Does surgical removal of primary melanoma trigger growth of occult metastases? An analytical epidemiological approach

A joint model of cancer incidence, metastasis, and mortality

Many diseases, especially cancer, are not static, but rather can be summarized by a series of events or stages (e.g. diagnosis, remission, recurrence, metastasis, death). Most available methods to analyze multi-stage data ignore intermediate events and focus on the terminal event or consider (time to) multiple events as independent. Competing-risk or semi-competing-risk models are often deficient in describing the complex relationship between disease progression events which are driven by a shared progression stochastic process. A multi-stage model can only examine two stages at a time and thus fails to capture the effect of one stage on the time spent between other stages. Moreover, most models do not account for latent stages. We propose a semi-parametric joint model of diagnosis, latent metastasis, and cancer death and use nonparametric maximum likelihood to estimate covariate effects on the risks of intermediate events and death and the dependence between them. We illustrate the model with Monte Carlo simulations and analysis of real data on prostate cancer from the SEER database.

Effects of Surgery and Chemotherapy on Metastatic Progression of Prostate Cancer: Evidence from the Natural History of the Disease Reconstructed through Mathematical Modeling

This article brings mathematical modeling to bear on the reconstruction of the natural history of prostate cancer and assessment of the effects of treatment on metastatic progression. We present a comprehensive, entirely mechanistic mathematical model of cancer progression accounting for primary tumor latency, shedding of metastases, their dormancy and growth at secondary sites. Parameters of the model were estimated from the following data collected from 12 prostate cancer patients: (1) age and volume of the primary tumor at presentation; and (2) volumes of detectable bone metastases surveyed at a later time. This allowed us to estimate, for each patient, the age at cancer onset and inception of the first metastasis, the expected metastasis latency time and the rates of growth of the primary tumor and metastases before and after the start of treatment. We found that for all patients: (1) inception of the first metastasis occurred when the primary tumor was undetectable; (2) inception of all or most of the surveyed metastases occurred before the start of treatment; (3) the rate of metastasis shedding is essentially constant in time regardless of the size of the primary tumor and so it is only marginally affected by treatment; and most importantly, (4) surgery, chemotherapy and possibly radiation bring about a dramatic increase (by dozens or hundred times for most patients) in the average rate of growth of metastases. Our analysis supports the notion of metastasis dormancy and the existence of prostate cancer stem cells. The model is applicable to all metastatic solid cancers, and our conclusions agree well with the results of a similar analysis based on a simpler model applied to a case of metastatic breast cancer.

Catalase delivery for inhibiting ROS-mediated tissue injury and tumor metastasis

Reactive oxygen species (ROS) have been suggested to be involved in a variety of human diseases. Catalase, an enzyme degrading hydrogen peroxide, can be used as a therapeutic agent for such diseases, but its successful application will depend on the distribution of the enzyme to the sites where ROS are generated. Chemical modification techniques have been used to control the tissue distribution of catalase, and delivery to hepatocytes (galactosylation), liver nonparenchymal cells (mannosylation or succinylation), kidney (cationization) and the blood pool (PEGylation) has been achieved. The effectiveness of catalase delivery has been demonstrated in animal models for hepatic ischemia/reperfusion injury, chemical-induced tissue injuries and tumor metastasis to the liver, lung and peritoneal organs. Significant inhibition was observed in the ROS-mediated oxidative tissue damages and ROS-mediated upregulation of expression of genes responsible for recruitment of inflammatory cells and for metastatic growth of tumor cells. Because oxygen plays a fundamental key role in our life and oxidative stress is implicated in a wide variety of human diseases, catalase delivery could have wide application in the near future.

PEGylated catalase prevents metastatic tumor growth aggravated by tumor removal

Although surgical removal is a primary option for treating tumors, it can lead to the increased growth of metastatic tumors. Because surgical procedures may generate reactive oxygen species (ROS), known promoters of tumor metastasis and growth, we investigated whether PEGylated catalase (PEG-catalase, plasma half-life of 13.6 h) was able to prevent this after surgical removal of a footpad tumor in mice. Murine melanoma cells labeled with the firefly luciferase gene were used to monitor the distribution of tumor cells. After inoculation into the footpad, tumor cells were found in the lung, and the number increased with time. The surgical removal of the footpad tumor significantly (p < 0.05) increased the number of metastatic tumor cells and the level of plasma lipoperoxides. An intravenous injection of PEG-catalase significantly (p < 0.05) suppressed the metastatic tumor growth as well as the peroxidation. Quantitative RT-PCR and Western blot analyses indicated that PEG-catalase markedly reduced the increase in the expression of epidermal growth factor receptor. These findings indicate that the removal of tumor produces ROS, which then aggravate metastatic tumor growth by activating several growth factors. PEG-catalase can effectively prevent this metastatic tumor growth by detoxifying the ROS.

Premenopausal status accelerates relapse in node positive breast cancer: hypothesis links angiogenesis, screening controversy

Much attention has been given to determining the benefit of mammographic screening to reduce breast cancer mortality. Eight randomized clinical trials have been conducted in four countries: the US, Canada, Scotland and Sweden. Trials report an early and stable 30% reduction in breast cancer mortality for women aged 50-59. For women under 50, unexpectedly, the early years of screening produce a disadvantage to the screened population. Only in later years does an advantage appear. To help understand this, we studied relapse patterns using a breast cancer database of 1,173 pre- and postmenopausal, node negative and positive patients treated with surgery only and having 16-20 years of follow-up. This approach is relevant since at least five of the eight screening trials began before the widespread use of adjuvant chemotherapy in the 1980s. Surgical cure rates were independent of menopausal status. However, a major difference in early relapse rate was found. In premenopausal and node positive patients, 27% of all distant relapses occurred within the first 10 months following resection. This is twice the early relapse frequency of any other clinical group. Using computer simulation, we interpret that these early relapses probably result from a disadvantage induced at surgery. A disinhibition or surgery/wounding induced angiogenic surge might be responsible. Disinhibition is known to occur in animal models such as Lewis lung where lung metastases are avascular and dormant until the primary is removed. Sudden outgrowth of tumor after wounding has been observed for a century. According to the simulation, in breast cancer this induction apparently accelerates inevitable relapses by a median of two years. This is offset in later years with a balancing reduction in relapses. These data suggest that the angiogenic switch may be upregulated more frequently among premenopausal women, perhaps depending upon the sex hormones. The acceleration would cause 0.11 deaths per 1,000 screened aged 40-49 subjects in years 2-3, a value comparable to the early year excess mortality in trials of a significant 0.15 deaths per 1,000 subjects. Equal screening advantage is predicted for node negative (but not node positive) pre- and postmenopausal patients. The acceleration of relapse after surgery may explain the paradoxical effect of mammographic screening for women under 50.