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Thesis (M.Sc. (Chemistry)) -- University of Limpopo, 2021 / Breast cancer is a malignant tumour that starts in the cells of the breast. Many studies revealed aromatase (CYP19A1) and cyclin-dependent kinase 2 (CDK2) as possible therapeutic targets regarding breast cancer treatment, because they play crucial roles in anti-apoptotic processes during cell proliferation. Quinoxaline derivatives have attracted a great deal of attention due to their biological activities against fungi, virus, bacteria and cancer. Computer modelling was employed in order to reduce time and cost by searching the library of molecules and identifying those which are likely to bind to the drug target. A library of new one hundred (100) nitro and amino quinoxaline alkyne derivatives were successfully designed and screened against target proteins (CYP19A1 and CDK2) using virtual screening technique and thirteen (13) molecules were identified to be hit compounds against both targets with the docking score ranging from -6.143 to -8.372 kcal/mol as a measure of binding affinity. The hit compounds were subjected to IFD in order to identify tight binding through intermolecular interactions with active site residues of the binding pocket of the target proteins. All identified nitro and amino quinoxaline alkyne derivatives were successfully synthesised in a multi-step reaction sequence and their spectroscopic analysis (NMR, FTIR and MS) were in good agreement with the proposed structures in a good to moderate yield. The newly synthesised novel amino and nitro-quinoxaline derivatives were evaluated for anti-proliferative activity against breast cancer (MCF-7). Compound 59 showed to possess good inhibition against MCF-7 with an IC50 of 9.102 μM, whereas compounds 34, 54, 56 and 61 showed promising activity against MCF-7 with an IC50 value of < 50 μM. However, the MTT assay results showed that 59 was found to be toxic with an IC50 value of 0.205 μM against Raw 264.7 cell line. The dose response investigations showed that 31 and 34 have the promising anti-cancer activity against CYP19A and the correlation between molecular modelling (in-silico) and CYP19A inhibition activities (in- vitro), was established as compounds 31 and 34 were identified to bind to the drug target (CYP19A) with the docking score of -8.372 and 7.630 kcal/mol respectively. All the synthesized compounds were evaluated for the antitubercular activity against Mtb H37Rv strain as a secondary study. Compounds 57-62 with nitro-quinoxaline derivatives exhibited stronger inhibitory effects on Mtb H37Rv strain. In addition, compounds 60 and 62 were found to be most active against Mtb H37Rv with the high activity at MIC90 of <0.65 and <0.64 μM respectively. All active compounds are currently investigated for their cytotoxicity which have not been investigated before. / National Research Foundation (NRF) and Sasol Inzalo Foundation

Paclitaxel was isolated from the bark of <i>Taxus brevifolia</i> in the late 1960s. It exerts its biological effect by promoting tubulin polymerization and stabilizing the resulting microtubules. Paclitaxel has become one of the most important current drugs for the treatment of breast and ovarian cancers. Studies aimed at understanding the biologically active conformation of paclitaxel bound on β–tubulin are described. In this work, the synthesis of isotopically labeled taxol analogs is described and the REDOR studies of this compound complexed to tubulin agrees with the hypothesis that palictaxel adopts T-taxol conformation. Based on T-taxol conformation, macrocyclic analogs of taxol have been prepared and their biological activities were evaluated. The results show a direct evidence to support T-taxol conformation. (+) Discodermolide is a polyketide isolated from the Caribbean deep sea sponge <i>Discodermia dissoluta</i> in 1990. Similar to paclitaxel, discodermolide interacts with tubulin and stabilizes the microtubule <i>in vivo</i>. Studies aimed at understanding the biologically active conformation of discodermolide bound on β–tubulin are described. In this work, the synthesis of fluorescent labeled discodermolide analogs is described and their biological activities were evaluated. Synthetic approaches to fluorescent labeled and isotopically labeled discodermolide analogs discodermolide are also described. / Ph. D.

Taxol (1) was first isolated from the bark of the Pacific yew about 35 years ago by Drs. Wall and Wani. Although its development as an anticancer agent was delayed by numerous reasons, including its scarcity and insolubility, the discovery of its tubulin-assembly activity and other factors motivated oncologists to overcome these problems. It has since become one of the most important current drugs for the treatment of several cancers, including breast and ovarian cancers. Like almost all anticancer drugs taxol does have some toxic side effects and many tumors also show significant resistance to therapy with taxol. Drug targeting studies aimed at improving its selectivity and efficacy is described. Two targeting methods, the estrogen receptor (ER) directed targeting and colloidal gold (cAu)directed targeting, were used in our research. In this dissertation, a series of estradiol-taxol conjugates (ETCs) were synthesized. They were active in four cytotoxicity assays and tubulin polymerization assay, but less active than taxol. One of them showed the desired selectivity for ER positive cancer cells. Recently, several studies have attempted to elucidate the bioactive binding conformation of taxol on microtubules. Three models have been proposed for this conformation. The T-taxol conformation was proposed by Dr. Snyder based on electron crystallographic density and molecular modeling. In this dessertation, a series of cyclopropyl-containing taxol analogs and macrocyclic taxol lactones were synthesized. The bioassay results showed they are less active than taxol. The molecular modeling studies suggested that the cyclopropyl-containing taxol analogs could not adopt the T-taxol conformation, which would result in the loss of bioactivities. It is an indirect evidence to support T-taxol conformation. As for macrocyclic taxol lactones, it is proposed that they would have a close contact between the ester moiety on the C-3' phenyl ring and Phe272 of the β-tubulin protein when they adopt T-taxol conformation. It will push the macrocyclics out of the binding pocket and lead to the lost of bioactivities. / Ph. D.

A LDE é uma nanoemulsão rica em colesterol com composição semelhante às lipoproteínas naturais. Devido a sua capacidade de ligação aos receptores da lipoproteína de baixa densidade (LDL) cuja expressão é aumentada em células neoplásicas, a LDE pode ser usada como veículo de agentes quimioterápicos concentrando os mesmos no tecido tumoral. A base racional da quimioterapia combinada é utilizar medicamentos que atuem em diferentes partes dos processos metabólicos da célula, aumentando dessa forma a probabilidade de destruição de uma maior quantidade de células tumorais. O principal fator limitante do uso combinado dos quimioterápicos paclitaxel e etoposídeo é o efeito mielossupressor. O direcionamento específico do fármaco às células tumorais promovido pela LDE, tornaria possível a terapia antitumoral combinada LDE-oleato de paclitaxel e LDEoleato de etoposídeo, sem produzir os efeitos colaterais observados com o uso combinado das formulações comerciais. O presente estudo tinha como objetivo avaliar os efeitos da terapia antitumoral combinada LDE-oleato de paclitaxel e LDEoleato de etoposídeo em comparação com a terapia dos respectivos fármacos isoladamente, bem como com a terapia combinada do paclitaxel e etoposídeo comerciais. A atividade antitumoral foi determinada em camundongos portadores de melanoma após a administração de intraperitoneal de LDE-oleato de paclitaxel 15 mg/kg e LDE-oleato de etoposídeo 10 mg/kg. Nos grupos dos fármacos comerciais injetou-se paclitaxel 3,75 mg/kg e etoposídeo 2,5 mg/Kg, ou paclitaxel 7,5 mg/Kg e etoposídeo 5 mg/kg. Os fármacos foram administrados em dois esquemas terapêuticos: 11º, 13º, 15º; e 11°, 14°, 19° dias após a inoculação do tumor. Todos os grupos apresentaram aumento na taxa de sobrevida em comparação ao grupo controle. Por outro lado, nos grupos LDE-fármacos foi observada uma redução dos efeitos de mielossupressão, visto que as doses administradas nestes grupos foram 2 e 4 vezes maiores do que nos demais. Os tratamentos do melanoma nos dois protocolos terapêuticos mostraram-se eficazes na redução da massa tumoral, sendo seu efeito inibitório acima de 90% nos grupos LDE-fármacos e na combinação dos quimioterápicos comerciais de maior dose. O número de metástases foi menor nos grupos de combinação LDE-Fármacos. Os resultados mostraram que a terapia antitumoral combinada LDE-oleato de paclitaxel e LDE-oleato de etoposídeo foi mais eficaz que as terapias isoladas destes fármacos e que a terapia combinada com o paclitaxel e etoposídeo comerciais. / LDE is a cholesterol-rich emulsion with similar composition to the natural lipoproteins. Due to its ability of binding to the Low Density Lipoprotein (LDL) receptors and concentrate in neoplastic cells which present overexpression of these receptors, LDE may be used as vehicle to target antineoplastic drugs against cancer cells. Combined chemotherapy is a therapeutic strategy against cancer that usually uses drugs that act in different parts of cells metabolism, increasing the chances of destruction of the cancer cells. In addition, adverse effects can be reduced when combining agents with different toxicities at lower doses than the usual in single therapy. The major limiting factor in combining the chemotherapeutic agents paclitaxel and etoposide is their side effects such as leukopenia, thrombocytopenia and anemia. The ability of LDE to carry the drug into the cell may bring a strong possibility of combining LDE- paclitaxel oleate and LDE-etoposide oleate without producing the toxic effects observed in the combined use of the commercial formulations of these drugs. The current study was designed to evaluate the effects of combined antitumoral therapy of LDE- paclitaxel oleate and LDE-etoposide oleate in comparison to the combination of commercial paclitaxel and etoposide formulations and to the single therapy with the same LDEagents. Antitumoral activity was determined in melanoma-bearing mice after injection of LDE-paclitaxel oleate 15 mg/kg and LDE-etoposide oleate 10 mg/kg, or commercial paclitaxel 3.75 mg/kg and etoposide 2.5 mg/kg, or commercial paclitaxel 7,5 mg/kg and etoposide 5 mg/kg. Drugs were administered in two protocols: 11º, 13º, 15º; and 11°, 14°, 19° days after tumor implantation. All groups had an increase in the survival rate in comparison to the control group, however LDE combination groups showed reduction in the bone marrow toxicity, since the doses used were 2 and 4 fold greater that in the commercial drugs groups. The tumor growth inhibition rate was greater in both LDE-drugs combination groups and in the higher dosage of paclitaxel and etoposide combination (over 90% in comparisson to the control). There were also great reduction of metastatic nodes in LDE-drugs combination groups in comparison to the commercial drugs combination groups. Our results showed that the antitumor combined therapy of LDE-paclitaxel oleate and LDE-etoposide oleate was more effective than the therapies with LDE-paclitaxel oleate and LDE-etoposide oleate alone, and the combined therapy of commercial paclitaxel and etoposide formulations.

Em estudos anteriores, mostramos que uma nanoemulsão artificial (NEm) de composição semelhante à da lipoproteína de baixa densidade se liga a receptores de lipoproteínas de baixa densidade após sua injeção na corrente sanguínea. Como tais receptores estão superexpressos em células com altas taxas de proliferação, como ocorre no cancer e na aterosclerose, a NEm pode ser utilizada como veículo para direcionar drogas a estas células, diminuindo sua toxicidade e aumentando sua ação farmacológica. Recentemente, reportamos que a associação de um derivado do agente antiproliferativo paclitaxel, o oleato de paclitaxel (OPTX) à NEm reduziu em 60% a área lesionada de aortas de coelhos submetidos à dieta rica em colesterol. Neste estudo, testamos o efeito sinérgico da terapia combinada do OPTX-NEm com um derivado do metotrexato, o di-dodecil metotrexato (DMTX), também associado à NEm. O MTX, além de sua ação antiproliferativa, também possui propriedades imunossupressoras. Coelhos machos da raça Nova Zelândia foram submetidos à dieta enriquecida com 1% de colesterol durante 8 semanas. A partir da quinta semana de consumo da dieta, 8 animais foram injetados semanalmente com solução salina por via endovenosa (grupo controle) e 8 receberam o tratamento combinado de OPTX-NEm (4mg/Kg) com DMTX-NEm (4mg/Kg), por 4 semanas. Ao final das 8 semanas, os animais foram sacrificados. As aortas dos animais foram retiradas, abertas longitudinalmente, fixadas em formalina tamponada a 10% e coradas com Escarlate R para a análise macroscópica da lesão. Os arcos aórticos foram seccionados em fragmentos de 5mm, embebidos em parafina e os cortes realizados foram corados com hematoxilina-eosina, para a determinação da área das camadas íntima e média. O tratamento combinado de OPTX-NEm com DMTX-NEm reduziu a área das lesões em 82%, em comparação ao grupo controle, e a razão da área da lesão/área total diminuiu de 0,82±0,08 para 0,08±0,06 (p<0,01). Por meio das avaliações da variação do consumo de ração, peso corporal e contagem de leucócitos totais (p>0,05), pode-se afirmar que os tratamentos não apresentaram toxicidade significativa, exceto pela queda na contagem de eritrócitos (p<0,05). Como conclusão, a quimioterapia combinada de OPTX e DMTX associados à NEm como veículo mostrou-se eficaz na redução da área de lesão aterosclerótica em coelhos e a toxicidade relacionada aos fármacos foi nitidamente reduzida. / In previous studies we have shown that an artificial nanoemulsion (NEm) that resemble LDL composition are taken-up by LDL receptors after injection into the bloodstream. As those receptors are upregulated in cells with higher proliferation rates, as occurs in cancer and atherosclerosis, NEm can be used as vehicle to direct drugs against those cells, diminishing toxicity and increasing pharmacological action. Recently, we reported that association of antiproliferative agent paclitaxel derivative, paclitaxel oleate (OPTX) to NEm reduced by 60% the lesion area of cholesterol-fed rabbits. In this study, the combined chemotherapy of OPTX-NEm with a methotrexate derivative, di-dodecil methotrexate (DMTX), also associated with NEm, was tested for synergistic effects. MTX, besides antiproliferative action, has also immunosuppressant properties. Male New Zealand rabbits were fed a 1% cholesterol diet for 60 days. Starting from day 30, 8 animals were treated with 4 weekly I.V. saline solution injections (control group) and 8 with combined OPTX-NEm (4 mg/kg) plus DMTX-NEm (4 mg/kg) for additional 30 days. On day 60, the animals were sacrificed for analysis. Aorta was excised, open longitudinally, placed in 10% buffered formalin and stained in Scarlet R for lesion macroscopic analysis. Segments of 5mm of the aortic arch were embedded in paraffin and sections were taken and stained in hematoxylin-eosin for intima and media area measurement. In comparison with controls, treatment with combined OPTX-NEm plus DMTX-NEm reduced the lesion area by 82% and the lesion/total area ratio was decreased from 0,82±0,08 to 0,08±0,06 (p<0.01). Except for decrease in erythrocyte count (p<0.05), treatments were devoid of significant toxicity, as evaluated by food intake, body weight and leucocyte count (p>0.05). In conclusion, this novel approach consisting in combined chemotherapy of OPTX and DMTX using NEm as a drug-targeting vehicle showed effective lesion area regression in rabbits and marked toxicity reduction.

A LDE é uma nanoemulsão rica em colesterol com composição semelhante às lipoproteínas naturais. Devido a sua capacidade de ligação aos receptores da lipoproteína de baixa densidade (LDL) cuja expressão é aumentada em células neoplásicas, a LDE pode ser usada como veículo de agentes quimioterápicos concentrando os mesmos no tecido tumoral. A base racional da quimioterapia combinada é utilizar medicamentos que atuem em diferentes partes dos processos metabólicos da célula, aumentando dessa forma a probabilidade de destruição de uma maior quantidade de células tumorais. O principal fator limitante do uso combinado dos quimioterápicos paclitaxel e etoposídeo é o efeito mielossupressor. O direcionamento específico do fármaco às células tumorais promovido pela LDE, tornaria possível a terapia antitumoral combinada LDE-oleato de paclitaxel e LDEoleato de etoposídeo, sem produzir os efeitos colaterais observados com o uso combinado das formulações comerciais. O presente estudo tinha como objetivo avaliar os efeitos da terapia antitumoral combinada LDE-oleato de paclitaxel e LDEoleato de etoposídeo em comparação com a terapia dos respectivos fármacos isoladamente, bem como com a terapia combinada do paclitaxel e etoposídeo comerciais. A atividade antitumoral foi determinada em camundongos portadores de melanoma após a administração de intraperitoneal de LDE-oleato de paclitaxel 15 mg/kg e LDE-oleato de etoposídeo 10 mg/kg. Nos grupos dos fármacos comerciais injetou-se paclitaxel 3,75 mg/kg e etoposídeo 2,5 mg/Kg, ou paclitaxel 7,5 mg/Kg e etoposídeo 5 mg/kg. Os fármacos foram administrados em dois esquemas terapêuticos: 11º, 13º, 15º; e 11°, 14°, 19° dias após a inoculação do tumor. Todos os grupos apresentaram aumento na taxa de sobrevida em comparação ao grupo controle. Por outro lado, nos grupos LDE-fármacos foi observada uma redução dos efeitos de mielossupressão, visto que as doses administradas nestes grupos foram 2 e 4 vezes maiores do que nos demais. Os tratamentos do melanoma nos dois protocolos terapêuticos mostraram-se eficazes na redução da massa tumoral, sendo seu efeito inibitório acima de 90% nos grupos LDE-fármacos e na combinação dos quimioterápicos comerciais de maior dose. O número de metástases foi menor nos grupos de combinação LDE-Fármacos. Os resultados mostraram que a terapia antitumoral combinada LDE-oleato de paclitaxel e LDE-oleato de etoposídeo foi mais eficaz que as terapias isoladas destes fármacos e que a terapia combinada com o paclitaxel e etoposídeo comerciais. / LDE is a cholesterol-rich emulsion with similar composition to the natural lipoproteins. Due to its ability of binding to the Low Density Lipoprotein (LDL) receptors and concentrate in neoplastic cells which present overexpression of these receptors, LDE may be used as vehicle to target antineoplastic drugs against cancer cells. Combined chemotherapy is a therapeutic strategy against cancer that usually uses drugs that act in different parts of cells metabolism, increasing the chances of destruction of the cancer cells. In addition, adverse effects can be reduced when combining agents with different toxicities at lower doses than the usual in single therapy. The major limiting factor in combining the chemotherapeutic agents paclitaxel and etoposide is their side effects such as leukopenia, thrombocytopenia and anemia. The ability of LDE to carry the drug into the cell may bring a strong possibility of combining LDE- paclitaxel oleate and LDE-etoposide oleate without producing the toxic effects observed in the combined use of the commercial formulations of these drugs. The current study was designed to evaluate the effects of combined antitumoral therapy of LDE- paclitaxel oleate and LDE-etoposide oleate in comparison to the combination of commercial paclitaxel and etoposide formulations and to the single therapy with the same LDEagents. Antitumoral activity was determined in melanoma-bearing mice after injection of LDE-paclitaxel oleate 15 mg/kg and LDE-etoposide oleate 10 mg/kg, or commercial paclitaxel 3.75 mg/kg and etoposide 2.5 mg/kg, or commercial paclitaxel 7,5 mg/kg and etoposide 5 mg/kg. Drugs were administered in two protocols: 11º, 13º, 15º; and 11°, 14°, 19° days after tumor implantation. All groups had an increase in the survival rate in comparison to the control group, however LDE combination groups showed reduction in the bone marrow toxicity, since the doses used were 2 and 4 fold greater that in the commercial drugs groups. The tumor growth inhibition rate was greater in both LDE-drugs combination groups and in the higher dosage of paclitaxel and etoposide combination (over 90% in comparisson to the control). There were also great reduction of metastatic nodes in LDE-drugs combination groups in comparison to the commercial drugs combination groups. Our results showed that the antitumor combined therapy of LDE-paclitaxel oleate and LDE-etoposide oleate was more effective than the therapies with LDE-paclitaxel oleate and LDE-etoposide oleate alone, and the combined therapy of commercial paclitaxel and etoposide formulations.

Colorectal cancer (CRC) is one of the most common malignancies worldwide. However, adjuvant chemotherapeutic agents exhibit poor accumulation in the tumor mass and frequently result in serious side effects due to nonspecific damage to normal organs. Therefore, the development of more selective anticancer drugs with targeted delivery to tumor sites is the current trend in cancer therapies. Among these sites, tumor neovasculature is an attractive target for anticancer agents. It is because tumor growth is largely limited by blood supply which is dependent on the extent of angiogenesis in the tumor. / Experimental analysis suggested that TCP-1 phage and synthetic TCP-1 peptide specifically homed to colorectal cancer tissues and co-localized with the tumor vasculature. Moreover, TCP-1 peptide also recognized the vasculature of human colorectal cancer specimens. Subsequently, the homing abilities of TCP-1 phage were extensively tested in other cancer models. Results showed that TCP-1 peptide could also target the vasculature of orthotopic gastric cancer induced by human colon cancer cell line (MKN45) in BALB/c nude mice. Meanwhile, TCP-1 phage exhibited binding activity to colorectal cancer cells such as colon 26 and SW1116. TCP-1 peptide could carry a pro-apoptotic peptide into these cells and markedly enhanced its pro-apoptotic action. / In summary, we have used the phage display technology to isolate two unique peptides TCP-1 and TCP-2, which targeted the vasculature of orthotopic colorectal cancer and also recognized the vasculature of human colorectal cancer. Moreover, they could deliver fluorescein or pro-apoptotic peptide only to the tumor vasculature but not to other normal tissues, for imaging detection and targeted therapy. In conclusion, both TCP-1 and TCP-2 may have significant clinical applications as carriers in diagnostic imaging and ligand-mediated targeted therapy for human colorectal cancer. / Similarly, TCP-2 phage or its peptide also targeted specifically the orthotopic colorectal cancer, and co-localized with the tumor vasculature in mice. Meanwhile, TCP-2 peptide recognized the vasculature of human colorectal cancer specimens. FITC-labeled TCP-2 peptide could also be used to detect cancer tissues in tumor-bearing mice. / To identify specific ligands targeting the tumor neovasculature, in vivo phage display technology has been extensively used. Several dozens of peptides homing to normal or diseased vasculature have been identified through this technology. However, these peptides target mainly the tumors growing at distant sites but not at the primary organ, thus limiting their clinical application. To obtain specific peptides targeting the neovasculature of colorectal cancer growing in situ, we established an orthotopic colorectal cancer model in normal BALB/c mice by using syngeneic colon cancer cells (colon 26). Subsequently, in vivo phage display technology was utilized to isolate peptides which specifically recognized the vasculature of the cancer. Four peptides (termed TCP-1, 2, 3, 4) were enriched more than once after four-round selections. Further investigation disclosed that TCP-1 and TCP-2 phages had relatively stronger binding abilities to cancer tissues among the four phage clones. They were chosen for further study. / We further demonstrated that TCP-1 could serve as a carrier for image detection and drug delivery. FITC-labeled TCP-1 could specifically produce a strong fluorescence signal in the tumors after intravenous injection into the orthotopic tumor-bearing mice. Moreover TCP-1, when conjugated with a pro-apoptotic peptide, could also specifically induce apoptosis of tumor vasculature in vivo. / Li, Zhijie. / Adviser: Cho Chiltin. / Source: Dissertation Abstracts International, Volume: 72-04, Section: B, page: . / Thesis (Ph.D.)--Chinese University of Hong Kong, 2010. / Includes bibliographical references (leaves 194-221). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. Ann Arbor, MI : ProQuest Information and Learning Company, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese.

Background According to the Hong Kong Cancer Registry, breast cancer is a leading causes of cancer death in among females in Hong Kong. Local data indicate breast cancer has increased over the years. Previous studies have shown that socioeconomic factors can affect incidence of breast cancer, survival rates and access to treatments. However, there is little literature regarding how socioeconomic status (SES) potentially affects local breast cancer patients. Moreover, there have been no formal studies concerning the economic burden of expensive drugs and treatments among Hong Kong women facing breast cancer. Objectives: The objectives of this study are 1) to investigate the presence of an association between demographical SES and the patient’s usage of targeted therapy, and 2) to briefly discuss how well government drug subsidies can protect patients from catastrophic payments due to expensive trastuzumab. Methods: This dissertation will use a data set from a survey called “The effect of decision aids on treatment decision making for breast cancer surgery: A randomized controlled trial”. The survey targets Cantonese-speaking Chinese females attending one of the forty public hospitals under the Hospital Authority (except for the Queen Elizabeth Hospital). Cross-tabulations and logistic regressions are used to determine the association between SES and patients’ status on using targeted therapy. Results: Bivariate analyses show that associations between SES and those using targeted therapy are only present for certain independent variables including age, education attainment and medical insurance coverage four months and ten months after surgery. The logistic regression indicates that the variables, besides medical insurance coverage, are unable to predict whether the patient chooses targeted therapy or not. Conclusion: To conclude, associations between SES and targeted therapy usage (i.e. either the patient is currently receiving or waiting for therapy) is weak. Even though associations between SES and health outcomes (such as survival and mortality) are well-established, previous studies have commented that the mechanism behind this association is difficult to disentangle. In addition, the association appears weak in this study probably due to the small sample side, complicated interactions between SES and treatment choice, and insufficient information. Second, after comparing the Samaritan Fund and Community Care Fund financial criteria with the monthly household income of females in my data set, it is noticeable that the middle class could be at risk to financial burdens when paying for expensive drugs. / published_or_final_version / Public Health / Master / Master of Public Health