Nonlinear modelling of cancer: bridging the gap between cells and tumours

Mechanics and Morphology of Proliferating Cell Collectives with Self-Inhibiting Growth

We study the dynamics of proliferating cell collectives whose microscopic constituents' growth is inhibited by macroscopic growth-induced stress. Discrete particle simulations of a growing collective show the emergence of concentric-ring patterns in cell size whose spatiotemporal structure is closely tied to the individual cell's stress response. Motivated by these observations, we derive a multiscale continuum theory whose parameters map directly to the discrete model. Analytical solutions of this theory show the concentric patterns arise from anisotropically accumulated resistance to growth over many cell cycles. This Letter shows how purely mechanical processes can affect the internal patterning and morphology of cell collectives, and provides a concise theoretical framework for connecting the micro- to macroscopic dynamics of proliferating matter.

Mathematical model of MMC chemotherapy for non-invasive bladder cancer treatment

Mitomycin-C (MMC) chemotherapy is a well-established anti-cancer treatment for non-muscle-invasive bladder cancer (NMIBC). However, despite comprehensive biological research, the complete mechanism of action and an ideal regimen of MMC have not been elucidated. In this study, we present a theoretical investigation of NMIBC growth and its treatment by continuous administration of MMC chemotherapy. Using temporal ordinary differential equations (ODEs) to describe cell populations and drug molecules, we formulated the first mathematical model of tumor-immune interactions in the treatment of MMC for NMIBC, based on biological sources. Several hypothetical scenarios for NMIBC under the assumption that tumor size correlates with cell count are presented, depicting the evolution of tumors classified as small, medium, and large. These scenarios align qualitatively with clinical observations of lower recurrence rates for tumor size ≤ 30[mm] with MMC treatment, demonstrating that cure appears up to a theoretical x[mm] tumor size threshold, given specific parameters within a feasible biological range. The unique use of mole units allows to introduce a new method for theoretical pre-treatment assessments by determining MMC drug doses required for a cure. In this way, our approach provides initial steps toward personalized MMC chemotherapy for NMIBC patients, offering the possibility of new insights and potentially holding the key to unlocking some of its mysteries.

Morphological Stability for in silico Models of Avascular Tumors

The landscape of computational modeling in cancer systems biology is diverse, offering a spectrum of models and frameworks, each with its own trade-offs and advantages. Ideally, models are meant to be useful in refining hypotheses, to sharpen experimental procedures and, in the longer run, even for applications in personalized medicine. One of the greatest challenges is to balance model realism and detail with experimental data to eventually produce useful data-driven models. We contribute to this quest by developing a transparent, highly parsimonious, first principle in silico model of a growing avascular tumor. We initially formulate the physiological considerations and the specific model within a stochastic cell-based framework. We next formulate a corresponding mean-field model using partial differential equations which is amenable to mathematical analysis. Despite a few notable differences between the two models, we are in this way able to successfully detail the impact of all parameters in the stability of the growth process and on the eventual tumor fate of the stochastic model. This facilitates the deduction of Bayesian priors for a given situation, but also provides important insights into the underlying mechanism of tumor growth and progression. Although the resulting model framework is relatively simple and transparent, it can still reproduce the full range of known emergent behavior. We identify a novel model instability arising from nutrient starvation and we also discuss additional insight concerning possible model additions and the effects of those. Thanks to the framework's flexibility, such additions can be readily included whenever the relevant data become available.

Selected aspects of avascular tumor growth reproduced by a hybrid model of cell dynamics and chemical kinetics

We here propose a hybrid computational framework to reproduce and analyze aspects of the avascular progression of a generic solid tumor. Our method first employs an individual-based approach to represent the population of tumor cells, which are distinguished in viable and necrotic agents. The active part of the disease is in turn differentiated according to a set of metabolic states. We then describe the spatio-temporal evolution of the concentration of oxygen and of tumor-secreted proteolytic enzymes using partial differential equations (PDEs). A differential equation finally governs the local degradation of the extracellular matrix (ECM) by the malignant mass. Numerical realizations of the model are run to reproduce tumor growth and invasion in a number scenarios that differ for cell properties (adhesiveness, duplication potential, proteolytic activity) and/or environmental conditions (level of tissue oxygenation and matrix density pattern). In particular, our simulations suggest that tumor aggressiveness, in terms of invasive depth and extension of necrotic tissue, can be reduced by (i) stable cell-cell contact interactions, (ii) poor tendency of malignant agents to chemotactically move upon oxygen gradients, and (iii) presence of an overdense matrix, if coupled by a disrupted proteolytic activity of the disease.

Equations describing semi-confluent cell growth (I) Analytical approximations

A set of differential equations with analytical solutions are presented that can quantitatively account for variable degrees of contact inhibition on cell growth in two- and three-dimensional cultures. The developed equations can be used for comparative purposes when assessing contribution of higher-order effects, such as culture geometry and nutrient depletion, on mean cell growth rate. These equations also offer experimentalists the opportunity to characterize cell culture experiments using a single reductive parameter.

"Patchiness" in mechanical stiffness across a tumor as an early-stage marker for malignancy

Mechanical phenotyping of tumors, either at an individual cell level or tumor cell population level is gaining traction as a diagnostic tool. However, the extent of diagnostic and prognostic information that can be gained through these measurements is still unclear. In this work, we focus on the heterogeneity in mechanical properties of cells obtained from a single source such as a tissue or tumor as a potential novel biomarker. We believe that this heterogeneity is a conventionally overlooked source of information in mechanical phenotyping data. We use mechanics-based in-silico models of cell-cell interactions and cell population dynamics within 3D environments to probe how heterogeneity in cell mechanics drives tissue and tumor dynamics. Our simulations show that the initial heterogeneity in the mechanical properties of individual cells and the arrangement of these heterogenous sub-populations within the environment can dictate overall cell population dynamics and cause a shift towards the growth of malignant cell phenotypes within healthy tissue environments. The overall heterogeneity in the cellular mechanotype and their spatial distributions is quantified by a "patchiness" index, which is the ratio of the global to local heterogeneity in cell populations. We observe that there exists a threshold value of the patchiness index beyond which an overall healthy population of cells will show a steady shift towards a more malignant phenotype. Based on these results, we propose that the "patchiness" of a tumor or tissue sample, can be an early indicator for malignant transformation and cancer occurrence in benign tumors or healthy tissues. Additionally, we suggest that tissue patchiness, measured either by biochemical or biophysical markers, can become an important metric in predicting tissue health and disease likelihood just as landscape patchiness is an important metric in ecology.

Calibration of agent based models for monophasic and biphasic tumour growth using approximate Bayesian computation

Agent-based models (ABMs) are readily used to capture the stochasticity in tumour evolution; however, these models are often challenging to validate with experimental measurements due to model complexity. The Voronoi cell-based model (VCBM) is an off-lattice agent-based model that captures individual cell shapes using a Voronoi tessellation and mimics the evolution of cancer cell proliferation and movement. Evidence suggests tumours can exhibit biphasic growth in vivo. To account for this phenomena, we extend the VCBM to capture the existence of two distinct growth phases. Prior work primarily focused on point estimation for the parameters without consideration of estimating uncertainty. In this paper, approximate Bayesian computation is employed to calibrate the model to in vivo measurements of breast, ovarian and pancreatic cancer. Our approach involves estimating the distribution of parameters that govern cancer cell proliferation and recovering outputs that match the experimental data. Our results show that the VCBM, and its biphasic extension, provides insight into tumour growth and quantifies uncertainty in the switching time between the two phases of the biphasic growth model. We find this approach enables precise estimates for the time taken for a daughter cell to become a mature cell. This allows us to propose future refinements to the model to improve accuracy, whilst also making conclusions about the differences in cancer cell characteristics.

Formation and Growth of Co-Culture Tumour Spheroids: New Compartment-Based Mathematical Models and Experiments

Co-culture tumour spheroid experiments are routinely performed to investigate cancer progression and test anti-cancer therapies. Therefore, methods to quantitatively characterise and interpret co-culture spheroid growth are of great interest. However, co-culture spheroid growth is complex. Multiple biological processes occur on overlapping timescales and different cell types within the spheroid may have different characteristics, such as differing proliferation rates or responses to nutrient availability. At present there is no standard, widely-accepted mathematical model of such complex spatio-temporal growth processes. Typical approaches to analyse these experiments focus on the late-time temporal evolution of spheroid size and overlook early-time spheroid formation, spheroid structure and geometry. Here, using a range of ordinary differential equation-based mathematical models and parameter estimation, we interpret new co-culture experimental data. We provide new biological insights about spheroid formation, growth, and structure. As part of this analysis we connect Greenspan's seminal mathematical model to co-culture data for the first time. Furthermore, we generalise a class of compartment-based spheroid mathematical models that have previously been restricted to one population so they can be applied to multiple populations. As special cases of the general model, we explore multiple natural two population extensions to Greenspan's seminal model and reveal biological mechanisms that can describe the internal dynamics of growing co-culture spheroids and those that cannot. This mathematical and statistical modelling-based framework is well-suited to analyse spheroids grown with multiple different cell types and the new class of mathematical models provide opportunities for further mathematical and biological insights.

A phase-field model for non-small cell lung cancer under the effects of immunotherapy

Formulating mathematical models that estimate tumor growth under therapy is vital for improving patient-specific treatment plans. In this context, we present our recent work on simulating non-small-scale cell lung cancer (NSCLC) in a simple, deterministic setting for two different patients receiving an immunotherapeutic treatment. At its core, our model consists of a Cahn-Hilliard-based phase-field model describing the evolution of proliferative and necrotic tumor cells. These are coupled to a simplified nutrient model that drives the growth of the proliferative cells and their decay into necrotic cells. The applied immunotherapy decreases the proliferative cell concentration. Here, we model the immunotherapeutic agent concentration in the entire lung over time by an ordinary differential equation (ODE). Finally, reaction terms provide a coupling between all these equations. By assuming spherical, symmetric tumor growth and constant nutrient inflow, we simplify this full 3D cancer simulation model to a reduced 1D model. We can then resort to patient data gathered from computed tomography (CT) scans over several years to calibrate our model. Our model covers the case in which the immunotherapy is successful and limits the tumor size, as well as the case predicting a sudden relapse, leading to exponential tumor growth. Finally, we move from the reduced model back to the full 3D cancer simulation in the lung tissue. Thereby, we demonstrate the predictive benefits that a more detailed patient-specific simulation including spatial information as a possible generalization within our framework could yield in the future.

Mathematical analysis and numerical simulation for fractal-fractional cancer model

The mathematical oncology has received a lot of interest in recent years since it helps illuminate pathways and provides valuable quantitative predictions, which will shape more effective and focused future therapies. We discuss a new fractal-fractional-order model of the interaction among tumor cells, healthy host cells and immune cells. The subject of this work appears to show the relevance and ramifications of the fractal-fractional order cancer mathematical model. We use fractal-fractional derivatives in the Caputo senses to increase the accuracy of the cancer and give a mathematical analysis of the proposed model. First, we obtain a general requirement for the existence and uniqueness of exact solutions via Perov's fixed point theorem. The numerical approaches used in this paper are based on the Grünwald-Letnikov nonstandard finite difference method due to its usefulness to discretize the derivative of the fractal-fractional order. Then, two types of stabilities, Lyapunov's and Ulam-Hyers' stabilities, are established for the Incommensurate fractional-order and the Incommensurate fractal-fractional, respectively. The numerical results of this study are compatible with the theoretical analysis. Our approaches generalize some published ones because we employ the fractal-fractional derivative in the Caputo sense, which is more suitable for considering biological phenomena due to the significant memory impact of these processes. Aside from that, our findings are new in that we use Perov's fixed point result to demonstrate the existence and uniqueness of the solutions. The way of expressing the Ulam-Hyers' stabilities by utilizing the matrices that converge to zero is also novel in this area.

Gell: A GPU-powered 3D hybrid simulator for large-scale multicellular system

As a powerful but computationally intensive method, hybrid computational models study the dynamics of multicellular systems by evolving discrete cells in reacting and diffusing extracellular microenvironments. As the scale and complexity of studied biological systems continuously increase, the exploding computational cost starts to limit large-scale cell-based simulations. To facilitate the large-scale hybrid computational simulation and make it feasible on easily accessible computational devices, we develop Gell (GPU Cell), a fast and memory-efficient open-source GPU-based hybrid computational modeling platform for large-scale system modeling. We fully parallelize the simulations on GPU for high computational efficiency and propose a novel voxel sorting method to further accelerate the modeling of massive cell-cell mechanical interaction with negligible additional memory footprint. As a result, Gell efficiently handles simulations involving tens of millions of cells on a personal computer. We compare the performance of Gell with a state-of-the-art paralleled CPU-based simulator on a hanging droplet spheroid growth task and further demonstrate Gell with a ductal carcinoma in situ (DCIS) simulation. Gell affords ~150X acceleration over the paralleled CPU method with one-tenth of the memory requirement.

Morphological instability of solid tumors in a nutrient-deficient environment

A phenomenological reaction-diffusion model that includes a nutrient-regulated growth rate of tumor cells is proposed to investigate the morphological instability of solid tumors during the avascular growth. We find that the surface instability could be induced more easily when tumor cells are placed in a harsher nutrient-deficient environment, while the instability is suppressed for tumor cells in a nutrient-rich environment due to the nutrient-regulated proliferation. In addition, the surface instability is shown to be influenced by the growth moving speed of tumor rims. Our analysis reveals that a larger growth movement of the tumor front results in a closer proximity of tumor cells to a nutrient-rich region, which tends to inhibit the surface instability. A nourished length that represents the proximity is defined to illustrate its close relation to the surface instability.

Tumor Evolution Models of Phase-Field Type with Nonlocal Effects and Angiogenesis

In this survey article, a variety of systems modeling tumor growth are discussed. In accordance with the hallmarks of cancer, the described models incorporate the primary characteristics of cancer evolution. Specifically, we focus on diffusive interface models and follow the phase-field approach that describes the tumor as a collection of cells. Such systems are based on a multiphase approach that employs constitutive laws and balance laws for individual constituents. In mathematical oncology, numerous biological phenomena are involved, including temporal and spatial nonlocal effects, complex nonlinearities, stochasticity, and mixed-dimensional couplings. Using the models, for instance, we can express angiogenesis and cell-to-matrix adhesion effects. Finally, we offer some methods for numerically approximating the models and show simulations of the tumor's evolution in response to various biological effects.

The Mathematical modeling of Cancer growth and angiogenesis by an individual based interacting system

We present a mathematical model for the complex system for the growth of a solid tumor. The system embeds proliferation of cells depending on the surrounding oxygen field, hypoxia caused by insufficient oxygen when the tumor reaches a certain size, consequent VEGF release and angiogenic new vasculature growth, re-oxygenation of the tumor and subsequent tumor growth restart. Specifically cancerous cells are represented by individual units, interacting as proliferating particles of a solid body, oxygen, and VEGF are fields with a source and a sink, and new angiogenic vasculature is described by a network of growing curves. The model, as shown by numerical simulations, captures both the time-evolution of the tumor growth before and after angiogenesis and its spatial properties, with different distribution of proliferating and hypoxic cells in the external and deep layers of the tumor, and the spatial structure of the angiogenic network. The microscopic description of the growth opens the possibility of tuning the model to patient-specific scenarios.

Data-driven spatio-temporal modelling of glioblastoma

Mathematical oncology provides unique and invaluable insights into tumour growth on both the microscopic and macroscopic levels. This review presents state-of-the-art modelling techniques and focuses on their role in understanding glioblastoma, a malignant form of brain cancer. For each approach, we summarize the scope, drawbacks and assets. We highlight the potential clinical applications of each modelling technique and discuss the connections between the mathematical models and the molecular and imaging data used to inform them. By doing so, we aim to prime cancer researchers with current and emerging computational tools for understanding tumour progression. By providing an in-depth picture of the different modelling techniques, we also aim to assist researchers who seek to build and develop their own models and the associated inference frameworks. Our article thus strikes a unique balance. On the one hand, we provide a comprehensive overview of the available modelling techniques and their applications, including key mathematical expressions. On the other hand, the content is accessible to mathematicians and biomedical scientists alike to accommodate the interdisciplinary nature of cancer research.

Designing experimental conditions to use the Lotka-Volterra model to infer tumor cell line interaction types

The Lotka-Volterra model is widely used to model interactions between two species. Here, we generate synthetic data mimicking competitive, mutualistic and antagonistic interactions between two tumor cell lines, and then use the Lotka-Volterra model to infer the interaction type. Structural identifiability of the Lotka-Volterra model is confirmed, and practical identifiability is assessed for three experimental designs: (a) use of a single data set, with a mixture of both cell lines observed over time, (b) a sequential design where growth rates and carrying capacities are estimated using data from experiments in which each cell line is grown in isolation, and then interaction parameters are estimated from an experiment involving a mixture of both cell lines, and (c) a parallel experimental design where all model parameters are fitted to data from two mixtures (containing both cell lines but with different initial ratios) simultaneously. Each design is tested on data generated from the Lotka-Volterra model with noise added, to determine efficacy in an ideal sense. In addition to assessing each design for practical identifiability, we investigate how the predictive power of the model - i.e., its ability to fit data for initial ratios other than those to which it was calibrated - is affected by the choice of experimental design. The parallel calibration procedure is found to be optimal and is further tested on in silico data generated from a spatially-resolved cellular automaton model, which accounts for oxygen consumption and allows for variation in the intensity level of the interaction between the two cell lines. We use this study to highlight the care that must be taken when interpreting parameter estimates for the spatially-averaged Lotka-Volterra model when it is calibrated against data produced by the spatially-resolved cellular automaton model, since baseline competition for space and resources in the CA model may contribute to a discrepancy between the type of interaction used to generate the CA data and the type of interaction inferred by the LV model.

Bio-Mechanical Model of Osteosarcoma Tumor Microenvironment: A Porous Media Approach

Osteosarcoma is the most common malignant bone tumor in children and adolescents with a poor prognosis. To describe the progression of osteosarcoma, we expanded a system of data-driven ODE from a previous study into a system of Reaction-Diffusion-Advection (RDA) equations and coupled it with Biot equations of poroelasticity to form a bio-mechanical model. The RDA system includes the spatio-temporal information of the key components of the tumor microenvironment. The Biot equations are comprised of an equation for the solid phase, which governs the movement of the solid tumor, and an equation for the fluid phase, which relates to the motion of cells. The model predicts the total number of cells and cytokines of the tumor microenvironment and simulates the tumor's size growth. We simulated different scenarios using this model to investigate the impact of several biomedical settings on tumors' growth. The results indicate the importance of macrophages in tumors' growth. Particularly, we have observed a high co-localization of macrophages and cancer cells, and the concentration of tumor cells increases as the number of macrophages increases.

A mathematical model with aberrant growth correction in tissue homeostasis and tumor cell growth

Cancer is usually considered a genetic disease caused by alterations in genes that control cellular behaviors, especially growth and division. Cancer cells differ from normal tissue cells in many ways that allow them to grow out of control and become invasive. However, experiments have shown that aberrant growth in many tissues burdened with varying numbers of mutant cells can be corrected, and wild-type cells are required for the active elimination of mutant cells. These findings reveal the dynamic cellular behaviors that lead to a tissue homeostatic state when faced with mutational and nonmutational insults. The current study was motivated by these observations and established a mathematical model of how a tissue copes with the aberrant behavior of mutant cells. The proposed model depicts the interaction between wild-type and mutant cells through a system of two delay differential equations, which include the random mutation of normal cells and the active extrusion of mutant cells. Based on the proposed model, we performed qualitative analysis to identify the conditions of either normal tissue homeostasis or uncontrolled growth with varying numbers of abnormal mutant cells. Bifurcation analysis suggests the conditions of bistability with either a small or large number of mutant cells, the coexistence of bistable steady states can be clinically beneficial by driving the state of mutant cell predominance to the attraction basin of the state with a low number of mutant cells. This result is further confirmed by the treatment strategy obtained from optimal control theory.

A Spatially Resolved Mechanistic Growth Law for Cancer Drug Development Predicting Tumor Growing Fractions

Mathematical models used in preclinical drug discovery tend to be empirical growth laws. Such models are well suited to fitting the data available, mostly longitudinal studies of tumor volume; however, they typically have little connection with the underlying physiologic processes. This lack of a mechanistic underpinning restricts their flexibility and potentially inhibits their translation across studies including from animal to human. Here we present a mathematical model describing tumor growth for the evaluation of single-agent cytotoxic compounds that is based on mechanistic principles. The model can predict spatial distributions of cell subpopulations and account for spatial drug distribution effects within tumors. Importantly, we demonstrate that the model can be reduced to a growth law similar in form to the ones currently implemented in pharmaceutical drug development for preclinical trials so that it can integrated into the current workflow. We validate this approach for both cell-derived xenograft and patient-derived xenograft (PDX) data. This shows that our theoretical model fits as well as the best performing and most widely used models. However, in addition, the model is also able to accurately predict the observed growing fraction of tumours. Our work opens up current preclinical modeling studies to also incorporating spatially resolved and multimodal data without significant added complexity and creates the opportunity to improve translation and tumor response predictions.

Significance

This theoretical model has the same mathematical structure as that currently used for drug development. However, its mechanistic basis enables prediction of growing fraction and spatial variations in drug distribution.

Tumor growth towards lower extracellular matrix conductivity regions under Darcy's Law and steady morphology

We study a classic Darcy's law model for tumor cell motion with inhomogeneous and isotropic conductivity. The tumor cells are assumed to be a constant density fluid flowing through porous extracellular matrix (ECM). The ECM is assumed to be rigid and motionless with constant porosity. One and two dimensional simulations show that the tumor mass grows from high to low conductivity regions when the tumor morphology is steady. In the one-dimensional case, we proved that when the tumor size is steady, the tumor grows towards lower conductivity regions. We conclude that this phenomenon is produced by the coupling of a special inward flow pattern in the steady tumor and Darcy's law which gives faster flow speed in higher conductivity regions.

The force of cell-cell adhesion in determining the outcome in a nonlocal advection diffusion model of wound healing

A model of wound healing is presented to investigate the connection of the force of cell-cell adhesion to the sensing radius of cells in their spatial environment. The model consists of a partial differential equation with nonlocal advection and diffusion terms, describing the movement of cells in a spatial environment. The model is applied to biological wound healing experiments to understand incomplete wound closure. The analysis demonstrates that for each value of the force of adhesion parameter, there is a critical value of the sensing radius above which complete wound healing does not occur.

Mathematical modeling of radiotherapy and its impact on tumor interactions with the immune system

Radiotherapy is a primary therapeutic modality widely utilized with curative intent. Traditionally tumor response was hypothesized to be due to high levels of cell death induced by irreparable DNA damage. However, the immunomodulatory aspect of radiation is now widely accepted. As such, interest into the combination of radiotherapy and immunotherapy is increasing, the synergy of which has the potential to improve tumor regression beyond that observed after either treatment alone. However, questions regarding the timing (sequential vs concurrent) and dose fractionation (hyper-, standard-, or hypo-fractionation) that result in improved anti-tumor immune responses, and thus potentially enhanced tumor inhibition, remain. Here we discuss the biological response to radiotherapy and its immunomodulatory properties before giving an overview of pre-clinical data and clinical trials concerned with answering these questions. Finally, we review published mathematical models of the impact of radiotherapy on tumor-immune interactions. Ranging from considering the impact of properties of the tumor microenvironment on the induction of anti-tumor responses, to the impact of choice of radiation site in the setting of metastatic disease, these models all have an underlying feature in common: the push towards personalized therapy.

Supporting Computational Apprenticeship Through Educational and Software Infrastructure: A Case Study in a Mathematical Oncology Research Lab

There is growing awareness of the need for mathematics and computing to quantitatively understand the complex dynamics and feedbacks in the life sciences. Although several institutions and research groups are conducting pioneering multidisciplinary research, communication and education across fields remain a bottleneck. The opportunity is ripe for using education research-supported mechanisms of cross-disciplinary training at the intersection of mathematics, computation, and biology. This case study uses the computational apprenticeship theoretical framework to describe the efforts of a computational biology lab to rapidly prototype, test, and refine a mentorship infrastructure for undergraduate research experiences. We describe the challenges, benefits, and lessons learned, as well as the utility of the computational apprenticeship framework in supporting computational/math students learning and contributing to biology, and biologists in learning computational methods. We also explore implications for undergraduate classroom instruction and cross-disciplinary scientific communication.

In Vitro, In Vivo, and In Silico Models of Lymphangiogenesis in Solid Malignancies

Lymphangiogenesis (LA) is the formation of new lymphatic vessels by lymphatic endothelial cells (LECs) sprouting from pre-existing lymphatic vessels. It is increasingly recognized as being involved in many diseases, such as in cancer and secondary lymphedema, which most often results from cancer treatments. For some cancers, excessive LA is associated with cancer progression and metastatic dissemination to the lymph nodes (LNs) through lymphatic vessels. The study of LA through in vitro, in vivo, and, more recently, in silico models is of paramount importance in providing novel insights and identifying the key molecular actors in the biological dysregulation of this process under pathological conditions. In this review, the different biological (in vitro and in vivo) models of LA, especially in a cancer context, are explained and discussed, highlighting their principal modeled features as well as their advantages and drawbacks. Imaging techniques of the lymphatics, complementary or even essential to in vivo models, are also clarified and allow the establishment of the link with computational approaches. In silico models are introduced, theoretically described, and illustrated with examples specific to the lymphatic system and the LA. Together, these models constitute a toolbox allowing the LA research to be brought to the next level.

A continuum mechanical framework for modeling tumor growth and treatment in two- and three-phase systems

The growth and treatment of tumors is an important problem to society that involves the manifestation of cellular phenomena at length scales on the order of centimeters. Continuum mechanical approaches are being increasingly used to model tumors at the largest length scales of concern. The issue of how to best connect such descriptions to smaller-scale descriptions remains open. We formulate a framework to derive macroscale models of tumor behavior using the thermodynamically constrained averaging theory (TCAT), which provides a firm connection with the microscale and constraints on permissible forms of closure relations. We build on developments in the porous medium mechanics literature to formulate fundamental entropy inequality expressions for a general class of three-phase, compositional models at the macroscale. We use the general framework derived to formulate two classes of models, a two-phase model and a three-phase model. The general TCAT framework derived forms the basis for a wide range of potential models of varying sophistication, which can be derived, approximated, and applied to understand not only tumor growth but also the effectiveness of various treatment modalities.

Optimal chemotherapy counteracts cancer adaptive resistance in a cell-based, spatially-extended, evolutionary model

Most aggressive cancers are incurable due to their fast evolution of drug resistance. We model cancer growth and adaptive response in a simplified cell-based (CB) setting, assuming a genetic resistance to two chemotherapeutic drugs. We show that optimal administration protocols can steer cells resistance and turned it into a weakness for the disease. Our work extends the population-based (PB) model proposed by Orlando et al. (Physical Biology, 2012), in which a homogeneous population of cancer cells evolves according to a fitness landscape. The landscape models three types of trade-offs, differing on whether the cells are more, less, or equal effective when generalizing resistance to two drugs as opposed to specializing to a single one. The CB framework allows us to include genetic heterogeneity, spatial competition, and drugs diffusion, as well as realistic administration protocols. By calibrating our model on Orlando et al.'s assumptions, we show that dynamical protocols that alternate the two drugs minimize the cancer size at the end of (or at mid-points during) treatment. These results significantly differ from those obtained with the homogeneous model---suggesting static protocols under the pro-generalizing and neutral allocation trade-offs---highlighting the important role of spatial and genetic heterogeneities. Our work is the first attempt to search for optimal treatments in a CB setting, a step forward toward realistic clinical applications.

Mathematical modeling of therapeutic neural stem cell migration in mouse brain with and without brain tumors

Neural stem cells (NSCs) offer a potential solution to treating brain tumors. This is because NSCs can circumvent the blood-brain barrier and migrate to areas of damage in the central nervous system, including tumors, stroke, and wound injuries. However, for successful clinical application of NSC treatment, a sufficient number of viable cells must reach the diseased or damaged area(s) in the brain, and evidence suggests that it may be affected by the paths the NSCs take through the brain, as well as the locations of tumors. To study the NSC migration in brain, we develop a mathematical model of therapeutic NSC migration towards brain tumor, that provides a low cost platform to investigate NSC treatment efficacy. Our model is an extension of the model developed in Rockne et al. (PLoS ONE 13, e0199967, 2018) that considers NSC migration in non-tumor bearing naive mouse brain. Here we modify the model in Rockne et al. in three ways: (i) we consider three-dimensional mouse brain geometry, (ii) we add chemotaxis to model the tumor-tropic nature of NSCs into tumor sites, and (iii) we model stochasticity of migration speed and chemosensitivity. The proposed model is used to study migration patterns of NSCs to sites of tumors for different injection strategies, in particular, intranasal and intracerebral delivery. We observe that intracerebral injection results in more NSCs arriving at the tumor site(s), but the relative fraction of NSCs depends on the location of injection relative to the target site(s). On the other hand, intranasal injection results in fewer NSCs at the tumor site, but yields a more even distribution of NSCs within and around the target tumor site(s).

A phenotype-structured model to reproduce the avascular growth of a tumor and its interaction with the surrounding environment

We here propose a one-dimensional spatially explicit phenotype-structured model to analyze selected aspects of avascular tumor progression. In particular, our approach distinguishes viable and necrotic cell fractions. The metabolically active part of the disease is, in turn, differentiated according to a continuous trait, that identifies cell variants with different degrees of motility and proliferation potential. A parabolic partial differential equation (PDE) then governs the spatio-temporal evolution of the phenotypic distribution of active cells within the host tissue. In this respect, active tumor agents are allowed to duplicate, move upon haptotactic and pressure stimuli, and eventually undergo necrosis. The mutual influence between the emerging malignancy and its environment (in terms of molecular landscape) is implemented by coupling the evolution law of the viable tumor mass with a parabolic PDE for oxygen kinetics and a differential equation that accounts for local consumption of extracellular matrix (ECM) elements. The resulting numerical realizations reproduce tumor growth and invasion in a number scenarios that differ for cell properties (i.e., individual migratory behavior, duplication and mutation potential) and environmental conditions (i.e., level of tissue oxygenation and homogeneity in the initial matrix profile). In particular, our simulations show that, in all cases, more mobile cell variants occupy the front edge of the tumor, whereas more proliferative clones are selected at the more internal regions. A necrotic core constantly occupies the bulk of the mass due to nutrient deprivation. This work may eventually suggest some biomedical strategies to partially reduce tumor aggressiveness, i.e., to enhance necrosis of malignant tissue and to promote the presence of more proliferative cell phenotypes over more invasive ones.

Derivation of continuum models from discrete models of mechanical forces in cell populations

In certain discrete models of populations of biological cells, the mechanical forces between the cells are center based or vertex based on the microscopic level where each cell is individually represented. The cells are circular or spherical in a center based model and polygonal or polyhedral in a vertex based model. On a higher, macroscopic level, the time evolution of the density of the cells is described by partial differential equations (PDEs). We derive relations between the modelling on the micro and macro levels in one, two, and three dimensions by regarding the micro model as a discretization of a PDE for conservation of mass on the macro level. The forces in the micro model correspond on the macro level to a gradient of the pressure scaled by quantities depending on the cell geometry. The two levels of modelling are compared in numerical experiments in one and two dimensions.

Bayesian inference of a non-local proliferation model

From a systems biology perspective, the majority of cancer models, although interesting and providing a qualitative explanation of some problems, have a major disadvantage in that they usually miss a genuine connection with experimental data. Having this in mind, in this paper, we aim at contributing to the improvement of many cancer models which contain a proliferation term. To this end, we propose a new non-local model of cell proliferation. We select data that are suitable to perform Bayesian inference for unknown parameters and we provide a discussion on the range of applicability of the model. Furthermore, we provide proof of the stability of posterior distributions in total variation norm which exploits the theory of spaces of measures equipped with the weighted flat norm. In a companion paper, we provide detailed proof of the well-posedness of the problem and we investigate the convergence of the escalator boxcar train (EBT) algorithm applied to solve the equation.

Tumor-immune ecosystem dynamics define an individual Radiation Immune Score to predict pan-cancer radiocurability

Radiotherapy efficacy is the result of radiation-mediated cytotoxicity coupled with stimulation of antitumor immune responses. We develop an in silico 3-dimensional agent-based model of diverse tumor-immune ecosystems (TIES) represented as anti- or pro-tumor immune phenotypes. We validate the model in 10,469 patients across 31 tumor types by demonstrating that clinically detected tumors have pro-tumor TIES. We then quantify the likelihood radiation induces antitumor TIES shifts toward immune-mediated tumor elimination by developing the individual Radiation Immune Score (iRIS). We show iRIS distribution across 31 tumor types is consistent with the clinical effectiveness of radiotherapy, and in combination with a molecular radiosensitivity index (RSI) combines to predict pan-cancer radiocurability. We show that iRIS correlates with local control and survival in a separate cohort of 59 lung cancer patients treated with radiation. In combination, iRIS and RSI predict radiation-induced TIES shifts in individual patients and identify candidates for radiation de-escalation and treatment escalation. This is the first clinically and biologically validated computational model to simulate and predict pan-cancer response and outcomes via the perturbation of the TIES by radiotherapy.

Experimental Validation of a Mathematical Model to Describe the Drug Cytotoxicity of Leukemic Cells

Chlorambucil (Chl), Melphalan (Mel), and Cytarabine (Cyt) are recognized drugs used in the chemotherapy of patients with advanced Chronic Lymphocytic Leukemia (CLL). The optimal treatment schedule and timing of Chl, Mel, and Cyt administration remains unknown and has traditionally been decided empirically and independently of preclinical in vitro efficacy studies. As a first step toward mathematical prediction of in vivo drug efficacy from in vitro cytotoxicity studies, we used murine A20 leukemic cells as a test case of CLL. We first found that logistic growth best described the proliferation of the cells in vitro. Then, we tested in vitro the cytotoxic efficacy of Chl, Mel, and Cyt against A20 cells. On the basis of these experimental data, we found the parameters for cancer cell death rates that were dependent on the concentration of the respective drugs and developed a mathematical model involving nonlinear ordinary differential equations. For the proposed mathematical model, three equilibrium states were analyzed using the general method of Lyapunov, with only one equilibrium being stable. We obtained a very good symmetry between the experimental results and numerical simulations of the model. Our novel model can be used as a general tool to study the cytotoxic activity of various drugs with different doses and modes of action by appropriate adjustment of the values for the selected parameters.

A computational model of glioma reveals opposing, stiffness-sensitive effects of leaky vasculature and tumor growth on tissue mechanical stress and porosity

A biphasic computational model of a growing, vascularized glioma within brain tissue was developed to account for unique features of gliomas, including soft surrounding brain tissue, their low stiffness relative to brain tissue, and a lack of draining lymphatics. This model is the first to couple nonlinear tissue deformation with porosity and tissue hydraulic conductivity to study the mechanical interaction of leaky vasculature and solid growth in an embedded glioma. The present model showed that leaky vasculature and elevated interstitial fluid pressure produce tensile stress within the tumor in opposition to the compressive stress produced by tumor growth. This tensile effect was more pronounced in softer tissue and resulted in a compressive stress concentration at the tumor rim that increased when tumor was softer than host. Aside from generating solid stress, fluid pressure-driven tissue deformation decreased the effective stiffness of the tumor while growth increased it, potentially leading to elevated stiffness in the tumor rim. A novel prediction of reduced porosity at the tumor rim was corroborated by direct comparison with estimates from our in vivo imaging studies. Antiangiogenic and radiation therapy were simulated by varying vascular leakiness and tissue hydraulic conductivity. These led to greater solid compression and interstitial pressure in the tumor, respectively, the former of which may promote tumor infiltration of the host. Our findings suggest that vascular leakiness has an important influence on in vivo solid stress, stiffness, and porosity fields in gliomas given their unique mechanical microenvironment.

Investigating Optimal Chemotherapy Options for Osteosarcoma Patients through a Mathematical Model

Simple Summary

Osteosarcoma is a rare type of cancer with poor prognoses. However, to the best of our knowledge, there are no mathematical models that study the impact of chemotherapy treatments on the osteosarcoma microenvironment. In this study, we developed a data driven mathematical model to analyze the dynamics of the important players in three groups of osteosarcoma tumors with distinct immune patterns in the presence of the most common chemotherapy drugs. The results indicate that the treatments’ start times and optimal dosages depend on the unique growth rate of the tumor, which implies the necessity of personalized medicine. Furthermore, the developed model can be extended by others to build models that can recommend individual-specific optimal dosages.

Abstract

Since all tumors are unique, they may respond differently to the same treatments. Therefore, it is necessary to study their characteristics individually to find their best treatment options. We built a mathematical model for the interactions between the most common chemotherapy drugs and the osteosarcoma microenvironments of three clusters of tumors with unique immune profiles. We then investigated the effects of chemotherapy with different treatment regimens and various treatment start times on the behaviors of immune and cancer cells in each cluster. Saliently, we suggest the optimal drug dosages for the tumors in each cluster. The results show that abundances of dendritic cells and HMGB1 increase when drugs are given and decrease when drugs are absent. Populations of helper T cells, cytotoxic cells, and IFN-γ grow, and populations of cancer cells and other immune cells shrink during treatment. According to the model, the MAP regimen does a good job at killing cancer, and is more effective than doxorubicin and cisplatin combined or methotrexate alone. The results also indicate that it is important to consider the tumor’s unique growth rate when deciding the treatment details, as fast growing tumors need early treatment start times and high dosages.

Digital twinning of Cellular Capsule Technology: Emerging outcomes from the perspective of porous media mechanics

Spheroids encapsulated within alginate capsules are emerging as suitable in vitro tools to investigate the impact of mechanical forces on tumor growth since the internal tumor pressure can be retrieved from the deformation of the capsule. Here we focus on the particular case of Cellular Capsule Technology (CCT). We show in this contribution that a modeling approach accounting for the triphasic nature of the spheroid (extracellular matrix, tumor cells and interstitial fluid) offers a new perspective of analysis revealing that the pressure retrieved experimentally cannot be interpreted as a direct picture of the pressure sustained by the tumor cells and, as such, cannot therefore be used to quantify the critical pressure which induces stress-induced phenotype switch in tumor cells. The proposed multiphase reactive poro-mechanical model was cross-validated. Parameter sensitivity analyses on the digital twin revealed that the main parameters determining the encapsulated growth configuration are different from those driving growth in free condition, confirming that radically different phenomena are at play. Results reported in this contribution support the idea that multiphase reactive poro-mechanics is an exceptional theoretical framework to attain an in-depth understanding of CCT experiments, to confirm their hypotheses and to further improve their design.

A mathematical framework for modelling 3D cell motility: applications to glioblastoma cell migration

The collection of 3D cell tracking data from live images of micro-tissues is a recent innovation made possible due to advances in imaging techniques. As such there is increased interest in studying cell motility in 3D in vitro model systems but a lack of rigorous methodology for analysing the resulting data sets. One such instance of the use of these in vitro models is in the study of cancerous tumours. Growing multicellular tumour spheroids in vitro allows for modelling of the tumour microenvironment and the study of tumour cell behaviours, such as migration, which improves understanding of these cells and in turn could potentially improve cancer treatments. In this paper, we present a workflow for the rigorous analysis of 3D cell tracking data, based on the persistent random walk model, but adaptable to other biologically informed mathematical models. We use statistical measures to assess the fit of the model to the motility data and to estimate model parameters and provide confidence intervals for those parameters, to allow for parametrization of the model taking correlation in the data into account. We use in silico simulations to validate the workflow in 3D before testing our method on cell tracking data taken from in vitro experiments on glioblastoma tumour cells, a brain cancer with a very poor prognosis. The presented approach is intended to be accessible to both modellers and experimentalists alike in that it provides tools for uncovering features of the data set that may suggest amendments to future experiments or modelling attempts.

Data Driven Mathematical Model of FOLFIRI Treatment for Colon Cancer

Many colon cancer patients show resistance to their treatments. Therefore, it is important to consider unique characteristic of each tumor to find the best treatment options for each patient. In this study, we develop a data driven mathematical model for interaction between the tumor microenvironment and FOLFIRI drug agents in colon cancer. Patients are divided into five distinct clusters based on their estimated immune cell fractions obtained from their primary tumors' gene expression data. We then analyze the effects of drugs on cancer cells and immune cells in each group, and we observe different responses to the FOLFIRI drugs between patients in different immune groups. For instance, patients in cluster 3 with the highest T-reg/T-helper ratio respond better to the FOLFIRI treatment, while patients in cluster 2 with the lowest T-reg/T-helper ratio resist the treatment. Moreover, we use ROC curve to validate the model using the tumor status of the patients at their follow up, and the model predicts well for the earlier follow up days.

In Silico Mathematical Modelling for Glioblastoma: A Critical Review and a Patient-Specific Case

Glioblastoma extensively infiltrates the brain; despite surgery and aggressive therapies, the prognosis is poor. A multidisciplinary approach combining mathematical, clinical and radiological data has the potential to foster our understanding of glioblastoma evolution in every single patient, with the aim of tailoring therapeutic weapons. In particular, the ultimate goal of biomathematics for cancer is the identification of the most suitable theoretical models and simulation tools, both to describe the biological complexity of carcinogenesis and to predict tumor evolution. In this report, we describe the results of a critical review about different mathematical models in neuro-oncology with their clinical implications. A comprehensive literature search and review for English-language articles concerning mathematical modelling in glioblastoma has been conducted. The review explored the different proposed models, classifying them and indicating the significative advances of each one. Furthermore, we present a specific case of a glioblastoma patient in which our recently proposed innovative mechanical model has been applied. The results of the mathematical models have the potential to provide a relevant benefit for clinicians and, more importantly, they might drive progress towards improving tumor control and patient's prognosis. Further prospective comparative trials, however, are still necessary to prove the impact of mathematical neuro-oncology in clinical practice.

Data-Driven Mathematical Model of Osteosarcoma

As the immune system has a significant role in tumor progression, in this paper, we develop a data-driven mathematical model to study the interactions between immune cells and the osteosarcoma microenvironment. Osteosarcoma tumors are divided into three clusters based on their relative abundance of immune cells as estimated from their gene expression profiles. We then analyze the tumor progression and effects of the immune system on cancer growth in each cluster. Cluster 3, which had approximately the same number of naive and M2 macrophages, had the slowest tumor growth, and cluster 2, with the highest population of naive macrophages, had the highest cancer population at the steady states. We also found that the fastest growth of cancer occurred when the anti-tumor immune cells and cytokines, including dendritic cells, helper T cells, cytotoxic cells, and IFN-γ, switched from increasing to decreasing, while the dynamics of regulatory T cells switched from decreasing to increasing. Importantly, the most impactful immune parameters on the number of cancer and total cells were the activation and decay rates of the macrophages and regulatory T cells for all clusters. This work presents the first osteosarcoma progression model, which can be later extended to investigate the effectiveness of various osteosarcoma treatments.

An Unbiased Predictive Model to Detect DNA Methylation Propensity of CpG Islands in the Human Genome

Background:

Epigenetic repression mechanisms play an important role in gene regulation, specifically in cancer development. In many cases, a CpG island’s (CGI) susceptibility or resistance to methylation is shown to be contributed by local DNA sequence features.

Objective:

To develop unbiased machine learning models–individually and combined for different biological features–that predict the methylation propensity of a CGI.

Methods:

We developed our model consisting of CGI sequence features on a dataset of 75 sequences (28 prone, 47 resistant) representing a genome-wide methylation structure. We tested our model on two independent datasets that are chromosome (132 sequences) and disease (70 sequences) specific.

Results:

We provided improvements in prediction accuracy over previous models. Our results indicate that combined features better predict the methylation propensity of a CGI (area under the curve (AUC) ~0.81). Our global methylation classifier performs well on independent datasets reaching an AUC of ~0.82 for the complete model and an AUC of ~0.88 for the model using select sequences that better represent their classes in the training set. We report certain de novo motifs and transcription factor binding site (TFBS) motifs that are consistently better in separating prone and resistant CGIs.

Conclusion:

Predictive models for the methylation propensity of CGIs lead to a better understanding of disease mechanisms and can be used to classify genes based on their tendency to contain methylation prone CGIs, which may lead to preventative treatment strategies. MATLAB® and Python™ scripts used for model building, prediction, and downstream analyses are available at https://github.com/dicleyalcin/methylProp_predictor.

Remote control of magnetic nanocomplexes for delivery and destruction of cancer cells

Although nanotechnology advances have been exploited for a myriad of purposes, including cancer diagnostics and treatment, still there is little discussion about the mechanisms of remote control. Our main aim here is to explain the possibility of a magnetic field control over magnetic nanocomplexes to improve their delivery, controlled release and antitumor activity. In doing so we considered the nonlinear dynamics of magnetomechanical and magnetochemical effects based on free radical mechanisms in cancer development for future pre-clinical studies.

Modelling cell guidance and curvature control in evolving biological tissues

Tissue geometry is an important influence on the evolution of many biological tissues. The local curvature of an evolving tissue induces tissue crowding or spreading, which leads to differential tissue growth rates, and to changes in cellular tension, which can influence cell behaviour. Here, we investigate how directed cell motion interacts with curvature control in evolving biological tissues. Directed cell motion is involved in the generation of angled tissue growth and anisotropic tissue material properties, such as tissue fibre orientation. We develop a new cell-based mathematical model of tissue growth that includes both curvature control and cell guidance mechanisms to investigate their interplay. The model is based on conservation principles applied to the density of tissue synthesising cells at or near the tissue's moving boundary. The resulting mathematical model is a partial differential equation for cell density on a moving boundary, which is solved numerically using a hybrid front-tracking method called the cell-based particle method. The inclusion of directed cell motion allows us to model new types of biological growth, where tangential cell motion is important for the evolution of the interface, or for the generation of anisotropic tissue properties. We illustrate such situations by applying the model to simulate both the resorption and infilling components of the bone remodelling process, and to simulate root hair growth. We also provide user-friendly MATLAB code to implement the algorithms.

Hybrid models of chemotaxis with application to leukocyte migration

Many chemical and biological systems involve reacting species with vastly different numbers of molecules/agents. Hybrid simulations model such phenomena by combining discrete (e.g., agent-based) and continuous (e.g., partial differential equation- or PDE-based) descriptors of the dynamics of reactants with small and large numbers of molecules/agents, respectively. We present a stochastic hybrid algorithm to model a stage of the immune response to inflammation, during which leukocytes reach a pathogen via chemotaxis. While large numbers of chemoattractant molecules justify the use of a PDE-based model to describe the spatiotemporal evolution of its concentration, relatively small numbers of leukocytes and bacteria involved in the process undermine the veracity of their continuum treatment by masking the effects of stochasticity and have to be treated discretely. Motility and interactions between leukocytes and bacteria are modeled via random walk and a stochastic simulation algorithm, respectively. Since the latter assumes the reacting species to be well mixed, the discrete component of our hybrid algorithm deploys stochastic operator splitting, in which the sequence of the diffusion and reaction operations is determined autonomously during each simulation step. We conduct a series of numerical experiments to ascertain the accuracy and computational efficiency of our hybrid simulations and, then, to demonstrate the importance of randomness for predicting leukocyte migration and fate during the immune response to inflammation.

Fractional Mathematical Oncology: On the potential of non-integer order calculus applied to interdisciplinary models

Mathematical Oncology investigates cancer-related phenomena through mathematical models as comprehensive as possible. Accordingly, an interdisciplinary approach involving concepts from biology to materials science can provide a deeper understanding of biological systems pertaining the disease. In this context, fractional calculus (also referred to as non-integer order) is a branch in mathematical analysis whose tools can describe complex phenomena comprising different time and space scales. Fractional-order models may allow a better description and understanding of oncological particularities, potentially contributing to decision-making in areas of interest such as tumor evolution, early diagnosis techniques and personalized treatment therapies. By following a phenomenological (i.e. mechanistic) approach, the present study surveys and explores different aspects of Fractional Mathematical Oncology, reviewing and discussing recent developments in view of their prospective applications.

Impact of tumor-parenchyma biomechanics on liver metastatic progression: a multi-model approach

Colorectal cancer and other cancers often metastasize to the liver in later stages of the disease, contributing significantly to patient death. While the biomechanical properties of the liver parenchyma (normal liver tissue) are known to affect tumor cell behavior in primary and metastatic tumors, the role of these properties in driving or inhibiting metastatic inception remains poorly understood, as are the longer-term multicellular dynamics. This study adopts a multi-model approach to study the dynamics of tumor-parenchyma biomechanical interactions during metastatic seeding and growth. We employ a detailed poroviscoelastic model of a liver lobule to study how micrometastases disrupt flow and pressure on short time scales. Results from short-time simulations in detailed single hepatic lobules motivate constitutive relations and biological hypotheses for a minimal agent-based model of metastatic growth in centimeter-scale tissue over months-long time scales. After a parameter space investigation, we find that the balance of basic tumor-parenchyma biomechanical interactions on shorter time scales (adhesion, repulsion, and elastic tissue deformation over minutes) and longer time scales (plastic tissue relaxation over hours) can explain a broad range of behaviors of micrometastases, without the need for complex molecular-scale signaling. These interactions may arrest the growth of micrometastases in a dormant state and prevent newly arriving cancer cells from establishing successful metastatic foci. Moreover, the simulations indicate ways in which dormant tumors could "reawaken" after changes in parenchymal tissue mechanical properties, as may arise during aging or following acute liver illness or injury. We conclude that the proposed modeling approach yields insight into the role of tumor-parenchyma biomechanics in promoting liver metastatic growth, and advances the longer term goal of identifying conditions to clinically arrest and reverse the course of late-stage cancer.