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A Thesis submitted to the Faculty of Health Sciences (Internal Medicine), University of the Witwatersrand, in fulfillment of the requirements for the degree of Doctor of Philosophy. Johannesburg, 2017 / South Africa has the largest ARV treatment programme in the world, wherein highly active antiretroviral treatment (HAART) has improved the health related quality of life (HRQoL) in HIV/AIDS patients. On the contrary, cancers not previously associated with HIV/AIDS (non-Aids defining cancers; NADCs) have been shown to be increasing, compared to the AIDS defining cancers (ADCs). Lung cancer, as a NADC has been documented in the HIV/AIDS population as a leading malignancy. The poor understanding of the association between ARV drugs and lung cancer places a burden on public health, both globally and in South Africa (SA). Furthermore, the deregulation of the cell-cycle is one of the hallmarks of cancer, including lung cancer. The main aim of this study was to elucidate the effects of HAART components Efavirenz (EFV) and Lopinavir/ritonavir (LPV/r) on cell-cycle related genes in an in vitro lung cancer model. To achieve this, cellular based, molecular and Bio-Informatics approaches were employed. First, the cytotoxic effects of EFV (at 4, 13, 26, 50 μM) and LPV/r (at 10, 32, 50, 80 μM), for 24h, 48h and 72h on normal lung fibroblasts (MRC-5) and lung adenocarcinoma (A549) cells, were evaluated using the Alamar Blue (AB) assay. This was then followed by cell-impedance “xCELLigence” real-time cell analysis (RTCA) assay. This was done to determine the effects of EFV (at 4, 13, 50 μM) and LPV/r (at 10, 32, 80 μM) on cell viability, cell death and proliferation. Cell-cycle analysis using propidium iodide (PI) by Fluorescence-activated cell sorting (FACS) was done to quantify DNA present at each of the cell-cycle stages of the cell-cycle in response to ARV treatment. Subsequently, an apoptosis assay using Annexin V FITC and Propidium iodide (PI) dual staining by FACS was carried out to confirm and quantify the ARVs potential apoptotic effects. Then, 4′,6-diamidino-2-phenylindole (DAPI) staining was used to assess changes in nuclear morphology exerted by the ARVs’ effects. A more in depth interrogation of the cell-cycle was performed using a focussed gene array panel of some 84 human cell-cycle related genes. First, total RNA was isolated from both treated and untreated MRC-5 and A549 cells and reverse transcribed to cDNA for use as template in the PCR array reactions. From the array gene expression results, by convention a ±2 fold up-or-down-regulation was used as the basis of target selection. Following this, a real-time quantitative PCR (RT-qPCR) validation of selected genes of interest was done to quantify and confirm the PCR array results. This was followed by in-silico Bio-informatics analysis to map the molecular pathways regulated by the identified targets. For this purpose, STRING, Database for Annotation, Visualization and Integrated Discovery (DAVID), Reactome and Ingenuity Pathway Analysis (IPA) databases were used. Interestingly, double-edged oncogenic properties of both EFV and LPV/r at different concentrations were identified. The proliferative effects of EFV at 4, 13μM and LPV/r at10 μM, were elucidated, while 26, 50μM of EFV, and 32μM of LPV/r had slight inhibitory effects on cell proliferation. LPV/r at concentrations of 50 and 80μM exerted cytotoxic effects on the cells, as demonstrated by the AB and xCELLigence RTCA assays. Cell-cycle analysis using PI staining, particularly showed cell-cycle arrest at 32μM LPV/r, and a shift to G2/M by 13μM EFV, plasma relevant doses, compared to the untreated cells. An increasing apoptosis percentage was observed with increasing LPV/r concentrations, that is, 80μM LPV/r raised the apoptosis percentage almost two-fold compared to 32μM. This was coupled by necrosis, observed in a time-dependant manner. DAPI staining confirmed loss of nuclear integrity post ARV exposure, suggesting that both EFV and LPV/r impose damage to the genomic DNA. To further assess the observed changes in nuclear morphology, the effects of EFV and LPV/r on the expression of an arrayed panel of human cell-cycle genes in cancer and normal lung cells was determined. Significantly differentially expressed targets were identified and further quantified and confirmed by RT-qPCR. Such targets included ATM, p53, cyclin-dependant kinase inhibitors (CDKIs), such as, p21, aurora kinase B (AURKB), Mitotic Arrest Deficient-Like 2 (MAD2L2) and the apoptosis related gene, caspase 3 (CASP3). Bio-Informatics analyses revealed close and direct protein-protein interactions (PPIs) between these targets, notably, with change in interaction between the gene products involved in DNA repair mechanisms, observed between ARV treated and untreated groups, as illustrated by STRING interactions. DAVID, Reactome and IPA analysis showed changes in expression of genes related to stress and toxicity and DNA damage response genes. In particular, ATM, p53 and its downstream targets such as GADD45A (growth arrest and DNA damage inducible alpha) gene were up-regulated by ARV treatment, while cyclin/CDK activity was down-regulated, resulting in reduced cell proliferation. Thus in summary, both EFV and LPV/r altered the expression levels of cell-cycle related genes, influencing overall cellular health, acting to either inhibit or stimulate cell proliferation. This suggests EFV’s and LPV/r’s proliferative and inhibitory roles in the proliferation of lung cells. Moreover, future directions can include the transfection of lung cells with HIV provirus followed by treatment of the cells with the same ARVs under study. This could be substantiated by including HIV positive patient samples on and off ARV drug treatment with lung cancer, including HIV negative patients with cancer as one of the controls. / MT2018

Purpose: The purpose of this thesis was to perform a scoping review of the current literature and available clinical practice guidelines to generate an understanding of the primary health care needs of women following treatment for breast cancer. Methods: Based on an extensive scoping review of the literature, research findings regarding the complications of breast cancer treatments and corresponding primary care interventions were synthesized. Additionally, validation of the findings of the scoping review was performed through semi-structured interviews with two primary care physicians and three post-treatment breast cancer patients. Results: Eleven broad categories related to the primary health care needs of women after undergoing treatments for breast cancer were identified. These included concerns related to: surgical complications, lymphedema, gynecologic and menopausal symptoms, psychosocial issues, additional primary cancers, cardiovascular implications, osteoporosis, lifestyle changes, fatigue, cognitive dysfunction, and pregnancy. Additionally, it was determined that the majority of existing clinical practice guidelines for breast cancer were outdated, and related to cancer detection and treatment as opposed to survivorship care. Summary: Findings from the scoping review and interviews demonstrate the vast range of primary care needs of women after undergoing treatment for breast cancer. Additionally, these results highlight the critical need for the development of a comprehensive set of current clinical practice guidelines which target primary care physicians and are specifically focused on the survivorship needs of women following breast cancer treatment. / Thesis (Master, Rehabilitation Science) -- Queen's University, 2011-07-22 16:09:35.682

Bakgrund: Att drabbas av cancer som ung vuxen innebär ett avbrott i livsprocessen och det kan upplevas som en katastrofal förändring. När en människa upplever att helheten hotas uppstår ett lidande, unga vuxna som drabbas av allvarlig sjukdom kan uppleva traumatisk kris. Det är viktigt att i ett tidigt stadium fånga upp och stötta unga vuxna med en cancerdiagnos eftersom lidandet kan lindras under sjukdomsprocessen. Individer som får social och professionellt stöd orkar engagera sig i återhämtningsprocessen och kan uppnå bättre livskvalité. Syfte: Studiens syfte var att belysa unga vuxnas behov av stöd under behandling av cancersjukdom. Metod: Studien har en kvalitativ ansats och kvalitativ innehållsanalys användes för att analysera bloggarna. Datamaterialet bestod av fem svenska bloggar publicerade på ung cancers webbsida. Resultat: Unga vuxna med en cancersjukdom upplevde att socialt stöd var värdefullt under cancerbehandling. Individerna upplevde emotionellt, informativt, praktisk och bekräftande stöd från familj och närstående samt från individer i liknande situation. Det professionella stödet uppskattades när individerna betraktades som en helhet dock visades det vara negativt när det brast i kommunikationen mellan patient och vårdgivare. Slutsats: Unga vuxna som drabbades av en cancersjukdom hade behov av både socialt och professionellt stöd för att hantera sjukdomen. / Background: To develop cancer as an adolescent or young adult means a break in a critical stage of the life process, and can be a devastating experience for the patient. When an individual feels their current existence is threatened there is an immediate crisis, followed by traumatization and suffering. This seems to be especially true for young adults. It is important to catch and support the young adults at an early stage in their cancer diagnosis because this can lead to a relief throughout the disease process. Individuals who receive social and professional support are able to engage themselves in their recovery process, and can achieve a better quality of life. Objective: The aim of this study was to highlight young adults' needs for support during treatment of cancer. Method: The study has a qualitative approach and a qualitative content analysis was used to analyze the blogs. The data consisted of five Swedish blogs published on young cancers (Ung Cancer) website. Results: Young adults with cancer felt that social support was valuable during cancer treatment. The individuals experienced emotional, informative, practical and appraisal support from family and relatives, as well as from individuals in similar situations. The professional support was appreciated when the holistic perspective of the individuals were considered. However, the support was shown to be negative when communication failed between patient and caregiver. Conclusion: Young adults who suffered from cancer were in need of both social and professional support to handle the situation mentally.

The subject of this thesis is to identify and quantificate costs of Breast Cancer Therapy. The goal is the quantification of costs for specific therapeutic modalities, which are used by the therapy. Obtained values are used for presentation of the cheapest and the most expensive mode of treatment.

Conselho Nacional de Desenvolvimento Científico e Tecnológico / A utilização de biomarcadores cardioespecíficos vem sendo recomendado como ferramenta útil na monitoração e identificação precoce de lesão cardíaca, em decorrência do potencial de cardiotoxicidade da terapêutica oncologica. O objetivo do presente estudo foi avaliar o nível plasmático do peptídeo natriurético do tipo B (BNP) e da expressão gênica do BNP e outros genes relacionados a sua síntese, a interleucina-6 (IL-6), fator β1 de transformação de crescimento (TGF-β1) e procolágeno tipo I, mediante a associação dos agentes antineoplásicos docetaxel e ciclofosfamida (TC) e da radiação ionizante (IR) no coração de ratas Wistar, 2 meses após o término do tratamento. Para isso, Ratas Wistar (3-4 meses, n=7) foram irradiadas no coração com dose única de 20Gy, em um campo ântero-posterior de 2x2cm2, em acelerador linear com feixe de energia nominal de 6 MeV; outras (n=7) foram tratadas (4 ciclos, com 7 dias de intervalo) com docetaxel (12,5 mg/Kg) e ciclofosfamida (50 mg/Kg) e irradiadas após 7 dias do tratamento quimioterápico. Como controle (n=7), animais não irradiados e não tratados com quimioterápicos. Após 2 meses do fim do tratamento, a eutanásia dos animais foi realizada. Amostras de plasma e tecido cardíaco, ventrículo esquerdo (VE), foram coletadas. Por ensaio ELISA foi quantificada a concentração plasmática de BNP; parte do tecido cardíaco foi fixado, incluído em parafina e cortado em micrótomo, para assinalar a presença de BNP no VE, avaliação qualitativa, pela técnica de imunohistoquímica (IHQ); e a outra parte para a técnica RT-qPCR, onde foram avaliados a expressão relativa de mRNA dos genes do BNP, IL-6, TGF-β1 e procolágeno tipo I. Na IHQ o grupo controle apresentou uma marcação pontual, enquanto que os grupos tratados apresentaram uma marcação mais difusa, sendo que o grupo TC+IR foi o que apresentou maior dispersão na marcação do BNP no tecido cardíaco. Embora não tenha sido observado no ensaio ELISA uma diferença significativa entre as concentrações plasmáticas de BNP dos grupos tratados em relação ao controle, nota-se uma tendência de aumento no grupo TC+IR. Na analise por RT-qPCR, a expressão relativa de BNP foi similar ao apresentado no ELISA. O grupo TC+IR foi o grupo que apresentou maior expressão gênica de BNP, porém a diferença não é significativa em relação ao controle. A única análise em que se obteve diferença na expressão gênica em relação ao controle foi a do gene IL-6 que apresentou expressão reduzida. Todos os demais genes analisados por RT-qPCR apresentaram uma expressão similar ao controle. Assim, os resultados obtidos sugerem que o BNP não se apresentou como um bom biomarcador cardioespecífico para identificação precoce de lesão cardíaca, no período a qual foi avaliado. As ratas Wistar, 2 meses após a submissão do tratamento, não apresentaram um resultado diferenciado em relação ao controle, nos genes TGF-β1 e procolágeno tipo I, sugerindo ausência de um quadro de remodelamento cardíaco. Entretanto, apresentou redução significativa do gene IL-6, no grupo TC+IR, propondo ação anti-inflamatória do BNP, que no mesmo grupo, apresentou uma tendência de aumento em sua expressão gênica. / The use of specific cardiac biomarkers has been recommended as a useful tool in the early identification and monitoring of cardiac injury, due to the potential cardiotoxicity of oncological therapy. The aim of this study is to investigate, analyze and evaluate the reaction of B-type natriuretic peptide (BNP), interleukin-6 (IL-6), transforming growth factor β1 (TGF-β1) and procollagen type I in its expression and release by the association of antineoplastic agents Docetaxel and Cyclophosphamide (TC) and ionizing radiation (IR) in the heart of Wistar rats, 2 months after the end of treatment. For this, Wistar rats (3-4 months, n = 7) were irradiated in the heart with a single dose of 20 Gy, in a anteroposterior field of 2x2cm2 in linear accelerator with nominal energy beam of 6 MeV, other (n = 7) were treated (four cycles with a 7-day interval) with docetaxel (12.5 mg / kg) and Cyclophosphamide (50 mg / kg) and irradiated after 7 days of chemotherapy. As a control (n = 7), non-irradiated animals not treated with chemotherapy. 2 months after the end of treatment, euthanasia was performed. Samples of plasma and heart tissue, left ventricular (LV) were collected. The plasma concentration of BNP was quantified by ELISA, part of the heart tissue was fixed, embedded in paraffin and cut in microtome, to signal the presence of BNP in the LV, qualitative evaluation by immunohistochemistry (IHC), and the other party to technique RT-qPCR were evaluated in the relative expression of mRNA of the genes of BNP, ANP, IL-6, TGF-β1 and procollagen type I. In the control group IHC showed a marking point, while the treated groups showed a more diffuse labeling, and the CT + RT group showed the greatest dispersion. Although it was not observed in the ELISA assay a significant difference between plasma concentrations of BNP treated groups compared to control, there is an increasing trend in the CT + RT group. In the analysis by RT-qPCR, the relative expression of BNP was similar to that shown in the ELISA. The CT + RT group was the group that showed higher gene expression of BNP, but the difference is not significant compared to control. The only analysis that which obtained difference in gene expression compared to control was the IL-6 gene that showed low expression. All other genes analyzed by RT-qPCR showed an expression similar to control. Therefore, the outcome is that BNP did not appear as a good specific cardiac biomarker for early identification of cardiac disease, within 2 months after treatment in Wistar rats, by effect of the action of cardiotoxic selected treatment protocols, since none of their quantitative assessments showed a differentiated result compared to control, however, there was no evidence that, in the meantime, there would be a scenario in development, or advanced of cardiac remodeling.

Conselho Nacional de Desenvolvimento Científico e Tecnológico / A utilização de biomarcadores cardioespecíficos vem sendo recomendado como ferramenta útil na monitoração e identificação precoce de lesão cardíaca, em decorrência do potencial de cardiotoxicidade da terapêutica oncologica. O objetivo do presente estudo foi avaliar o nível plasmático do peptídeo natriurético do tipo B (BNP) e da expressão gênica do BNP e outros genes relacionados a sua síntese, a interleucina-6 (IL-6), fator β1 de transformação de crescimento (TGF-β1) e procolágeno tipo I, mediante a associação dos agentes antineoplásicos docetaxel e ciclofosfamida (TC) e da radiação ionizante (IR) no coração de ratas Wistar, 2 meses após o término do tratamento. Para isso, Ratas Wistar (3-4 meses, n=7) foram irradiadas no coração com dose única de 20Gy, em um campo ântero-posterior de 2x2cm2, em acelerador linear com feixe de energia nominal de 6 MeV; outras (n=7) foram tratadas (4 ciclos, com 7 dias de intervalo) com docetaxel (12,5 mg/Kg) e ciclofosfamida (50 mg/Kg) e irradiadas após 7 dias do tratamento quimioterápico. Como controle (n=7), animais não irradiados e não tratados com quimioterápicos. Após 2 meses do fim do tratamento, a eutanásia dos animais foi realizada. Amostras de plasma e tecido cardíaco, ventrículo esquerdo (VE), foram coletadas. Por ensaio ELISA foi quantificada a concentração plasmática de BNP; parte do tecido cardíaco foi fixado, incluído em parafina e cortado em micrótomo, para assinalar a presença de BNP no VE, avaliação qualitativa, pela técnica de imunohistoquímica (IHQ); e a outra parte para a técnica RT-qPCR, onde foram avaliados a expressão relativa de mRNA dos genes do BNP, IL-6, TGF-β1 e procolágeno tipo I. Na IHQ o grupo controle apresentou uma marcação pontual, enquanto que os grupos tratados apresentaram uma marcação mais difusa, sendo que o grupo TC+IR foi o que apresentou maior dispersão na marcação do BNP no tecido cardíaco. Embora não tenha sido observado no ensaio ELISA uma diferença significativa entre as concentrações plasmáticas de BNP dos grupos tratados em relação ao controle, nota-se uma tendência de aumento no grupo TC+IR. Na analise por RT-qPCR, a expressão relativa de BNP foi similar ao apresentado no ELISA. O grupo TC+IR foi o grupo que apresentou maior expressão gênica de BNP, porém a diferença não é significativa em relação ao controle. A única análise em que se obteve diferença na expressão gênica em relação ao controle foi a do gene IL-6 que apresentou expressão reduzida. Todos os demais genes analisados por RT-qPCR apresentaram uma expressão similar ao controle. Assim, os resultados obtidos sugerem que o BNP não se apresentou como um bom biomarcador cardioespecífico para identificação precoce de lesão cardíaca, no período a qual foi avaliado. As ratas Wistar, 2 meses após a submissão do tratamento, não apresentaram um resultado diferenciado em relação ao controle, nos genes TGF-β1 e procolágeno tipo I, sugerindo ausência de um quadro de remodelamento cardíaco. Entretanto, apresentou redução significativa do gene IL-6, no grupo TC+IR, propondo ação anti-inflamatória do BNP, que no mesmo grupo, apresentou uma tendência de aumento em sua expressão gênica. / The use of specific cardiac biomarkers has been recommended as a useful tool in the early identification and monitoring of cardiac injury, due to the potential cardiotoxicity of oncological therapy. The aim of this study is to investigate, analyze and evaluate the reaction of B-type natriuretic peptide (BNP), interleukin-6 (IL-6), transforming growth factor β1 (TGF-β1) and procollagen type I in its expression and release by the association of antineoplastic agents Docetaxel and Cyclophosphamide (TC) and ionizing radiation (IR) in the heart of Wistar rats, 2 months after the end of treatment. For this, Wistar rats (3-4 months, n = 7) were irradiated in the heart with a single dose of 20 Gy, in a anteroposterior field of 2x2cm2 in linear accelerator with nominal energy beam of 6 MeV, other (n = 7) were treated (four cycles with a 7-day interval) with docetaxel (12.5 mg / kg) and Cyclophosphamide (50 mg / kg) and irradiated after 7 days of chemotherapy. As a control (n = 7), non-irradiated animals not treated with chemotherapy. 2 months after the end of treatment, euthanasia was performed. Samples of plasma and heart tissue, left ventricular (LV) were collected. The plasma concentration of BNP was quantified by ELISA, part of the heart tissue was fixed, embedded in paraffin and cut in microtome, to signal the presence of BNP in the LV, qualitative evaluation by immunohistochemistry (IHC), and the other party to technique RT-qPCR were evaluated in the relative expression of mRNA of the genes of BNP, ANP, IL-6, TGF-β1 and procollagen type I. In the control group IHC showed a marking point, while the treated groups showed a more diffuse labeling, and the CT + RT group showed the greatest dispersion. Although it was not observed in the ELISA assay a significant difference between plasma concentrations of BNP treated groups compared to control, there is an increasing trend in the CT + RT group. In the analysis by RT-qPCR, the relative expression of BNP was similar to that shown in the ELISA. The CT + RT group was the group that showed higher gene expression of BNP, but the difference is not significant compared to control. The only analysis that which obtained difference in gene expression compared to control was the IL-6 gene that showed low expression. All other genes analyzed by RT-qPCR showed an expression similar to control. Therefore, the outcome is that BNP did not appear as a good specific cardiac biomarker for early identification of cardiac disease, within 2 months after treatment in Wistar rats, by effect of the action of cardiotoxic selected treatment protocols, since none of their quantitative assessments showed a differentiated result compared to control, however, there was no evidence that, in the meantime, there would be a scenario in development, or advanced of cardiac remodeling.

Submitted by Carlos Vinícius Jenezi Santos (carlosjenezi@hotmail.com) on 2018-06-14T01:26:32Z No. of bitstreams: 1 TA FINAL CARLOS JENEZI_FINAL.pdf: 643498 bytes, checksum: 5e5b5637c7f7928188cf615e7b3c73da (MD5) / Rejected by Simone de Andrade Lopes Pires (simone.lopes@fgv.br), reason: Prezada Carlos, Recebemos a postagem do seu trabalho na biblioteca digital e para ser aprovado serão necessários alguns ajustes: 1º CAPA: correção do nome da escola. FUNDAÇÃO GETULIO VARGAS, não tem acento no "U". Atenciosamente, SRA on 2018-06-14T16:50:14Z (GMT) / Submitted by Carlos Vinícius Jenezi Santos (carlosjenezi@hotmail.com) on 2018-06-14T19:13:59Z No. of bitstreams: 1 TA FINAL CARLOS JENEZI_FINAL.pdf: 641921 bytes, checksum: 7faadbc4b9f5d7002cf03cd791f5615d (MD5) / Approved for entry into archive by Simone de Andrade Lopes Pires (simone.lopes@fgv.br) on 2018-06-15T16:47:48Z (GMT) No. of bitstreams: 1 TA FINAL CARLOS JENEZI_FINAL.pdf: 641921 bytes, checksum: 7faadbc4b9f5d7002cf03cd791f5615d (MD5) / Approved for entry into archive by Isabele Garcia (isabele.garcia@fgv.br) on 2018-06-15T19:08:54Z (GMT) No. of bitstreams: 1 TA FINAL CARLOS JENEZI_FINAL.pdf: 641921 bytes, checksum: 7faadbc4b9f5d7002cf03cd791f5615d (MD5) / Made available in DSpace on 2018-06-15T19:08:54Z (GMT). No. of bitstreams: 1 TA FINAL CARLOS JENEZI_FINAL.pdf: 641921 bytes, checksum: 7faadbc4b9f5d7002cf03cd791f5615d (MD5) Previous issue date: 2018-06-13 / Este estudo analisa a questão da viabilidade socioeconômica do tratamento de câncer de pulmão, umas das neoplasias com maior incidência e mais alta taxa de mortalidade, através de imunoterapia. Este tipo de tratamento, a maior inovação no combate ao câncer nas última décadas, traz importantes desafios de acesso em função do alto custo de tratamento. Alternativas que possam eventualmente garantir o acesso à essas terapias foram aprofundadas através da análise sobre estudos já realizados sobre o tema e também através de pesquisas em profundidade com profissionais que atuam na área, sejam eles da assistência ou da gestão. O estudo se baseou em três hipóteses, que foram aprofundadas e ampliadas após a etapa de pesquisas, trazendo nossos fatores ao tema discutido. A primeira hipótese debateu sobre a garantia constitucional brasileira de acesso universal e integral da saúde pela população e o papel do Estado na promoção de saúde. A segunda discutiu critérios socioeconômicos para decisão de protocolos de tratamento. A terceira discorreu sobre metodologias de maior precisão diagnóstica, garantindo a utilização de medicamentos de alto custo somente em situações de comprovado ganho terapêutico. Ao fim, o estudo procura apontar alternativas que possam garantir o acesso populacional à tratamentos inovadores dentro da realidade socioeconômica brasileira. / This study analyzes the question of the socioeconomic viability of the treatment of lung cancer, one of the neoplasias with higher incidence and higher mortality rate, through immunotherapy. This type of treatment, the greatest innovation in the fight against cancer in the last decades, brings important challenges of access due to the high cost of treatment. Alternatives that could possibly guarantee access to these therapies were deepened through the analysis of studies already done about this subject and also through in-depth research with professionals working in the area, whether in the cancer care or management. The study was based on three hypotheses, which were deepened and expanded after the research stage, bringing new factors to the topic discussed. The first hypothesis discussed the Brazilian Constitution, that guarantee the universal and comprehensive access to health by the Brazilian population and the role of the State in health promotion. The second discussed socioeconomic criteria for definition of treatment guidelines. The third one debates about methodologies with greater diagnostic precision, guaranteeing the use of high cost drugs only in situations of proven therapeutic gain. Finally, the study seeks to identify alternatives that can guarantee the population access to innovative treatments within the Brazilian socioeconomic reality.

Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Cancer is a disease characterized by complexity and unpredictability. Consequently, its treatment is difficult and all too often unsuccessful. Almost all cancers are treated with some combination of the traditional anti-cancer armamentarium: surgery, chemotherapy, and radiotherapy. Recently, however, gene therapy has emerged as a promising addition to this existing repertoire. Its application as a single agent, or in combination with other anti-cancer treatments is proving successful in both pre-clinical and clinical settings. In this work I have investigated the combination of a conventional chemotherapy drug, cisplatin, with a type of cancer gene therapy known as cytosine deaminase + 5-fluorocytosine suicide gene therapy. Suicide gene therapy is the intracellular conversion of non-toxic prodrug to its active form by a metabolic enzyme of non-mammalian origin. There are many established enzyme/prodrug combinations, but here the bacterial enzyme cytosine dearninase (CDA) was used to convert inert 5-fluorocytosine (5FC) to highly toxic 5-fluorouracil (5FU). Of the various vector systems for therapeutic gene delivery, adenoviral (Ad) vectors have proven particularly suitable for application to cancer. This work used a first generation adenovirus type 5 vector expressing the enzyme cytosine deaminase (AdCDA) cloned from E. coli. The combination of AdCDA/5FC with cisplatin was chosen because the combination of 5FU and cisplatin, both of which are used extensively in cancer treatment, has proven effective clinically and demonstrates synergy in vitro. This combination was evaluated in murine mammary carcinoma MTIA2 cells, human colorectal carcinoma HT29 cells, HT29pl4 cells, the photofrin resistant sub-line of HT29 cells, and murine melanoma Bl6/FIO cells. The classical clonogenic assay was used to evaluate this combination treatment since it provides an accurate indication of the effectiveness a cancer treatment will have in vivo. AdCDA infected MTIA2, HT29, and HT29pl4 cell lines exhibited a dose response to increasing concentrations of SFC that was significantly different from control vector infected cells. Similarly, uninfected cells demonstrated a dose response to increasing concentrations of cisplatin. The effect of the combination on clonogenic survival, administered in the sequence of a 48 h exposure to SFC followed by 1 h exposure to cisplatin, was greater than additive compared to the effect of the two treatments alone. F10 cells exhibited a dose response to increasing concentrations of cisplatin. However, it could not be shown reproducibly that AdCDA infected FlO cells exhibited a dose response to SFC that differed significantly from control vector infected cells. Work with the FlO cells was inconclusive regarding the combination treatment, but it rendered information regarding the sensitivity of these cells to what is hypothesized to be an unidentified component present in some preparations of 5FC. Evaluation of this treatment in vivo, using both murine and human tumor cell lines, will further define the potential of AdCDA/5FC + cisplatin as a clinically relevant cancer treatment. / Thesis / Master of Science (MSc)