Therapeutic implications of circadian rhythms in cancer patients

The Circadian Clock, the Immune System, and Viral Infections: The Intricate Relationship Between Biological Time and Host-Virus Interaction

Living beings spend their lives and carry out their daily activities interacting with environmental situations that present space-time variations and that involve contact with other life forms, which may behave as commensals or as invaders and/or parasites. The characteristics of the environment, as well as the processes that support the maintenance of life and that characterize the execution of activities of daily life generally present periodic variations, which are mostly synchronized with the light–dark cycle determined by Earth’s rotation on its axis. These rhythms with 24-h periodicity, defined as circadian, influence events linked to the interaction between hosts and hosted microorganisms and can dramatically determine the outcome of this interplay. As for the various pathological conditions resulting from host–microorganism interactions, a particularly interesting scenario concerns infections by viruses. When a viral agent enters the body, it alters the biological processes of the infected cells in order to favour its replication and to spread to various tissues. Though our knowledge concerning the mutual influence between the biological clock and viruses is still limited, recent studies start to unravel interesting aspects of the clock–virus molecular interplay. Three different aspects of this interplay are addressed in this mini-review and include the circadian regulation of both innate and adaptive immune systems, the impact of the biological clock on viral infection itself, and finally the putative perturbations that the virus may confer to the clock leading to its deregulation.

Circadian expression of clock genes in human peripheral leukocytes

In mammals, behavioral and physiological processes display 24-h rhythms that are regulated by a circadian system. In the present study, we investigated the possibility that the expression of clock genes in peripheral leukocytes can be used to assess the circadian clock system. We found that Per1 and Per2 exhibit circadian oscillations in mRNA expression in mouse peripheral leukocytes. Furthermore, the rhythms of Per1 and Per2 mRNA expression in peripheral leukocytes are severely blunted in homozygous Cry1/2 double-deficient mice that are known to have an abolished biological clock. We have examined the circadian expression of clock genes in human leukocytes and found that Per1 mRNA exhibits a robust circadian expression while Per2 and Bmal1 mRNA showed weak rhythm. These observations suggest that monitoring Per1 mRNA expression in human leukocytes may be useful for investigating the function of the circadian system in physiological and pathophysiological states.

Circadian time keeping: the daily ups and downs of genes, cells, and organisms

Light-sensitive organisms - from cyanobacteria to humans - contain circadian clocks that produce approximately 24-h cycles in the absence of external time cues. In various systems, clock genes have been identified and their functions examined. Negative feedback loops in clock gene expression were initially believed to control circadian rhythms in all organisms. However, recent experiments with cyanobacteria and the filamentous fungus Neurospora crassa tend to favour protein phosphorylation cycles as the basic timekeeper principle in these species. The study of clock genes in mammals has led to a further surprise; practically all body cells were found to harbour self-sustained circadian oscillators. These clocks are co-ordinated by a central pacemaker in the animal, but they keep ticking in a cell-autonomous fashion when maintained in tissue culture. In mammals, most physiology is influenced by the circadian timing, including rest-activity rhythms, heartbeat frequency, arterial blood pressure, renal plasma flow, urine production, intestinal peristaltic motility, and metabolism.

Chronopharmaceutics: gimmick or clinically relevant approach to drug delivery?

Due to advances in chronobiology, chronopharmacology, and global market constraints, the traditional goal of pharmaceutics (e.g. design drug delivery systems with a constant drug release rate) is becoming obsolete. However, the major bottleneck in the development of drug delivery systems that match the circadian rhythm (chronopharmaceutical drug delivery systems: ChrDDS) may be the availability of appropriate technology. The last decade has witnessed the emergence of ChrDDS against several diseases. The increasing research interest surrounding ChrDDS may lead to the creation of a new sub-discipline in pharmaceutics known as chronopharmaceutics. This review introduces the concept of chronopharmaceutics, addresses theoretical/formal approaches to this sub-discipline, underscores potential disease-targets, revisits existing technologies and examples of ChrDDS. Future development in chronopharmaceutics may be made at the interface of other emerging disciplines such as system biology and nanomedicine. Such novel and more biological approaches to drug delivery may lead to safer and more efficient disease therapy in the future.

Daily oscillations in liver function: diurnal vs circadian rhythmicity

The rodent suprachiasmatic nucleus (SCN), a site in the brain that contains a light-entrained biological (circadian) clock, has been thought of as the master oscillator, regulating processes as diverse as cell division, reproductive cycles, sleep, and feeding. However, a second circadian system exists that can be entrained by meal feeding and has an influence over metabolism and behavior. Recent advances in the molecular genetics of circadian clocks are revealing clock characteristics such as rhythmic clock gene expression in a variety of non-neural tissues such as liver. Although little is known regarding the function of these clock genes in the liver, there is a large literature that addresses the capabilities of this organ to keep time. This time-keeping capability may be an adaptive function allowing for the prediction of mealtime and therefore improved digestion and energy usage. Consequently, an understanding of these rhythms is of great importance. This review summarizes the results of studies on diurnal and circadian rhythmicity in the rodent liver. We hope to lend support to the hypothesis that there are functionally important circadian clocks outside of the brain that are not light- or SCN-dependent. Rather, these clocks are largely responsive to stimuli involved in nutrient intake. The interaction between these two systems may be very important for the ability of organisms to synchronize their internal physiology.

[Randomised study to evaluate the chronotolerance of a combination infusional chemotherapy with 5-fluorouracil, folinic acid and carboplatin in non small cell lung cancer (NSCLC) patients]

An infusional ambulatory chronotherapy with 5-FU, folinic acid (FOL) and carboplatin was administered to 45 advanced NSCLC patients. The patients were randomised into 3 groups varying according to the time of administration peak of drugs (reference hours: 4 a.m. for 5 FU (and FOL); 4 p.m. for carboplatin; +/-8 h). The reference schedule appeared best tolerated (regarding hematology and mucositis). This study has prospectively validated the chronotolerance concepts of this complex combination chemotherapy.

A phase I clinical trial of spicamycin derivative KRN5500 (NSC 650426) using a phase I accelerated titration "2B" design

The spicamycin derivative KRN5500 was considered as a potential anti-cancer agent based on in vitro and preclinical studies. A Phase I study involving 24 cancer patients in whom tumors were refractory to all other conventional therapies was conducted to determine the dose limiting toxicity, maximum tolerated dose, effectiveness, and pharmacokinetic parameters of this drug administered by 1-h IV infusion daily for five consecutive days every 3 weeks. Using an accelerated dose titration strategy, 8.4 mg/m2/d x 5 days was the maximum administered dose. Severe gastrointestinal and hepatic toxicities were observed at doses at or above 4.3 mg/m2/d x 5. The recommended Phase II dose i s 4.3mg/m2/d x 5. The distribution of KRN5500 followed a two-compartment model, and clearance did not decrease significantly over the dose range 0.8-8.4 mg/m2/d x 5. No significant correlation was observed between plasma levels and toxicity. No tumor responses were observed among the 14 patients evaluable for response.

Chronomodulated chemotherapy: clinical value and possibilities for dissemination in the United States

Modern medicine has been relatively slow to apply chronotherapeutic principles to standard oncologic practice. Despite the impressive body of evidence supporting the use of chronochemotherapy, with only a rare exception most oncology clinics in the United States lack the expertise and capability to implement it. At the same time, American medicine has increasingly come to recognize the importance of toxicity mitigation, cytoprotection, and quality of life for patients undergoing cancer treatment. However, toxicity mitigation strategies such as chronomodulated infusional chemotherapy and novel cytoprotective agents are not widely embraced by U.S. physicians. This article explores some reasons why this situation exists, including the influence of non-medical biases that may affect management decisions on the application of chemotherapy. The author conducted a survey of U.S. companies representing the three private insurance payers available (HMO, PPO, Indemnity) as well as representatives of Medicare and Medicaid. Responses to the survey confirmed that U.S. insurers do not at present officially reimburse for chronotherapy; however, changes will come about through educational efforts aimed at increasing awareness among insurers as to the clinical benefits and cost-effectiveness of this mode of treatment. At this juncture, the outlook for cancer chronotherapy as a first-line approach to the treatment of metastatic cancer in the United States remains uncertain. Under the current method of insurance reimbursement, the advancement of chronotherapy in the United States is threatened despite evidence that such treatment is both therapeutically sound and cost-effective.

Analysis of circadian and ultradian rhythms of skin surface properties of face and forearm of healthy women

Biologic rhythms of cells and organisms are well documented and have been extensively studied at the physiologic and molecular levels. For the skin, many circadian changes have been investigated but few systematic studies comparing skin at different body sites have been reported. In this study we investigated facial and forearm skin circadian rhythms in eight healthy Caucasian women. Noninvasive methods were used to assess skin capacitance, sebum excretion, skin temperature, transepidermal water loss, and skin surface pH on fixed sites of the face and the volar forearm during a 48 h span under standardized environmental conditions. Using the cosinor or ANOVA methods, circadian rhythms could be detected for sebum excretion (face), transepidermal water loss (face and forearm), skin temperature (forearm), pH (face), and capacitance (forearm). No circadian rhythmicity was found for the other biophysical parameters. In addition to the 24 h rhythm component, rhythms with periods of 8 h were found for sebum excretion, of 8 and 12 h for transepidermal water loss (face and forearm), and of 12 h for skin temperature (forearm). Our study confirms that rhythms of skin surface parameters are readily measurable and that these rhythms differ between different sites. Furthermore, we demonstrate for the first time that, for transepidermal water loss (face and forearm), sebum excretion, and skin temperature (forearm), in addition to circadian rhythms, ultradian and/or component rhythms can be detected.

A clockwork organ

The vertebrate circadian clock was thought to be highly localized to specific anatomical structures: the mammalian suprachiasmatic nucleus (SCN), and the retina and pineal gland in lower vertebrates. However, recent findings in the zebrafish, rat and in cultured cells have suggested that the vertebrate circadian timing system may in fact be highly distributed, with most if not all cells containing a clock. Our understanding of the clock mechanism has progressed extensively through the use of mutant screening and forward genetic approaches. The first vertebrate clock gene was identified only a few years ago in the mouse by such an approach. More recently, using a syntenic comparative genetic approach, the molecular basis of the the tau mutation in the hamster was determined. The tau gene in the hamster appears to encode casein kinase 1 epsilon, a protein previously shown to be important for PER protein turnover in the Drosophila circadian system. A number of additional clock genes have now been described. These proteins appear to play central roles in the transcription-translation negative feedback loop responsible for clock function. Post-translational modification, protein dimerization and nuclear transport all appear to be essential features of how clocks are thought to tick.