strategies for gastrointestinal cancers have evolved towards greater personalisation, making treatment de-escalation an increasingly relevant option for selected patients. Two main approaches are explored: omitting one component of multimodality treatment or reducing radiotherapy dose or volume. For oesophageal squamous cell carcinoma, active surveillance with salvage surgery after chemoradiotherapy, offers a non-inferior alternative to systematic surgery in patients with complete clinical response, while adenocarcinoma management is shifting towards perioperative chemotherapy with fluorouracil, leucovorin, oxaliplatin, and docetaxel, with durvalumab. In rectal cancer, growing evidence from watch-and-wait strategies or chemotherapy-alone approaches supports selective omission of radiotherapy or surgery in low-risk tumours. Chemoradiotherapy combined with immunotherapy in patients with microsatellite stability increases the response rate while novel node-sparing radiotherapy volumes suggest a paradigm shift, preserving lymph nodes to sustain immune priming for checkpoint inhibitors. For early-stage anal canal carcinoma, the PLATO-ACT4 trial demonstrated that reduced-dose chemoradiotherapy (41.4Gy) achieves comparable locoregional control with improved tolerance and quality of life compared to standard-dose treatment. Together, these strategies illustrate a shift towards individualised, response and risk-adapted therapy in digestive oncology. However, most de-escalation approaches still rely on limited follow-up or selected populations, and shared decision-making incorporating patient preferences and quality-of-life trade-offs should increasingly guide these choices. Ongoing trials (NEEDS, GRECCAR 14/16, DECREASE) will help refine patient selection and confirm the long-term safety of these de-escalated strategies.