Toward a chronotherapy of neoplasia: tolerance of treatment depends upon host rhythms

Circadian Rhythm Disruption in Cancer Survivors: From Oncogenesis to Quality of Life

BACKGROUND

Circadian rhythms are approximately 24-hour cycles in physiological and behavioral processes. They are entrained to the external solar day via blue wavelength light. Disruptions in these intrinsic rhythms can lead to circadian dysfunction, which has several negative implications on human health, including cancer development and progression.

AIMS

Here we review the molecular mechanisms of circadian disruption and their impact on tumor development and progression, discuss the interplay between circadian dysfunction and cancer in basic scientific studies and clinical data, and propose the potential clinical implications of these data that may be used to improve patient outcomes and reduce cost of treatment.

MATERIALS & METHODS

Using scientific literature databases, relevant studies were analyzed to draw overarching conclusions of the relationship between circadian rhythm dysruption and cancer.

CONCLUSIONS

Circadian disruption can be mediated by a number of environmental factors such as exposure to light at night, shift work, jetlag, and social jetlag which drive oncogenesis. Tumor growth and progression, as well as treatment, can lead to long-term alterations in circadian rhythms that negatively affect quality of life in cancer survivors.

Chrono-Endocrinology in Clinical Practice: A Journey from Pathophysiological to Therapeutic Aspects

This review was aimed at collecting the knowledge on the pathophysiological and clinical aspects of endocrine rhythms and their implications in clinical practice, derived from the published literature and from some personal experiences on this topic. We chose to review, according to the PRISMA guidelines, the results of original and observational studies, reviews, meta-analyses and case reports published up to March 2024. Thus, after summarizing the general aspects of biological rhythms, we will describe the characteristics of several endocrine rhythms and the consequences of their disruption, paying particular attention to the implications in clinical practice. Rhythmic endocrine secretions, like other physiological rhythms, are genetically determined and regulated by a central hypothalamic CLOCK located in the suprachiasmatic nucleus, which links the timing of the rhythms to independent clocks, in a hierarchical organization for the regulation of physiology and behavior. However, some environmental factors, such as daily cycles of light/darkness, sleep/wake, and timing of food intake, may influence the rhythm characteristics. Endocrine rhythms are involved in important physiological processes and their disruption may cause several disorders and also cancer. Thus, it is very important to prevent disruptions of endocrine rhythms and to restore a previously altered rhythm by an early corrective chronotherapy.

Developments on tumour site-specific chrono-oncology towards personalised treatment

Research into chronotherapy has seen notable developments over the past decades, with a clear focus on the identification of circadian clock genes as potential treatment targets. Moreover, new factors are investigated, such as gender and the role of cancer stem cells in influencing the outcome of chronomodulated treatments. These factors could add to the arsenal of parameters that assist with patient stratification and treatment personalisation. Literature analysis showed that certain anatomical sites received more attention and the associated studies reported clinically significant results, even though some findings are contradictory. The aim of this work was to review the existing studies on chrono-oncology using a tumour site-specific approach and to highlight the status of research in various cancers. Inconsistencies in data reporting, the nature of the studies and the highly heterogeneous patient characteristics, highlight the need for well-designed randomised controlled trials to elucidate the real potential of chronotherapy in oncology.

The Time for Chronotherapy in Radiation Oncology

Five decades ago, Franz Halberg conceived the idea of ​​a circadian-based therapy for cancer, given the differential tolerance to treatment derived from the intrinsic host rhythms. Nowadays, different experimental models have demonstrated that both the toxicity and efficacy of several anticancer drugs vary by more than 50% as a function of dosing time. Accordingly, it has been shown that chemotherapeutic regimens optimally timed with the circadian cycle have jointly improved patient outcomes both at the preclinical and clinical levels. Along with chemotherapy, radiation therapy is widely used for cancer treatment, but its effectiveness relies mainly on its ability to damage DNA. Notably, the DNA damage response including DNA repair, DNA damage checkpoints, and apoptosis is gated by the circadian clock. Thus, the therapeutic potential of circadian-based radiotherapy against cancer is mainly dependent upon the control that the molecular clock exerts on DNA repair enzymes across the cell cycle. Unfortunately, the time of treatment administration is not usually considered in clinical practice as it varies along the daytime working hours. Currently, only a few studies have evaluated whether the timing of radiotherapy affects the treatment outcome. Several of these studies show that it is possible to reduce the toxicity of the treatment if it is applied at a specific time range, although with some inconsistencies. In this Perspective, we review the main advances in the field of chronoradiotherapy, the possible causes of the inconsistencies observed in the studies so far and provide some recommendations for future trials.

Chronothyroidology: Chronobiological Aspects in Thyroid Function and Diseases

Chronobiology is the scientific discipline which considers biological phenomena in relation to time, which assumes itself biological identity. Many physiological processes are cyclically regulated by intrinsic clocks and many pathological events show a circadian time-related occurrence. Even the pituitary–thyroid axis is under the control of a central clock, and the hormones of the pituitary–thyroid axis exhibit circadian, ultradian and circannual rhythmicity. This review, after describing briefly the essential principles of chronobiology, will be focused on the results of personal experiences and of other studies on this issue, paying particular attention to those regarding the thyroid implications, appearing in the literature as reviews, metanalyses, original and observational studies until 28 February 2021 and acquired from two databases (Scopus and PubMed). The first input to biological rhythms is given by a central clock located in the suprachiasmatic nucleus (SCN), which dictates the timing from its hypothalamic site to satellite clocks that contribute in a hierarchical way to regulate the physiological rhythmicity. Disruption of the rhythmic organization can favor the onset of important disorders, including thyroid diseases. Several studies on the interrelationship between thyroid function and circadian rhythmicity demonstrated that thyroid dysfunctions may affect negatively circadian organization, disrupting TSH rhythm. Conversely, alterations of clock machinery may cause important perturbations at the cellular level, which may favor thyroid dysfunctions and also cancer.

Role of the Immune System and the Circadian Rhythm in the Pathogenesis of Chronic Pancreatitis: Establishing a Personalized Signature for Improving the Effect of Immunotherapies for Chronic Pancreatitis

Pancreatitis, in both acute and chronic forms, poses a major therapeutic challenge and is associated with great morbidity and several complications. The nature of pancreatic injury in chronic pancreatitis (CP) and the wide range of causative processes that lead to CP have made effective therapy a true unmet need. Multiple physiological, genetic, environmental, and behavioral factors contribute to the development of CP. As a result, several fields of research are aimed at identifying and addressing the factors that contribute to pancreatic injury. In this article, we review the current understanding of the pathogenesis and natural history of CP. We focus on the autonomous nervous system, immune system, and role of a chronobiological therapeutic approach to alleviate symptoms and prevent or reverse pancreatic injury associated with CP. We aim to demonstrate that individualizing chronopharmacological treatments for CP is a promising direction for future treatment using immune, nervous, and circadian systems.

Radiation chronotherapy-clinical impact of treatment time-of-day: a systematic review

PURPOSE

Many brain tumor patients suffer from radiation-induced toxicities. Chronotherapy is a treatment modality that utilizes circadian rhythms to optimize the effect on tumor while minimizing negative outcomes on healthy tissue. This review aims to systematically examine the literature on the application of a radiation chronotherapeutic for all cancers and determine the possible advantages of incorporating a circadian-based fixed time-of-day for radiotherapy into CNS cancers.

METHODS

A systematic review of the literature was conducted in two electronic databases from inception to February 1, 2019. Primary research manuscripts were screened for those related to adult human subjects exposed to ionizing radiation using the chronotherapy technique.

RESULTS

Nine manuscripts were included in the review from 79 eligible articles. Three were prospective randomized trails and 6 were retrospective reviews. This survey revealed that overall survival and tumor control do not have consistent effects with only 60% and 55.5% of paper which included the variables having some significance, respectively. Treatment symptoms were the primary endpoint for both the prospective trials and were examined in 3 of the retrospective reviews; effects were observed in sensitive tissue for all 5 studies including mucosal linings and skin basal layer.

CONCLUSIONS

Existing literature suggests that the application of radiation chronotherapy may reduce negative symptom outcome within highly proliferative tissues. Further examination of radiation chronotherapy in well-designed prospective trials and studies in brain tumor patients are merited.

Endocrine rhythms and sport: it is time to take time into account

BACKGROUND

Studies of time-related biological phenomena have contributed to establishing a new scientific discipline, the chronobiology, which considers biological phenomena in relation to time. Sports activity profoundly affects the temporal organization of the organism and endocrine rhythms play a key role in the chronoorganization of individuals and are particularly important for correct physical activity. Correctly reading rhythmic hormonal variations of the human organism opens new horizons to sports medicine.

OBJECTIVE

This review is aimed at clarifying the relationship between endocrine rhythms and sports activities on the basis of the latest data in the literature.

METHOD

Data acquisition was obtained from three databases (PubMed, Scopus and SPORTDiscus), paying particular attention to reviews, meta-analysis, original and observational studies on this issue.

RESULTS

After the description of the general characteristics and parameters of biological rhythms, the main endocrine rhythms will be described, highlighting in particular the interrelationships with sports activity and focusing on the factors which can affect negatively their characteristics and consequently the psychophysical performances of the athletes.

CONCLUSION

Knowledge of this issue may allow establishing the best form of competitive or amateur activity, through the collaboration of an informed athlete and a sports physician attentive to biological rhythms. By taking into account that alteration of physiological rhythmic temporal organization can favour the onset of important diseases, including cancer, this will lead to the expected performances without impairing the correct chronoorganization of the athlete.

Wireless programmable electrochemical drug delivery micropump with fully integrated electrochemical dosing sensors

We present a fully integrated implantable electrolysis-based micropump with incorporated EI dosing sensors. Wireless powering and data telemetry (through amplitude and frequency modulation) were utilized to achieve variable flow control and a bi-directional data link with the sensors. Wireless infusion rate control (0.14-1.04 μL/min) and dose sensing (bolus resolution of 0.55-2 μL) were each calibrated separately with the final circuit architecture and then simultaneous wireless flow control and dose sensing were demonstrated. Recombination detection using the dosing system, as well as, effects of coil separation distance and misalignment in wireless power and data transfer were studied. A custom-made normally closed spring-loaded ball check valve was designed and incorporated at the reservoir outlet to prevent backflow of fluids as a result of the reverse pressure gradient caused by recombination of electrolysis gases. Successful delivery, infusion rate control, and dose sensing were achieved in simulated brain tissue.

On-demand wireless infusion rate control in an implantable micropump for patient-tailored treatment of chronic conditions

Wireless infusion rate control and programmability for an implantable, low power, electrochemical micropump is presented. Flow rate control was achieved through adjustment of the wiper position of a current potentiometer in the wireless receiver (0.6-3.2 mA output current with a resolution of 0.2 mA per step). An off-the-shelf Bluetooth module and Basic Stamp microcontroller kit was used to initiate amplitude-shift keying (ASK) modulation of the inductive power signal. Accurate flow control of two model regimens was achieved on benchtop. Wireless transmission (power transfer and control) was not affected by simulated tissue material placed between the transmitter and receiver.

The utility of Apc-mutant rats in modeling human colon cancer

Prior to the advent of genetic engineering in the mouse, the rat was the model of choice for investigating the etiology of cancer. Now, recent advances in the manipulation of the rat genome, combined with a growing recognition of the physiological differences between mice and rats, have reignited interest in the rat as a model of human cancer. Two recently developed rat models, the polyposis in the rat colon (Pirc) and Kyoto Apc Delta (KAD) strains, each carry mutations in the intestinal-cancer-associated adenomatous polyposis coli (Apc) gene. In contrast to mouse models carrying Apc mutations, in which cancers develop mainly in the small intestine rather than in the colon and there is no gender bias, these rat models exhibit colonic predisposition and gender-specific susceptibility, as seen in human colon cancer. The rat also provides other experimental resources as a model organism that are not provided by the mouse: the structure of its chromosomes facilitates the analysis of genomic events, the size of its colon permits longitudinal analysis of tumor growth, and the size of biological samples from the animal facilitates multiplexed molecular analyses of the tumor and its host. Thus, the underlying biology and experimental resources of these rat models provide important avenues for investigation. We anticipate that advances in disease modeling in the rat will synergize with resources that are being developed in the mouse to provide a deeper understanding of human colon cancer.

Report of clinical studies on chronochemotherapy for advanced non-small cell lung cancer in China

Chronochemotherapy has been proposed as a promising modality to provide timely optimized medication to achieve maximum efficacy with minimum side effect for patients with non-small cell lung cancer for years. We collected the data of 11 clinical studies performed in China with the purpose to compare the difference between chronochemotherapy and traditional chemotherapy. Results showed that chronochemotherapy has a more favorable efficacy and safety than traditional chemotherapy.

MEMS-enabled implantable drug infusion pumps for laboratory animal research, preclinical, and clinical applications

Innovation in implantable drug delivery devices is needed for novel pharmaceutical compounds such as certain biologics, gene therapy, and other small molecules that are not suitable for administration by oral, topical, or intravenous routes. This invasive dosing scheme seeks to directly bypass physiological barriers presented by the human body, release the appropriate drug amount at the site of treatment, and maintain the drug bioavailability for the required duration of administration to achieve drug efficacy. Advances in microtechnologies have led to novel MEMS-enabled implantable drug infusion pumps with unique performance and feature sets. In vivo demonstration of micropumps for laboratory animal research and preclinical studies include acute rapid radiolabeling, short-term delivery of nanomedicine for cancer treatment, and chronic ocular drug dosing. Investigation of MEMS actuators, valves, and other microstructures for on-demand dosing control may enable next generation implantable pumps with high performance within a miniaturized form factor for clinical applications.

Tumor growth rate determines the timing of optimal chronomodulated treatment schedules

In host and cancer tissues, drug metabolism and susceptibility to drugs vary in a circadian (24 h) manner. In particular, the efficacy of a cell cycle specific (CCS) cytotoxic agent is affected by the daily modulation of cell cycle activity in the target tissues. Anti-cancer chronotherapy, in which treatments are administered at a particular time each day, aims at exploiting these biological rhythms to reduce toxicity and improve efficacy of the treatment. The circadian status, which is the timing of physiological and behavioral activity relative to daily environmental cues, largely determines the best timing of treatments. However, the influence of variations in tumor kinetics has not been considered in determining appropriate treatment schedules. We used a simple model for cell populations under chronomodulated treatment to identify which biological parameters are important for the successful design of a chronotherapy strategy. We show that the duration of the phase of the cell cycle targeted by the treatment and the cell proliferation rate are crucial in determining the best times to administer CCS drugs. Thus, optimal treatment times depend not only on the circadian status of the patient but also on the cell cycle kinetics of the tumor. Then, we developed a theoretical analysis of treatment outcome (TATO) to relate the circadian status and cell cycle kinetic parameters to the treatment outcomes. We show that the best and the worst CCS drug administration schedules are those with 24 h intervals, implying that 24 h chronomodulated treatments can be ineffective or even harmful if administered at wrong circadian times. We show that for certain tumors, administration times at intervals different from 24 h may reduce these risks without compromising overall efficacy.

Chronotherapy of cancers aims at exploiting daily physiological rhythms to improve anti-cancer efficacy and tolerance to drugs by administering treatments at a specific time of the day. Recent clinical trials have shown that chronotherapy can be beneficial in improving quality of life and median life span in patients, but that it can also have negative effects if the timing is wrong. A theoretical basis for the rational development of individualized therapy schedules is still lacking. Here, we use a simple cell population model to show how biological rhythms and the cell cycle interact to modulate the response to cancer therapy. In particular, we show that the proliferation rate of cancer cells determines when treatments are most effective. We provide a simple formulation of the problem that can be used to compute an objective response function based on the drug sensitivity and the proliferation rate of tumor cells. Finally, we show that in some cases, treating at a different time every day may be more appropriate than standard daily chronotherapy. These results constitute an important step in designing individualized chronotherapy treatments, and point out to ways to design better clinical trials.

Stress, geomagnetic disturbance, infradian and circadian sampling for circulating corticosterone and models of human depression?

While certain circadian hormonal changes are prominent, their predictable assessment requires a standardization of conditions of sampling. The 24-hour rhythm in circulating corticosterone of rodents, known since the 1950s, was studied as a presumed proxy for stress on 108 rats divided into 9 groups of 6 male and 9 groups of 6 female animals sampled every 4 hours for 24 hours. In a first stress study, the "no-rhythm" (zero-amplitude) assumption failed to be rejected at the 5% probability level in the two control groups and in 16 out of the 18 groups considered. A circadian rhythm could be detected with statistical significance, however, in three separate follow-up studies in the same laboratory, each on 168 rats kept on two antiphasic lighting regimens, with 4-hourly sampling for 7 or 14 days. In the first stress study, pooling of certain groups helped the detection and assessment of the circadian corticosterone rhythm. Without extrapolating to hormones other than corticosterone, which may shift more slowly or adjust differently and in response to different synchronizers, the three follow-up studies yielded uncertainty measures (95% confidence intervals) for the point estimate of its circadian period, of possible use in any future study as a reference standard. The happenstance of a magnetic disturbance at the start of two follow-up studies was associated with the detection of a circasemiseptan component, raising the question whether a geomagnetic disturbance could be considered as a "load". Far beyond the limitations of sample size, the methodological requirements for standardization in the experimental laboratory concerning designs of studies are considered in the context of models of depression. Lessons from nature's unforeseen geomagnetic contribution and from human studies are noted, all to support the advocacy, in the study of loads, of sampling schedules covering more than 24 hours.

Stress/strain/life revisited. Quantification by blood pressure chronomics: benetensive, transtensive or maletensive chrono-vasculo-neuro-immuno-modulation

We propose to initiate the automatic self-assessment of wear and tear as "stress and strain" by the time structures of blood pressure (BP) and heart rate (HR), in order to arrive eventually at an individualized timely and timed routine of life and to early preventive intervention as soon as needed. The routine may involve physiological scheduling of physical and mental activities and meals, and if need be of non-drug or drug treatment for stress amplification, e.g., by exercise, and/or strain (not stress) relief by relaxation. In so doing, we recognize the circulation as a pillar and marker of preventive and active neuroimmunomodulation (NIM), suggesting that some concerns of a vasculo- and broader NIM can be quantified by transdisciplinary chronobiology using its cartography--chronomics--of time structures, i.e., chronomes, from chronos = time and nomos = rule. Thus, we are introducing the chronomics of BP, HR and of other variables in the historical context of pioneers who were indispensable to experimental medicine. We build upon their contributions, but we must point out when, in the past, by necessity rather than choice, the giants provided rationalizing truisms that are no substitute for systematic serial data collection and appropriate computer analysis. A time-unspecified spotcheck as a baseline is much better than no measurement, but very often it is not enough, and it is always insufficient when an estimate of variability constitutes the information needed. For dynamic cycles, there are only reference cycles as a routine, although when maps are available, single timed spotchecks can be invaluable. With reference to their historical context, here we rely only upon data which necessity, rather than philosophy, compels us to collect.

Time structures, chronomes, of soldiers' stature mimicking hale cycle in neonatal body length

The systematic patterns in human adult physical stature are explored in connection with Wolf's relative sunspot numbers. This topic should be of interest to economists, physicians as well as physicists. There is a need for more than a check of any similarity of curves in variables approximating the economy and human stature and for more than the application of mathematical models, as done herein. Ours is at best a halting step at one frequency, presented only to document the challenge of a transdisciplinary approach to multifrequency intermodulations of hosts of variables, yet to be untangled. The circumstance that at birth some decisions concerning adult stature are already made is challenging. The signature of the environment in terms of the about 21-year Hale bipolarity cycle of Wolf's relative sunspot numbers found in adult soldiers shows that the association at birth is not a transient one, even if other evidence beyond our scope herein points to the possibility that observations on presumably healthy soldiers can be extrapolated to abnormal growth. Nonetheless, the task for those concerned with short stature could become preventive if the sensitive stages when growth may be inhibited by the environment could be found, as well as means to shield from or counter the undesirable effects.

Chronomics: circadian and circaseptan timing of radiotherapy, drugs, calories, perhaps nutriceuticals and beyond

We suggest a putative benefit from timing nutriceuticals (substances that are both nutrients and pharmaceuticals) such as antioxidants for preventive or curative health care, based on the proven merits of timing nutrients, drugs, and other treatments, as documented, i.a., in India. The necessity of timing melatonin, a major antioxidant, is noted. A protocol to extend the scope of chronoradiotherapy awaits testing. Imaging in time by mapping rhythms and broader time structures, chronomes, for earliest diagnoses, for example detection of vascular disease risk, is recommended. The study of rhythms and broader chronomes leads to a dynamic functional genomics, guided by imaging in time of free radicals and antioxidants, amongst many other variables.

Inverse correlation of epidermal growth factor receptor messenger RNA induction and suppression of anchorage-independent growth by OSI-774, an epidermal growth factor receptor tyrosine kinase inhibitor, in glioblastoma multiforme cell lines

OBJECT

Quantitative and qualitative alterations in the epidermal growth factor receptor (EGFR) commonly occur in many cancers in humans, including malignant gliomas. The aim of the current study was to evaluate molecular and cellular effects of OSI-774, a novel EGFR tyrosine kinase inhibitor, on nine glioblastoma multiforme (GBM) cell lines.

METHODS

The effects of OSI-774 on expression of EGFR messenger (m)RNA and protein, proliferation, anchorage-independent growth, and apoptosis were examined using semiquantitative reverse transcription-polymerase chain reaction, immunocytochemical analysis, Coulter counting, soft agar cloning, and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling/fluorescence-activated cell sorting, respectively. All p53 genes were completely and bidirectionally sequenced. Suppression of anchorage-independent growth by OSI-774 was inversely correlated to the induction of EGFR mRNA during relative serum starvation (r = -0.74) and was unrelated to p53 status. Overall, suppression of anchorage-independent growth was a considerably stronger effect of OSI-774 than inhibition of proliferation. The extent of OSI-774-induced apoptosis positively correlated with both proliferation and anchorage-independent growth of GBM cell lines (r = 0.75 and 0.79, respectively). In a single cell line derived from a secondary GBM, exposure to concentrations of greater than or equal to 1 micromol/L resulted in a substantial net cell loss during proliferation studies.

CONCLUSIONS

The induction of EGFR mRNA may constitute a cellular mechanism to counteract the inhibitory effect of OSI-774 on the anchorage-independent growth of GBM cells. In contrast, no considerable correlation could be established between baseline expression levels of EGFR (both mRNA and protein) in GBM cell lines and their biological response to OSI-774. The OSI-774 induced greater (p53-independent) apoptosis in more malignant GBM phenotypes and may be a promising therapeutic agent against secondary GBM.

Inverse correlation of epidermal growth factor receptor messenger RNA induction and suppression of anchorage-independent growth by OSI-774, an epidermal growth factor receptor tyrosine kinase inhibitor, in glioblastoma multiforme cell lines

Object

Quantitative and qualitative alterations in the epidermal growth factor receptor (EGFR) commonly occur in many cancers in humans, including malignant gliomas. The aim of the current study was to evaluate molecular and cellular effects of OSI-774, a novel EGFR tyrosine kinase inhibitor, on nine glioblastoma multiforme (GBM) cell lines.

Methods

The effects of OSI-774 on expression of EGFR messenger (m)RNA and protein, proliferation, anchorage-independent growth, and apoptosis were examined using semiquantitative reverse transcription–polymerase chain reaction, immunocytochemical analysis, Coulter counting, soft agar cloning, and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling/fluorescence-activated cell sorting, respectively. All p53 genes were completely and bidirectionally sequenced.

Suppression of anchorage-independent growth by OSI-774 was inversely correlated to the induction of EGFR mRNA during relative serum starvation (r = −0.74) and was unrelated to p53 status. Overall, suppression of anchorage-independent growth was a considerably stronger effect of OSI-774 than inhibition of proliferation. The extent of OSI-774–induced apoptosis positively correlated with both proliferation and anchorage-independent growth of GBM cell lines (r = 0.75 and 0.79, respectively). In a single cell line derived from a secondary GBM, exposure to concentrations of greater than or equal to 1 μmol/L resulted in a substantial net cell loss during proliferation studies.

Conclusions

The induction of EGFR mRNA may constitute a cellular mechanism to counteract the inhibitory effect of OSI-774 on the anchorage-independent growth of GBM cells. In contrast, no considerable correlation could be established between baseline expression levels of EGFR (both mRNA and protein) in GBM cell lines and their biological response to OSI-774. The OSI-774 induced greater (p53-independent) apoptosis in more malignant GBM phenotypes and may be a promising therapeutic agent against secondary GBM.

Transdisciplinary unifying implications of circadian findings in the 1950s

Afew puzzles relating to a small fraction of my endeavors in the 1950s are summarized herein, with answers to a few questions of the Editor-in-Chief, to suggest that the rules of variability in time complement the rules of genetics as a biological variability in space. I advocate to replace truisms such as a relative constancy or homeostasis, that have served bioscience very well for very long. They were never intended, however, to lower a curtain of ignorance over everyday physiology. In raising these curtains, we unveil a range of dynamics, resolvable in the data collection and as-one-goes analysis by computers built into smaller and smaller devices, for a continued self-surveillance of the normal and for an individualized detection of the abnormal. The current medical art based on spotchecks interpreted by reference to a time-unqualified normal range can become a science of time series with tests relating to the individual in inferential statistical terms. This is already doable for the case of blood pressure, but eventually should become possible for many other variables interpreted today only based on the quicksand of clinical trials on groups. These ignore individual differences and hence the individual's needs. Chronomics (mapping time structures) with the major aim of quantifying normalcy by dynamic reference values for detecting earliest risk elevation, also yields the dividend of allowing molecular biology to focus on the normal as well as on the grossly abnormal.

Chronotherapy for cancer

Cancer chronotherapy is attracting attention as a novel and logical therapy in which anti-cancer drugs are administered with optimal timing according to circadian rhythms of anti-cancer action and those of adverse effects on normal cells. Advances in chronobiology have identified the suprachiasmatic nucleus (SCN) as the center of biological rhythms and the area in which clock genes such as PER1, PER2, PER3, CLOCK, BMAL1, TIM, CRY1, CRY2, tau act to generate and coordinate biological rhythms. These findings have led to the development of chronotherapy. Clinically, patients with advanced gastrointestinal cancer have been treated by chronomodulated chemotherapy with good response. For colorectal cancer patients with unresectable liver metastases, chronotherapy with l-OHP + 5-FU + FA (folinic acid) has been reported to allow complete surgical resection of liver metastases, resulting in 39-50% 5-year survival. Many believe that chronotherapy will become accepted as a refined and advantageous therapeutic option for not only cancer but also for other diseases, due to its universally applicable principles.

The circadian clock: pacemaker and tumour suppressor

The circadian rhythms are daily oscillations in various biological processes that are regulated by an endogenous clock. Disruption of these rhythms has been associated with cancer in humans. One of the cellular processes that is regulated by circadian rhythm is cell proliferation, which often shows asynchrony between normal and malignant tissues. This asynchrony highlights the importance of the circadian clock in tumour suppression in vivo and is one of the theoretical foundations for cancer chronotherapy. Investigation of the mechanisms by which the circadian clock controls cell proliferation and other cellular functions might lead to new therapeutic targets.

Circadian rhythm of tumor promotion in the two-stage model of mouse tumorigenesis

The question of whether cancer risk is influenced by time-of-day exposure to potentially carcinogenic agents was approached in this study by exposing mouse skin to a single initiating dose of 7,12-dimethylbenz [A-]anthracene, followed by a 12 week regime of bi-weekly skin treatments with the tumor promoter, 12-0-tetradecanoyl-phorbol acetate (TPA), given at four different circadian clock times (CCTs). Tumor incidence, average number of tumors per mouse and tumor size showed a dominant circadian component with an acrophase occurring at 23:00 h CCT. Pre-treatment with all trans-retinoic acid, prior to bi-weekly TPA promotion, reduced tumor incidence, average number and size of tumors per animal by greater than 80%, but did not suppress the underlying circadian rhythm of sensitivity to TPA-induced tumor formation.

Marker rhythms of circadian system function: a study of patients with metastatic colorectal cancer and good performance status

Cancer patients may exhibit normal or altered circadian rhythms in tumor and healthy tissues. Four rhythms known to reflect circadian clock function were studied in 18 patients with metastatic colorectal cancer and good performance status. Rest-activity was monitored by wrist actigraphy for 72 h before treatment, and its circadian rhythm was estimated by an autocorrelation coefficient at 24h and a dichotomy index that compared the activity level when in and out of bed. Blood samples (9-11 time points, 3-6 h apart) were drawn on day 1 and day 4 of the first course of chronochemotherapy (5-fluorouracil: 800 mg/m2/day; folinic acid: 300 mg/m2/day; oxaliplatin: 25 mg/m2/day). Group 24h rhythms were validated statistically for plasma concentrations of melatonin, 6-alpha-sulfatoxymelatonin, and cortisol and for lymphocyte counts. Significant individual 24h rhythms were displayed in melatonin by 15 patients, cortisol by seven patients, lymphocytes by five patients, and prominent circadian rhythms in activity were displayed by 10 patients; only one patient exhibited significant rhythms in all the variables. The results suggest the rhythms of melatonin, cortisol, lymphocytes, and rest/activity reflect different components of the circadian system, which may be altered differently during cancer processes. Such 24h rhythm alterations appeared to be independent of conventional clinical factors.

From circadian rhythms to cancer chronotherapeutics

Mammalian circadian rhythms result from a complex organization involving molecular clocks within nearly all "normal" cells and a dedicated neuroanatomical system, which coordinates the so-called "peripheral oscillators." The core of the central clock system is constituted by the suprachiasmatic nuclei that are located on the floor of the hypothalamus. Our understanding of the mechanisms of circadian rhythm generation and coordination processes has grown rapidly over the past few years. In parallel, we have learnt how to use the predictable changes in cellular metabolism or proliferation along the 24h time scale in order to improve treatment outcome for a variety of diseases, including cancer. The chronotherapeutics of malignant diseases has emerged as a result of a consistent development ranging from experimental, clinical, and technological prerequisites to multicenter clinical trials of chronomodulated delivery schedules. Indeed large dosing-time dependencies characterize the tolerability of anticancer agents in mice or rats, a better efficacy usually results from treatment administration near the least toxic circadian time in rodent tumor models. Programmable in time multichannel pumps have allowed to test the chronotherapy concepts in cancer patients and to implement chronomodulated delivery schedules in current practice. Clinical phase I and II trials have established the feasibility, the safety, and the activity of the chronotherapy schedules, so that this treatment method has undergone further evaluation in international multicenter phase III trials. Overall, more than 2,000 patients with metastatic disease have been registered in chronotherapy trials. Improved tolerability and/or better antitumor activity have been demonstrated in randomized multicenter studies involving large patient cohorts. The relation between circadian rhythmicity and quality of life and even survival has also been a puzzling finding over the recent years. An essential step toward further developments of circadian-timed therapy has been the recent constitution of a Chronotherapy cooperative group within the European Organization for Research and Treatment of Cancer. This group now involves over 40 institutions in 12 countries. It is conducting currently six trials and preparing four new studies. The 19 contributions in this special issue reflect the current status and perspectives of the several components of cancer chronotherapeutics.

Chronobiology of the mammalian response to ionizing radiation. Potential applications in oncology

Ionizing radiation from all sources under appropriate conditions leads to cell death and tissue damage. It is used in cancer treatment under the assumption of a higher radiosensitivity of the fast dividing tumor cells as compared with adjacent host tissues. The radiosensitivities of proliferating host tissues like bone marrow and gastrointestinal lining epithelium are dose limiting. Since these host tissues and many tumors show circadian and other periodicities in their cell proliferation, the timing of radiation treatment according to host and/or tumor rhythms is expected to improve the toxic/therapeutic ratio of the treatment. The experimental data on the chronobiology of radiation exposure show circadian rhythmicity in radiation response after whole body irradiation in mice and rats with highest toxicity in light-dark 12h:12h synchronized animals during their daily activity span. Bone marrow toxicity as well as gastrointestinal epithelial damage show circadian rhythms in part due to radiation damage to the stem cells involved and especially in the intestine also due to damage to the microvasculature. Chronoradiotherapy of malignant tumors seems promising, alone or in combination with response modifiers, provided the host and potential tumor rhythms can be monitored.

Circadian concepts in normal and neoplastic breast

Normal breast exhibits rhythmic properties linked to the hormonal environment of the gland in animals and humans. Breast tumors also display rhythmic properties; however, they differ from those found normally in animals and humans. Breast cancer in humans is characterized by disruption or modification of normal circadian patterns, which may be of prognostic value. The relationships between melatonin biology and breast cancer require exploration. The present work summarizes the data concerning circadian concepts in breast cancer and explores future directions in the breast cancer treatment by chronomodulation of medications during the 24h, taking advantage of the circadian time structure of breast tissue to improve the treatment outcome.

Tumor-based rhythms of anticancer efficacy in experimental models

Experimental tumor models constitute a prerequisite toward chronotherapy testing in cancer patients. Studies in experimental models are required to understand the relation between tumor rhythms and antitumor treatments efficacy. In healthy tissues, cell proliferation, and differentiation processes are regulated precisely and exhibit marked circadian rhythmicity. Experimental and human tumors can retain circadian rhythms or display altered oscillations. Healthy tissues can also display rhythm modifications, possibly related to cancer stage. Cellular rhythms modulate the metabolism of cytotoxic agents and the cellular response to them; hence, they determine the chronopharmacology of anticancer drugs. Circadian rhythms in host tolerability and/or cancer chemotherapy efficacy have been demonstrated with nontoxic doses of drugs in several experimental tumor models, while in other ones a circadian-time effect was only seen within a specific dose range. The usual coupling between tolerability and efficacy rhythms of anticancer agents has resulted in significant improvement of their therapeutic index. Results of laboratory animal studies have been extrapolated to the design of clinical cancer therapy trials involving a chronobiological approach.

Circadian rhythms of basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), insulin-like growth factor-1 (IGF-1), insulin-like growth factor binding protein-3 (IGFBP-3), cortisol, and melatonin in women with breast cancer

BACKGROUND

Circadian rhythms in plasma concentrations of many hormones and cytokines determine their effects on target cells.

METHODS

Circadian variations were studied in cortisol, melatonin, cytokines (basic fibroblast growth factor IbFGF], EGF, insulin-like growth factor-1 [IGF-1]), and a cytokine receptor (insulin-like growth factor binding protein-3 [IGFBP-3]) in the plasma of 28 patients with metastatic breast cancer. All patients followed a diurnal activity pattern. Blood was drawn at 3h intervals during waking hours and once during the night, at 03:00. The plasma levels obtained by enzyme-linked immunoassay (ELISA) or radioimmunoassay (RIA) were evaluated by population mean cosinor (using local midnight as the phase reference) and by one-way analysis of variance (ANOVA).

RESULTS

Cortisol and melatonin showed a high-amplitude circadian rhythm and a superimposed 12h frequency. bFGF showed a circadian rhythm with an acrophase around 13:00 with a peak-to-trough interval (double amplitude) of 18.2% and a superimposed 12h frequency. EGF showed a circadian rhythm with an acrophase around 14:20, a peak-to-trough interval of 25.8%, and a superimposed 12h frequency. IGF-1 showed a high value in the morning, which is statistically different (t test) from the low value at 10:00, but a regular circadian or ultradian rhythm was not recognizable as a group phenomenon. IGFBP-3 showed a low-amplitude (peak-to-trough difference 8.4%) circadian rhythm with the acrophase around 11:00 and low values during the night.

CONCLUSIONS

(1) Circadian periodicity is maintained in hospitalized patients with metastatic breast cancer. (2) Ultradian (12h) variations were superimposed on the circadian rhythms of the hormones and several of the cytokines measured. (3) Studies of hormones and cytokines in cancer patients have to take their biologic rhythms into consideration. (4) The circadian periodicity of tumor growth stimulating or restraining factors raises questions about circadian and/or ultradian variations in the pathophysiology of breast cancer.

Biological time and in vivo research: a field guide to pitfalls

Biological rhythmicity is a fundamental characteristic of all life forms, from primitive bacteria to man. The molecular biology, genetics, and the neurobiology of the biological clock(s) are being elucidated. Daily (circadian) statistically significant fluctuations occur in all of the normal biological variables studied in the experimental animal and the human. Many researchers, however, are not aware of the negative impact biological rhythmicity can have on experimental design and/or data interpretation. This article serves not as a review, but as a "field guide" to the pitfalls that can occur when research is performed in the absence of an understanding of biological rhythmicity. The major topics discussed are: 1) data transfer from the diurnally in-active/resting/sleeping lab animal to the diurnally active human, 2) frequency of sampling, 3) free-running vs. synchronization, 4) alternating periods of resistance and susceptibility, 5) phase shifting of a rhythm, 6) the assumption that one mean +/- S.E. from control animals can be "stretched" across an experimental time span, and 7) plotting data on an "hours after treatment" format vs. a "time of day" format. The hope is that by avoiding the pitfalls, biological time will become an ally in the endeavor to understand human biology.

Biological clocks and the digestive system

Circadian rhythms play a major role in regulating the digestive systems of many organisms. Cell proliferation, migration, differentiation, and even structure vary as a function of time of day in many different digestive organs (i.e., stomach, gut, liver, and pancreas) and cell types, resulting in regionally specific temporal variations in protein and gene expression. Feeding and light set the hands of the digestive clock(s). However, the clockwork has a genetic basis. During the last 10 years, new developments have emerged in our understanding of how cells keep time. Surprisingly, clock genes in mammals are expressed not only in specialized time keepers in the brain, but also in peripheral organs, suggesting that the ability to keep time may also belong to cells within the digestive system. This article reviews several classic examples of circadian variation in the digestive system, with an emphasis on rhythms in cell proliferation, function, and structure. It also briefly summarizes several new ideas about how cells in the brain and possibly the digestive system keep time.

Circadian rhythms and cancer chemotherapy

Experimental and clinical pertinent data regarding circadian rhythmicities are reviewed in (1) target tissues, i.e., healthy tissues (actively proliferating or not) and tumor tissues, (2) pharmacology of anticancer agents, (3) toxicity and tolerance of these agents and (4) antitumor activity of cancer chemotherapy. The basic concepts of chronotolerance and/or of chronoefficacy have brought new hopes for further amelioration in the management of cancer patients. Quite recent published Phase II and III clinical trials have demonstrated that new improvements on the therapeutic index have been achieved through ambulatory chronotherapy for various solid tumors.

Primate parturition and the role of the maternal circadian system

Several 24-h rhythms have been observed in the mother and in the fetus during primate gestation. In the mother, 24-h rhythms occur in biophysical variables, pregnancy-associated plasma hormones and preparturient myometrial activity. In addition, both pregnant non-human primates and pregnant women deliver preferentially during the night and early morning hours. A crucial question pertaining circadian rhythms is whether 24-h rhythms that may be observed during pregnancy are endogenous in nature and entrained by the light-dark cycle or whether the daily photoperiod is a causal stimulus. Our work has addressed the role of the maternal and fetal circadian system for 24-h rhythms in pregnancy-associated maternal plasma hormones, preparturient myometrial activity and parturition in human and non-human primate pregnancy. In the present review, the results of some of our studies are being discussed in combination with data available from the literature. It is apparent that 24-h rhythms that may be observed during primate pregnancy are determined by the maternal circadian system, suggesting that the developing fetus receives information about the ambient time of the day via the mother. Fetal entrainment by the mother may ensure fetal cooperation so that parturition occurs at the most favorable time of the day. We conclude that the functioning of the maternal circadian system is integral to the pregnant state. Thus, proper care and management of pregnant women and the ultimate outcome of obstetrics may benefit from more timely methodologies. A chronopharmacological attitude towards the prevention of premature labor and the induction and augmentation of labor at term may yield new therapeutic strategies. Such an approach will enable delivery to take place under optimal conditions for mother and child.

Chronopharmacologic issues in space

Times of heightened susceptibility are expressed by nonrandom patterns in the incidence of various diseases, not only along the scale of a day but also of a week and a year. Whereas these rhythms can be synchronized by the environment, their endogenicity is revealed by their persistence in the absence of time cues with a period slightly but statistically significantly different from the environmental match. In the case of some circadians, the gene involved has been identified and heritabiliy in humans determined by studies on twins. Vital signs are now amenable to automatic monitoring around the clock. When analyzed by chronobiologic software, the data provide information regarding the given individual's time structure (chronome). Such physiologic monitoring serves the multiple purposes of deriving time-specified reference norms on the basis of which rhythm alteration can detect an elevated risk early, thus prompting timely preventive action and timed treatment whenever warranted. For long journeys in space, the design of a multi-disease prophylactic pill poses a chronopharmacologic challenge. Drugs such as aspirin and carnitine, used for the prevention of strokes, myocardial infarctions and depression, all show striking chronome-dependent effects which can determine not only the presence or the absence of a desired effect, but even yield effects in opposite directions.

Acute toxicity of ganciclovir: effect of dietary restriction and chronobiology

The effect of diet, age and time of dose delivery on the mortality of female B6C3F1 mice from ganciclovir sodium (DHPG) was determined for both single (SD; 400 mg DHPG/kg, ip) and multiple doses (MD; same dose ip for 10 additional days) of the drug. Young (7-10 months) and middle-aged (MA; 19-22 months) mice (B6C3F1), both fed ad lib. (AL) and calorie restricted (CR), were dosed at 0, 6, 12 and 18 hr after lights on (HALO; SD study) and at 12.00 hr (MD study). The SD study mortality rate was 38% (AL) and 1.7% (CR) (P < 0.00001). Mortality was 53% (AL, young; P < 0.00001), over 20% (AL, MA), over 1.8% (CR, MA; P = 0.00004) or more than 1.7% (CR, young; P = 0.00002). Effects were independent of lean body mass differences between AL and CR mice. In the SD study, comparing AL mice only, the greatest mortality was seen in young mice at 6 HALO, (73%; P = 0.0034) and lowest mortality in MA mice at 12 HALO (8%; P = 0.026), whereas in the MD study mortality was 63% AL and 33% CR (P = 0.015). By age, MD mortality was 80% (AL, young; P = 0.0035), 50% (CR, MA), 47% (AL, MA), and 15% (CR, young; P = 0.0013). CR protected both young and MA mice in SD and young mice in MD. Lowest mortality for AL was at 12 HALO. It is suggested that dosing at 12 HALO may protect by decreasing DHPG uptake during a period of minimal DNA synthesis in the affected organ(s). CR and timing of DHPG dose may obviate the necessity to discontinue DHPG because of toxicity in humans. The most significant finding of this study is the impact of diet on mortality.

Nursing chronotherapeutics: a conceptual framework

Nurses frequently make decisions about when treatments and actions are performed. The nursing concern driving this review is the timing of nursing activities to optimize desired and minimize untoward effects. A nursing conceptual framework is proposed that highlights individual and environmental factors, as they relate to rhythmic responses; as well as places within the framework for nursing actions based on customary and usual temporal patterns.

Influence of circadian rhythms on radiosensitivity: single and fractionated dose studies in mouse skin

In rodent skin significant increases in labelling and mitotic indices have been reported during the period of maximum nocturnal activity. It has been suggested that sparing of radiation damage in fast-proliferating normal tissues could be achieved if treatments were given at the time of day when the maximum number of normal cells were most radioresistant. If changes in radiosensitivity do occur in tissues with circadian fluctuations in the cell kinetic parameters, then the magnitude of these changes should be dependent on the size of dose per fraction. Because of the implications for clinical radiotherapy, especially in regimes where multiple fractions per day are given (MFD), possible diurnal variations in radiosensitivity were investigated using single dose and fractionated X-ray regimens (5F/5 days, 8F/8 days), in rodent skin. Treatments were delivered at 1, 3, 5 a.m. (time of highest DNA synthetic activity in mouse epidermis), 6 and 7 a.m. (highest mitotic activity) and at 5 p.m. (minimum labelling and mitotic indices). To investigate a large range of doses per fraction, fractionated X-rays were given alone or followed by neutron top-up doses. Using a range of doses per fraction of 30 Gy down to 1 Gy, we did not detect any change in radiosensitivity with any of the schedules. Our results suggest that a decrease in normal tissue tolerance is unlikely to be observed in patients even if irradiated at a time of day at which a maximum increase in radiosensitivity might be predicted on the basis of a high mitotic index.

Cytometry and time-dependent variations in peripheral blood and bone marrow cells: a literature review and relevance to the chronotherapy of cancer

By flow cytometry of individual cells, multiple cell properties can be analyzed. Such parameters may be important in relation to cytotoxic treatment of cancer. For example, DNA measurements will answer questions regarding cell kinetics. Myelosuppression is the major dose-limiting toxicity during cancer treatment. Therefore, the study of cell cycle parameters in bone marrow cells is highly relevant. However, inattention to the existence and potential importance of biological rhythms may introduce artifacts and misleading results. The literature of rhythms in hematology is reviewed. Time-dependent variations in hematological variables have been extensively studied and rhythms have been described for all kinds of blood cells. Also the numbers of hemopoietic stem cells in the bone marrow undergo circadian variations. Our group has shown how such variations change with aging in mice. The relevance of time sequence studies in aging research of hemopoiesis was clearly demonstrated. In animal studies using cytometry, our group has demonstrated extensive circadian variations in cell cycle distribution of bone marrow cells, especially the DNA synthesis (S-phase). In humans a few and rather small time sequence studies of the bone marrow have been performed, so far. In this overview the clinical implications of circadian rhythms of S-phase variations measured by flow cytometry of human bone marrow cells are discussed. Male volunteers were examined every 4 h around-the-clock. The data indicated a lower proliferative activity during night, suggesting the possibility of reducing the bone marrow toxicity to cancer treatment when taking these time-dependent variations into consideration.

Drug delivery systems. 4. Implants in drug delivery

In comparison with many of the other drug delivery systems, implantable pumps and implants for variable rate delivery are at a crude stage of development. Although exceptions exist, the typical implantable pump consists of an electromechanically complex mechanism to regulate drug delivery from a percutaneous refillable reservoir, while power to drive the system comes from a transcutaneous energy transmission system. The potential for electrical or mechanical failure is high, and the systems are not yet sufficiently convenient or easy to use to recommend in a routine therapy. Problems with refilling of an apparently well designed implanted reservoir have been observed while, at the same time, cutaneous energy transmission systems are not well established. In most instances, the development of an elementary osmotic pump system dosage form follows a well defined path of physical-chemical formulation and clinical testing. The benefits most often provided by the dosage form are expected to be (1) increase in selectivity of drug action achieved by the system's zero-order release rate, and (2) decrease in frequency of administration. The success in achieving these values is quantifiable from the pharmacology of the drug substance and its pharmacokinetics. Osmotic and other technical approaches to producing economical, rate-controlled dosage forms will make it possible for all new pharmaecutical products to carry kinetic specification of rate as well as static specification of content. This review considers the characteristics of the ideal implantable pump, the clinical situations which require pumps, the limitations of portable pumps, and the detailed characteristics of existing implantable pumps and implants. Most of the review, however, focuses on insulin delivery because of the importance of this subject.

Circaseptan (about 7-day) modulation of circadian rhythm in corneal mitoses of Holtzman rats

An infradian modulation with a 168 h or circaseptan period characterizes epithelial corneal mitoses in adult female and male Holtzman rats, standardized at 24 +/- 1 degree C and approximately 50% relative humidity on six different sequences of light (L) alternating every 12 h with darkness (D). To approximate sampling over a 24 h LD span by convenient sampling within a single hour, the LD 12:12 regimen was staggered by 4 h in the six environments. Bedding was changed 3 days before each day of killing. During each of eight or 12 consecutive days, male and female rats, respectively, were killed and the eyeballs were removed. Mitotic indices in the cornea were determined separately for each eye and the data were analyzed by linear and nonlinear least-squares rhythmometry. For a prominent circadian component of mitotic activity, the 95% confidence interval (CI) of the period extends from 23.6 to 24.3 h for the data from males and from 23.7 to 24.2 h for those from female rats. The circadian amplitude is larger in males as compared to females. The peaks in the 24 h cosine functions best approximating the data, the circadian acrophases, are at -64 degrees or -48 degrees, i.e., 4 h 16 min or 3 h 12 min from lights-on in male and female rats, respectively. In the data from the two genders, the 24 h synchronized circadian acrophases are thus only 16 degrees, i.e., 1 h and 4 min apart. A test for an anticipated circaseptan (7-day) period shows that this particular infradian periodicity is superimposed upon the circadian one in data from both genders.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of melatonin and serotonin in aging

The hypothesis presented in this paper defines aging as a pathological process originating in the pineal gland. This results in a diminished output of melatonin, along with a diminished melatonin to serotonin ratio, leading to a decline in adaptive processes and a predictable syndrome manifested by the "diseases of the aged" (DOA) and subsequent death of the organism. That is, aging is a syndrome of relative melatonin deficiency resulting from the gradual failure of the pineal gland.

Circadian and ultradian rhythms of proliferation in human ovarian cancer

Synchronous waves of proliferation in tumor cells taken from patients with ovarian cancer were observed using flow cytometry to measure the fraction of cells undergoing DNA replication and displaying tumor-cell-specific immunofluorescence. When saline washings of the abdominal cavity were analyzed at 2-4 hr intervals round-the-clock, the percentage of cells in the chromosome replication cycle (S + G2 percentage) showed 12-hr and often higher frequency rhythms in proliferation. These higher frequency rhythms in DNA replication show a relatively constant phase relationship to the patient's circadian clock with peak proliferation occurring most commonly at 10 a.m. to 12 noon and again at 10 p.m. This proliferation rhythm is therefore partially out of phase with the 24-hr rhythms in proliferation seen in normal cells. The findings on human cancer reveal a fundamental difference in the temporal organization of normal and tumor cell growth that should be exploited for therapeutic benefit.