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The use of radiosensitizing agents in the therapy of glioblastoma multiforme-a comprehensive review. Strahlenther Onkol 2022; 198:507-526. [PMID: 35503461 PMCID: PMC9165247 DOI: 10.1007/s00066-022-01942-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/30/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Glioblastoma is the most common malignant brain tumor in human adults. Despite several improvements in resective as well as adjuvant therapy over the last decades, its overall prognosis remains poor. As a means of improving patient outcome, the possibility of enhancing radiation response by using radiosensitizing agents has been tested in an array of studies. METHODS A comprehensive review of clinical trials involving radiation therapy in combination with radiosensitizing agents on patients diagnosed with glioblastoma was performed in the National Center for Biotechnology Information's PubMed database. RESULTS A total of 96 papers addressing this matter were published between 1976 and 2021, of which 63 matched the subject of this paper. All papers were reviewed, and their findings discussed in the context of their underlining mechanisms of radiosensitization. CONCLUSION In the history of glioblastoma treatment, several approaches of optimizing radiation-effectiveness using radiosensitizers have been made. Even though several different strategies and agents have been explored, clear evidence of improved patient outcome is still missing. Tissue-selectiveness and penetration of the blood-brain barrier seem to be major roadblocks; nevertheless, modern strategies try to circumvent these obstacles, using novel sensitizers based on preclinical data or alternative ways of delivery.
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Ni XR, Guo CC, Yu YJ, Yu ZH, Cai HP, Wu WC, Ma JX, Chen FR, Wang J, Chen ZP. Combination of levetiracetam and IFN-α increased temozolomide efficacy in MGMT-positive glioma. Cancer Chemother Pharmacol 2020; 86:773-782. [PMID: 33074386 DOI: 10.1007/s00280-020-04169-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/06/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE Glioma, especially glioblastoma (GBM), is the most aggressive malignant brain tumor and its standard therapy is often ineffective because of temozolomide (TMZ) resistance. Reversal of the TMZ resistance might improve the prognosis of glioma patients. We previously found that interferon-α (IFN-α) and anti-epileptic drug levetiracetam (LEV) could sensitize glioma to TMZ, respectively. In this study, we further investigated the efficiency of combining of LEV and IFN-α for improving the efficacy of TMZ. METHODS We evaluated whether LEV and IFN-α could increase TMZ efficacy using colony formation assay and cell viability assay with MGMT-positive and MGMT-negative glioma cell lines in vitro. Subcutaneous xenografts and orthotopic xenografts mice models were used in vivo to observe the tumor growth and mice survival upon treatments with TMZ, TMZ + IFN-α, TMZ + LEV, or TMZ + LEV + IFN-α. The expression levels of MGMT, markers of pro-apoptotic and anti-apoptotic in tumor samples were analyzed by Western blotting. RESULTS The combinational use of IFN-α, LEV, and TMZ showed the best anti-tumor activity in MGMT-positive cell lines (U138, GSC-1, U118, and T98 G). TMZ + LEV + IFN-α further obviously increased TMZ + LEV or TMZ + IFN-α efficiency in MGMT-positive cell lines, while not in negative cell lines (SKMG-4, U87, U373, and U251) in vitro, which were also observed in subcutaneous mice models (U138, GSC-1 compared to SKMG-4, U87) and orthotopic models (GSC-1) in vivo. Strikingly, the combination of LEV and IFN-α together with TMZ significantly prolonged the survival of mice with orthotopic GSC-1 glioma. Furthermore, we confirmed that the combination of LEV and IFN-α enhanced the inhibition of MGMT and the activation of apoptosis in U138 tumor on the basis of TMZ treatment. CONCLUSIONS The combination use of LEV and IFN-α could be an optimal method to overcome TMZ resistance through obvious MGMT inhibition in MGMT-positive glioma.
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Affiliation(s)
- Xiang-Rong Ni
- Department of Neurosurgery/Neuro-Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Rd East, Guangdong, 510060, People's Republic of China
| | - Cheng-Cheng Guo
- Department of Neurosurgery/Neuro-Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Rd East, Guangdong, 510060, People's Republic of China
| | - Yan-Jiao Yu
- Department of Neurosurgery/Neuro-Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Rd East, Guangdong, 510060, People's Republic of China
| | - Zhi-Hui Yu
- Department of Neurosurgery/Neuro-Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Rd East, Guangdong, 510060, People's Republic of China
| | - Hai-Ping Cai
- Department of Neurosurgery/Neuro-Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Rd East, Guangdong, 510060, People's Republic of China
| | - Wei-Chi Wu
- Department of Neurosurgery/Neuro-Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Rd East, Guangdong, 510060, People's Republic of China
| | - Jun-Xiao Ma
- Department of Neurosurgery/Neuro-Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Rd East, Guangdong, 510060, People's Republic of China
| | - Fu-Rong Chen
- Department of Neurosurgery/Neuro-Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Rd East, Guangdong, 510060, People's Republic of China
| | - Jing Wang
- Department of Neurosurgery/Neuro-Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Rd East, Guangdong, 510060, People's Republic of China.
| | - Zhong-Ping Chen
- Department of Neurosurgery/Neuro-Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng Rd East, Guangdong, 510060, People's Republic of China.
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Goedegebuure RSA, Vonk C, Kooij LP, Derks S, Thijssen VLJL. Combining Radiation Therapy With Interferons: Back to the Future. Int J Radiat Oncol Biol Phys 2020; 108:56-69. [PMID: 32068114 DOI: 10.1016/j.ijrobp.2020.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 12/27/2022]
Abstract
Radiation therapy has been linked to the induction of an intratumoral type I interferon (IFN) response, which positively affects the response to treatment. This has spiked the interest to combine radiation therapy with IFN-based treatment. Interestingly, this combination treatment has been considered previously, since preclinical studies demonstrated a radiosensitizing effect of interferons. As a result, multiple clinical trials have been performed combining radiation therapy with interferons in different tumor types. Although potential benefit has been suggested, the outcomes of the trials are diverse and challenging to interpret. In addition, increased grade ≥3 toxicity frequently resulted in a negative recommendation regarding the combination therapy. The latter appears premature because many studies were small and several aspects of the combination treatment have not yet been sufficiently explored to justify such a definite conclusion. This review summarizes the available literature on this combination therapy, with a focus on IFN-α and IFN-β. Based on preclinical studies and clinical trials, we evaluated the potential opportunities and describe the current challenges. In addition, we identify several issues that should be addressed to fully exploit the potential benefit of this combinatorial treatment approach.
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Affiliation(s)
- Ruben S A Goedegebuure
- Amsterdam UMC, location VUmc, Medical Oncology, Cancer Center Amsterdam, Amsterdam, The Netherlands; Oncode Institute, Utrecht, The Netherlands
| | - Christian Vonk
- Amsterdam UMC, location VUmc, Radiation Oncology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Laura P Kooij
- Amsterdam UMC, location VUmc, Radiation Oncology, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Sarah Derks
- Amsterdam UMC, location VUmc, Medical Oncology, Cancer Center Amsterdam, Amsterdam, The Netherlands; Oncode Institute, Utrecht, The Netherlands
| | - Victor L J L Thijssen
- Amsterdam UMC, location VUmc, Medical Oncology, Cancer Center Amsterdam, Amsterdam, The Netherlands; Amsterdam UMC, location VUmc, Radiation Oncology, Cancer Center Amsterdam, Amsterdam, The Netherlands.
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Bello-Rivero I, Garcia-Vega Y, Duncan-Roberts Y, Vazquez-Blomquistc D, Santana-Milian H, Besada-Perez V, Rios-Cabrera M. HeberFERON, a new formulation of IFNs with improved pharmacodynamics: Perspective for cancer treatment. Semin Oncol 2018; 45:27-33. [PMID: 30318081 DOI: 10.1053/j.seminoncol.2018.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 04/20/2018] [Indexed: 12/22/2022]
Abstract
The rational combination of recombinant IFN-α2b and IFN-γ resulted in a new formulation of interferons (HeberFERON) with improved pharmacodynamics. In basal cell carcinomas HeberFERON produces a more rapid antitumor effect and results in a larger number of complete responses. In patients with glioblastoma multiforme, the administration of HeberFERON after surgery and radiotherapy results in an estimated overall survival of 19 months. Patients with stage III or IV renal cell carcinoma also appear to benefit from the intravenous administration of HeberFERON, with prolongation of survival and good quality of live. HeberFERON offers a promising alternative formulation of interferons for the treatment of cancer with a very favorable safety profile.
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Affiliation(s)
- Iraldo Bello-Rivero
- Clinical Research Department, Center for Genetic Engineering and Biotechnology, Havana, Cuba.
| | | | | | | | - Hector Santana-Milian
- Formulation Department, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Vladimir Besada-Perez
- Proteomic Department, Center for Genetic Engineering and Biotechnology, Havana, Cuba
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Zhou W, Jiang Z, Li X, Xu Y, Shao Z. Cytokines: shifting the balance between glioma cells and tumor microenvironment after irradiation. J Cancer Res Clin Oncol 2014; 141:575-89. [PMID: 25005789 DOI: 10.1007/s00432-014-1772-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 06/30/2014] [Indexed: 12/13/2022]
Abstract
Malignant gliomas invariably recur after irradiation, showing radioresistance. Meanwhile, cranial irradiation can bring some risk for developing cognitive dysfunction. There is increasing evidence that cytokines play their peculiar roles in these processes. On the one hand, cytokines directly influence the progression of malignant glioma, promoting or suppressing tumor progression. On the other hand, cytokines indirectly contribute to the immunologic response against gliomas, exhibiting pro-inflammatory or immunosuppressive activities. We propose that cytokines are not simply unregulated products from tumor cells or immune cells, but mediators finely adjust the balance between glioma cells and tumor microenvironment after irradiation. The paper, therefore, focuses on the changes of cytokines after irradiation, analyzing how these mediate the response of tumor cells and normal cells to irradiation. In addition, cytokine-based immunotherapeutic strategies, accompanied with irradiation, for the treatment of gliomas are also discussed.
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Affiliation(s)
- Wei Zhou
- Department of Radiation Oncology, Cancer Centre, Qilu Hospital, Shandong University, 44 Wenhuaxi Road, Jinan, 250012, Shandong, China
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Iwami K, Natsume A, Wakabayashi T. Cytokine networks in glioma. Neurosurg Rev 2011; 34:253-63; discussion 263-4. [DOI: 10.1007/s10143-011-0320-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Revised: 12/18/2010] [Accepted: 01/28/2011] [Indexed: 12/25/2022]
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Two phase II trials of temozolomide with interferon-alpha2b (pegylated and non-pegylated) in patients with recurrent glioblastoma multiforme. Br J Cancer 2009; 101:615-20. [PMID: 19672263 PMCID: PMC2736828 DOI: 10.1038/sj.bjc.6605189] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Because of the poor outcomes for patients with recurrent glioblastoma multiforme (GBM), and some laboratory and clinical evidence of efficacy using interferon in GBM, we assessed the toxicity and efficacy of temozolomide (TMZ) combined with either short-acting (IFN) or long-acting (pegylated) interferon alpha2b (PEG) in two single-arm phase II studies, and compared the results to 6-month progression-free survival (PFS-6) data from historical controls. METHODS Two single-arm phase II studies were carried out in adults with GBM. Patients were treated with the standard regimen of TMZ (150-200 mg m(-2) per day x 5 days every month) combined with either 4 million units per m(2) subcutaneously (SQ) three times weekly of IFN or 0.5 microg kg(-1) SQ weekly of PEG. Physical exams and imaging evaluations were carried out every 8 weeks. RESULTS On the IFN study, 34 adults (74% men) were enrolled, and 29 adults (55% men) on the PEG study; median Karnofsky performance status was 80 and 90 for the IFN and PEG studies, respectively. Grade 3 or 4 toxicities were common, leucopoenia and thrombocytopoenia occurring in 35-38% and 18-21% of patients, respectively. Grade 3 or 4 fatigue occurred in 18% of patients on both studies. Lymphopoenia was infrequent. PFS-6 was 31% for 29 evaluable patients in the IFN study and 38% for 26 evaluable patients in the PEG study. CONCLUSION In recurrent GBM patients, both studies of standard dose TMZ with either IFN or PEG showed improved efficacy when compared to historical controls, or reports using TMZ alone. Even though the TMZ+PEG study met criteria for further study, the results of both of these studies must be considered in light of the standard of care (TMZ plus radiotherapy) for newly diagnosed GBM, which has evolved since the inception of these studies. Despite the results of the current studies being eclipsed by the new GBM standard of care, these results can still inform the development of newer approaches for GBM, either in an earlier, upfront setting, or by extrapolation of the results and consideration of the use of PEG or IFN in conjunction with other antiglioma strategies.
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Pinilla-Arias D, Mateo-Sierra O, Gutiérrez F, Fernández-Carballal C, Carrillo R. Inmunoterapia en astrocitomas de alto grado: principios y estado actual. Neurocirugia (Astur) 2005. [DOI: 10.1016/s1130-1473(05)70401-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hayes RL, Arbit E, Odaimi M, Pannullo S, Scheff R, Kravchinskiy D, Zaroulis C. Adoptive cellular immunotherapy for the treatment of malignant gliomas. Crit Rev Oncol Hematol 2001; 39:31-42. [PMID: 11418300 DOI: 10.1016/s1040-8428(01)00122-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
UNLABELLED The median survival for adults with recurrent primary malignant gliomas is 56 weeks following surgery, radiation, and chemotherapy. Generally, reoperation can extend the median survival an additional 26-32 weeks. We have developed an aggressive treatment program that utilizes low doses of interleukin-2 (IL-2) combined with ex vivo activated killer cells (LAK) infused via an indwelling catheter placed into the surgical resection cavity. Autologous leukocytes were collected during a standard 3-4 h, outpatient leukapheresis procedure, then activated ex vivo for 4-5 days with high doses of IL-2. The treatment protocol consisted of two 2-week cycles of therapy over a 6-week period. Patients with stable disease or objective response on follow-up MRI scans were retreated at 3-month intervals. Acute and cumulative IL-2-related toxicities were observed, but limited, and included fever, headache and transient neurologic irritation. Corticosteroid levels and usage were strictly controlled during immunotherapy, although higher doses were used intermittently to mitigate toxicity. Biologic changes included lymphocytic infiltration, regional eosinophilia, tumor necrosis, and the localized production of IL-2, IFN-gamma and IL-12, demonstrated by in situ hybridization and immunohistochemistry. SUMMARY IL-2 plus autogeneic LAK cells can be safely administered intracavitary to treat high grade primary brain tumors with limited toxicity within the central nervous system. Six out of 28 patients had long-term survival of greater than 2 years post-reoperation plus immunotherapy with 2 patients alive over 8 years. The presence of a marked regional eosinophilia appeared to correlate with increased survival and may be predictive of a biologic and therapeutic response. Regional adoptive immune therapy was well tolerated and should be considered an option for patients with high-grade tumors refractive to standard therapeutic approaches.
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Affiliation(s)
- R L Hayes
- Department of Medicine, Immunotherapy Program, Sanford R. Nalitt Institute for Cancer and Blood-Related Diseases, Staten Island University Hospital, 256 Mason Avenue, Staten Island, NY 10305, USA.
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Rajkumar SV, Buckner JC, Schomberg PJ, Cascino TL, Burch PA, Dinapoli RP. Phase I evaluation of radiation combined with recombinant interferon alpha-2a and BCNU for patients with high-grade glioma. Int J Radiat Oncol Biol Phys 1998; 40:297-302. [PMID: 9457812 DOI: 10.1016/s0360-3016(97)00739-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE A Phase I study to determine the safety, toxicity, and maximum tolerated dose (MTD) of carmustine (BCNU) and interferon alpha-2a (IFN-a) when combined with radiation as initial therapy in high-grade glioma. METHODS AND MATERIALS Patients with newly diagnosed Grade 3 or 4 astrocytoma, oligoastrocytoma, or gliosarcoma were enrolled after surgery. All received radiation therapy to the brain (64.8 Gy/36 fractions), combined with a single dose of BCNU (200 mg/m2) at the start of radiation. Chemotherapy after completing radiation consisted of BCNU 150 mg/m2 once every 7 weeks, and IFN-a 12 x 10(6) units/m2 subcutaneously Days 1-3 each week of a 7-week cycle. Subsequent dose modification was based on constitutional symptoms for IFN-a and on myelosuppression for BCNU. RESULTS Fifteen patients were entered on the study. Four were excluded because they did not receive IFN-a (3 refused treatment and 1 patient left the study due to multiple medical problems). Eleven were evaluable for toxicity and efficacy. Nonhematological toxicity, mainly lethargy and flu-like symptoms, were dose-limiting for IFN-a. After the first 6 patients were treated per the initial protocol, the frequency of IFN-a administration was decreased to Days 1-3 on weeks 1, 3, and 5 of the 7-week cycle for 5 additional patients. Lethargy, fever, chills, myalgias, alopecia, and anorexia occurred in all patients. Other toxicities included nausea and vomiting (91%), central-nervous-system depression or mood changes (64%), headaches (55%), and elevation of liver enzymes (36%). Grade 3-4 leukopenia occurred in 4 (45%) of 11 patients, and Grade 3-4 thrombocytopenia in 3 (27%) of 11 patients. Due to myelosuppressive effects, BCNU dose was not escalated. Median survival of the cohort was 44 months. Objective responses occurred in 5 (56%) of 9 patients and median duration of response was 33 months. The MTD of this combination after radiation therapy is IFN-a 12 x 10(6) units/m2 Days 1-3, on Weeks 1, 3, and 5 of a 7-week cycle and BCNU 150 mg/m2 Day 1, every 7 weeks. CONCLUSIONS Treatment with radiation, IFN-a, and BCNU is feasible and effective in patients with high-grade gliomas, although constitutional symptoms from IFN-a are substantial.
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Affiliation(s)
- S V Rajkumar
- Division of Medical Oncology, Mayo Clinic and Foundation, Rochester, MN 55905, USA
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Dillman RO, Crispin R, Oldham RK. The Cancer Biotherapy Research Group [CBRG], formerly the National Biotherapy Study Group [NBSG]: a 10-year perspective. Cancer Biother Radiopharm 1997; 12:229-42. [PMID: 10851470 DOI: 10.1089/cbr.1997.12.229] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Cancer Biotherapy Research Group [CBRG], formerly known as the National Biotherapy Study Group [NBSG], celebrated its 10th anniversary in 1997. CBRG is a not-for-profit cancer clinical trials group of community oncologists whose activities for the most part have been funded by their associated community hospitals. From its inception the Group has focused on clinical investigations of biological agents in the treatment of patients with advanced cancer. This article reviews the history of the Group, its structure, accomplishments, and its current objectives and challenges.
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Affiliation(s)
- R O Dillman
- Hoag Cancer Center, Cancer Biotherapy Research Group, Newport Beach, California 92658, USA
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