Microscopic residual disease is a risk factor in the primary treatment of breast cancer

Blueprint for cancer research: Critical gaps and opportunities

We are experiencing a revolution in cancer. Advances in screening, targeted and immune therapies, big data, computational methodologies, and significant new knowledge of cancer biology are transforming the ways in which we prevent, detect, diagnose, treat, and survive cancer. These advances are enabling durable progress in the goal to achieve personalized cancer care. Despite these gains, more work is needed to develop better tools and strategies to limit cancer as a major health concern. One persistent gap is the inconsistent coordination among researchers and caregivers to implement evidence-based programs that rely on a fuller understanding of the molecular, cellular, and systems biology mechanisms underpinning different types of cancer. Here, the authors integrate conversations with over 90 leading cancer experts to highlight current challenges, encourage a robust and diverse national research portfolio, and capture timely opportunities to advance evidence-based approaches for all patients with cancer and for all communities.

Clinical development of targeted and immune based anti-cancer therapies

Cancer is currently the second leading cause of death globally and is expected to be responsible for approximately 9.6 million deaths in 2018. With an unprecedented understanding of the molecular pathways that drive the development and progression of human cancers, novel targeted therapies have become an exciting new development for anti-cancer medicine. These targeted therapies, also known as biologic therapies, have become a major modality of medical treatment, by acting to block the growth of cancer cells by specifically targeting molecules required for cell growth and tumorigenesis. Due to their specificity, these new therapies are expected to have better efficacy and limited adverse side effects when compared with other treatment options, including hormonal and cytotoxic therapies. In this review, we explore the clinical development, successes and challenges facing targeted anti-cancer therapies, including both small molecule inhibitors and antibody targeted therapies. Herein, we introduce targeted therapies to epidermal growth factor receptor (EGFR), vascular endothelial growth factor (VEGF), human epidermal growth factor receptor 2 (HER2), anaplastic lymphoma kinase (ALK), BRAF, and the inhibitors of the T-cell mediated immune response, cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed cell death protein-1 (PD-1)/ PD-1 ligand (PD-1 L).

Forward-planned, multiple-segment, tangential fields with concomitant boost in the treatment of breast cancer

We report on the utility of forward-planned, 3-dimensional (3D), multiple-segment tangential fields for radiation treatment of patients with breast cancer. The technique accurately targets breast tissue and the tumor bed and reduces dose inhomogeneity in the target. By decreasing excess dose to the skin and lung, a concomitant boost to the tumor bed can be delivered during the initial treatment, thereby decreasing the overall treatment time by one week. More than 120 breast cancer patients have been treated with this breast conservation technique in our clinic. For each patient, a 3D treatment plan based upon breast and tumor bed volumes delineated on computed tomography (CT) was developed. Segmented tangent fields were iteratively created to reduce "hot spots" produced by traditional tangents. The tumor bed received a concomitant boost with additional conformal photon beams. The final tumor bed boost was delivered either with conformal photon beams or conventional electron beams. All patients received 45 Gy to the breast target, plus an additional 5 Gy to the surgical excision site, bringing the total dose to 50 Gy to the boost target volume in 25 fractions. The final boost to the excision site brought the total target dose to 60 Gy. With minimum follow-up of 4 months and median follow-up of 11 months, all patients have excellent cosmetic results. There has been minimal breast edema and minimal skin changes. There have been no local relapses to date. Forward planning of multi-segment fields is facilitated with 3D planning and multileaf collimation. The treatment technique offers improvement in target dose homogeneity and the ability to confidently concomitantly boost the excision site. The technique also offers the advantage for physics and therapy staff to develop familiarity with multiple segment fields, as a precursor to intensity-modulated radiation therapy (IMRT) techniques.

Dynamic response of cancer under the influence of immunological activity and therapy

The dynamical basis of tumoral growth has been controversial. Many models have been proposed to explain cancer development. The descriptions employ exponential, potential, logistic or Gompertzian growth laws. Some of these models are concerned with the interaction between cancer and the immunological system. Among other properties, these models are concerned with the microscopic behavior of tumors and the emergence of cancer. We propose a modification of a previous model by Stepanova, which describes the specific immunological response against cancer. The modification consists of the substitution of a Gompertian law for the exponential rate used for tumoral growth. This modification is motivated by the numerous works confirming that Gompertz's equation correctly describes solid tumor growth. The modified model predicts that near zero, tumors always tend to grow. Immunological contraposition never suffices to induce a complete regression of the tumor. Instead, a stable microscopic equilibrium between cancer and immunological activity can be attained. In other words, our model predicts that the theory of immune surveillance is plausible. A macroscopic equilibrium in which the system develops cancer is also possible. In this case, immunological activity is depleted. This is consistent with the phenomena of cancer tolerance. Both equilibrium points can coexist or can exist without the other. In all cases the fixed point at zero tumor size is unstable. Since immunity cannot induce a complete tumor regression, a therapy is required. We include constant-dose therapies and show that they are insufficient. Final levels of immunocompetent cells and tumoral cells are finite, thus post-treatment regrowth of the tumor is certain. We also evaluate late-intensification therapies which are successful. They induce an asymptotic regression to zero tumor size. Immune response is also suppressed by the therapy, and thus plays a negligible role in the remission. We conclude that treatment evaluation should be successful without taking into account immunological effects.