Background Adjuvant chemotherapy, endocrine therapy, anti-HER2 therapy and radiotherapy significantly improve recurrence free and overall survivals in early breast cancers. Indications for a particular therapy have been well defined. Examples include oestrogen receptor positivity for endocrine therapy; HER2/Neu protein overexpression for anti-HER2 therapy; young age group, lymph node positivity, nuclear grade 3 and triple negativity (ie, ER/PR/HER2 negative) etc for chemotherapy; lumpectomy, > 5 cm tumour size, > 4 lymph nodes involvement etc for radiotherapy. Compared to no chemotherapy adjuvant chemotherapy can reduce the 10 years breast cancer mortality risk by one third although the absolute benefit depends on the absolute risk before the adjuvant chemotherapy as the risk reduction is proportional. The absolute risk depends on the various clinical and histopathological risk factors such as age, nuclear grade, tumour size, lymph node involvement, oestrogen hormone and HER2 receptor expressions. Various clinical guidelines, prognostic/ predictive tools and tests have been developed to calculate the absolute breast cancer specific survival risks and chemotherapy benefits to help in making the decision of “potential benefit outweighs the potential treatment toxicities” to recommend the adjuvant chemotherapy on individual basis. This principle aims to identify patients with very good prognosis for whom the toxic chemotherapy could be safely omitted and also patients with prognosis poor enough to justify offering toxic chemotherapies. However, no studies have specifically focussed on identifying patients in whom the chemotherapy could not deliver the expected benefit. Analysing molecular biomarker proteins that are functionally important in the cancer biology and chemotherapy cell killing mechanism using readily available and relatively inexpensive immunohistochemistry (IHC) method might be able to identify this Biomarkers to individualise adjuvant systemic therapy in early breast cancer Page 5 group of patients and find the targets against which novel therapy could be developed to improve their survival outcomes.

Cancer has often been set apart from other illnesses and diseases, receiving separate sources of funding and a high level of media and public coverage. Each year around 230,000 people in England will be diagnosed with cancer and incidence is projected to nearly double by 2020 (Department of Health [DoH], 2007a & 2007b). The development of government initiatives such as The NHS Cancer Plan (DoH, 2000) and The Cancer Reform Strategy (DoH, 2007a), signals that cancer care will remain a government and National Health Service priority. This thesis is comprised of three papers. The first two, a literature review and empirical study, focus on two under-researched areas within the field of cancer. Chapter one presents a critical review of research on the relationship between human-animal interaction (HAI) and psychological wellbeing, as applied to people with cancer. Research in the field of HAI incorporates activities associated with pet ownership, pet/animal assisted therapy and animal-assisted activity. HAI is increasingly used in a variety of healthcare settings with reported psychological and physical benefits. The review reveals empirical support for the association between HAI and improvements in mood, and highlights limitations within the current evidence base and directions for further research. Chapter two presents an empirical study exploring women‘s experiences of surviving early stage ovarian cancer. There is a paucity of research into what the experience of survivorship means for these women. The paper focuses on possible changes to personal and social identity using Interpretative Phenomenological Analysis. Findings revealed four superordinate themes comprising: participant‘s reflections on, and response to, diagnosis and treatment; the meaning which the experience of survivorship holds for them; the impact of the cancer experience, including changes to personal identity. Clinical implications of the findings and directions for further research are discussed. Chapter three consists of a reflective paper considering some of the issues which arose for the researcher during the research process. They include considerations which may be of potential benefit to other clinicians or researchers within the field of HAI or cancer care.

Organ motion - whether due to respiration, cardiac motion or digestive processes - is one of the major problems in external beam radiotherapy as it limits the achievable precision in dose delivery. Adaptive radiotherapy (ART) is a novel approach for a more precise dose delivery where measured patient-specific variations are used to change the delivery pattern throughout the treatment course. The aim of the work described in this thesis has been to contribute to the progress of ART by developing dynamic phantoms for the simulation of target motion, evaluating adaptive treatment strategies, and providing tools for the assessment of optimal patient-specific treatment parameters. A dynamic, anthropomorphic and tissue equivalent thorax phantom has been developed and assessed. The phantom provides accurate, three-dimensional regular or irregular motion of both a tumour within the lungs and the chest wall independently. It has been designed to investigate the effect of organ motion on the dose delivered to a moving target, to evaluate the potential benefit of adaptive treatment strategies and to assess ART delivery systems. The potential of the phantom has been evaluated through experiments on a respiratory-gated CT system and during tests on a real-time motion tracking system. In addition, the principles used for the thoracic phantom have been used to design dynamic phantoms for the prostate and bladder. An adaptive off-line correction strategy accounting for inter-fractional prostate motion has been evaluated using radiobiological modelling. This work revealed that it is important to consider the normal tissue complication probability of the rectum and the direction of anterior-posterior prostate motion when determining the optimal timing for re-optimisation of the treatment plan. Specifically, relying on calculations of the tumour control probability alone provides misleading results. In general off-line correction based on only a few observations in the early treatment course is shown to improve the probability of uncomplicated tumour control. Target coverage for respiratory-gated radiotherapy has been modelled with simulated and real breathing traces. The results have demonstrated that maximum benefit is achieved with amplitude gating at end of exhalation. The analysis showed that treatment parameters should be adjusted prior to each fraction. As part of this work a model that assists on deciding the most appropriate gating parameters on an individual patient basis has been developed. Finally, a treatment strategy decision support tool has been developed and applied to respiratory data obtained from patients. The tool not only identifies whether tumour mobility justifies implementing an adaptive treatment technique but where it does the tool supports selecting the optimal ART technique to be used together with the appropriate treatment parameters that will provide the greatest benefit to an individual lung cancer patient.

Studies have shown that elevated COX2 expression in colorectal cancer is associated with enhanced metastasis, although the mechanism is unclear. Cancer cells are characterised by the ability of invasive cells detaching from the primary site by downregulation of adhesion molecules such as E-Cadherins. Subsequently, these cells invade through basement membrane onto extracellular matrix by metalloproteinases (MMP). Interaction of cells and extracellular matrix involves cell adhesion molecules such as CD44 and b1-integrins. Finally, intravasation requires cancer cells adhering onto endothelium, an interaction between epithelial Sialyl-Lewis Antigens (SLAs) and endothelial (E)-Selectins. Colorectal cancer cell lines (HT29, CaCO2 and Colo205) and human dermal microvascular endothelial cells (HDMECs) were subjected to different agents (LPS, butyrate, dexamethasone, PGE2 and NS398) in order to determine their COX2, MMP2, E-Cadherins, b1-integrins, CD44, SLAs and E-selectins expression. An index of cells’ invasive potential was assayed using Matrigel chamber simulating extracellular matrix and coculture with HDMECs. HT29 expressed more COX2 than CaCO2. Colo205 was COX2-negative. LPS induced COX2 expression in HT29 but had no significant effects on CaCO2 and Colo205, whereas dexamethasone was inhibitory to the same effect. Butyrate did not demonstrate any significant changes to COX2 expression in all cell lines. NS398 caused a dose and time-dependent inhibition of COX2 activity, as demonstrated by PGE2 assay.

Measuring fine track widths with optical instruments has become increasingly difficult as the dimensions of the features of interest have become smaller than the traditional optical resolution limit. This has caused a move to non-optical methods such as scanning electron and atomic force microscopy techniques, or novel optical methods combined with signal processing techniques to provide measurements of these samples. This thesis presents one method to increase the measurement capabilities of an optical system. This is achieved by combining an optical profiler such as a scanning interferometer, with an artificial neural network (ANN). Once trained the ANN can calculate the object parameter for other tracks not contained in the training set. This process works extremely well; with experimental results showing that a 60nm track width can be calculated with a 2nm error using an optical system with a spot size of 2.6 microns. The technique can be extended to obtain other parameters such as height, sidewall slope and for other structures such as double tracks. Various aspects of the ANNs have been investigated, such as the training range, the size of network and the impact of noise etc. These studies show that the technique is extremely robust, and has huge potential for general usage.

The project set out to use a very precise three dimensional tracking system to identify changes in joint condition for use in clinical assessment. Untried and untested the CODA-3 was brought into the department and put through a six month period of validification in order to evaluate it's capabilities. These are described in detail in the text. Once satisfied that the equipment was capable of measuring minute rapidly changing position of it's prismatic markers, pilot studies were devised to assess it's ability to reproduce the results from well recognised gait-analysis techniques. It gave promising results. The next task was to determine which set of parameters we could derive using CODA-3 that would be of use in describing the kinematics of the diseased and/or prosthetic knee for use as a tool in clinical assessment. Using FORTRAN, subroutines were written and run on a DEC LSI-11 computer, to collect, store and analyse the x, y and z coordinates of the eight CODA landmarks. It was hoped that by appropriate siting of the markers the velocities and accelerations of the segments comprising a joint could be monitored throughout the gait cycle. The resultant patterns of these parameters were plotted out, and the actual data values stored. It was hypothesised that weaknesses in a joint, whether or not detectable by clinical examination would, at points in the gait cycle of maximum joint loading be seen as ectopics in the smooth waveform of the acceleration and velocity of the profiles expected from the normal knee. The results the author presents would suggest that if the limitations of this particular model could be overcome (as it is reported they will be) then the technique has the capability of highlighting abnormalities in a joint. The author is doubtful however that these same weaknesses could not be detected by the clinician. The system may well have other applications related to this area of work and these are discussed.

Interval timing behaviour refers to the ability of animals and humans to adapt their behaviour to temporal regularities in their environments. Two important classes of interval timing behaviour are temporal discrimination (discriminating between the durations of external events) and temporal differentiation (behavioural adaptation during an ongoing interval). It has been known for many years that drugs that affect central dopaminergic function can alter both forms of timing behaviour. More recently, evidence has been accumulated which shows that manipulation of central 5-hydroxytryptaminergic (5-HTergic) function can also influence interval timing behaviour. The experiments described in this thesis examined the effects of drugs acting at some subtypes of 5-HT receptors on temporal discrimination and temporal differentiation in the rat. Chapter 1 contains a review of the relevant literature. First, the anatomy, biochemistry and receptor pharmacology of the 5-HTergic system is outlined, and a selective review of the role of 5-HT in some behaviours relevant to this project is presented. This is followed by an overview of the behavioural methodology that has been used to study timing behaviour in animals, and an account of the major theories of timing behaviour. Finally, the behavioural pharmacology of timing behaviour is reviewed. Chapters 2-7 describe a series of experiments examining the effects of drugs acting at 5-HT1A, 5-HT2A/2C, and 5-HT3 receptors on temporal discrimination and temporal differentiation. Experiment 1 examined the effect of the 5-HT3 receptor agonist m-chlorophenylbiguanide (m-CPBG) and the non-selective agonist quipazine on temporal discrimination performance in the discrete-trials psychophysical procedure. Quipazine produced a dose-dependent disruption of temporal discrimination, consisting of a rightward displacement and flattening of the fitted psychometric function, reflected in a significant increase in the values of the indifference point T50 and the Weber fraction. m-CPBG had no significant effect on either T50 or the Weber fraction. The effects of quipazine were completely abolished by the 5-HT2A receptor antagonist ketanserin, but not by the 5-HT3 receptor antagonist topanyl 3,5-dichlorobenzoate (MDL-72222), indicating that the effect of quipazine was mediated by 5-HT 2A, and not 5-HT 3 receptors. In experiment 2, the effects of quipazine and m-CPBG were examined on temporal differentiation performance in the free-operant psychophysical procedure. Quipazine dose-dependently displaced the psychometric function to the left, reducing the value of T50, and significantly increased the Weber fraction. m-CPBG had no effect on the parameters of the function. The effects of quipazine were reversed by co-administration of ketanserin, but not by co-administration of MD L-72222. These results suggest that while 5-HT 2A receptor stimulation has a robust influence on temporal differentiation, 5-HT3 receptor stimulation does not. Experiment 3 further examined the effect of 5-HT2A receptor stimulation on temporal discrimination. The 5-HT 2A/2C receptor agonist 2,5- dimethoxy-4-iodoamphetamine (DOI) increased the Weber fraction and tended to increase T50. Ketanserin and the highly selective 5-HT2A receptor antagonist (± )2,3-dimethoxyphenyl-1-(2-( 4-piperidine )-methanol) (MDL-I00907) fully antagonized the effects of DOI The results indicate that DOI disrupts temporal discrimination via stimulation of 5-HT2A receptors. Experiment 4 examined whether intra-striatal injection of DOI would affect temporal discrimination, and whether the effect of systemically administered DOI on temporal discrimination would be blocked either by MDL-100907 or by 8-( 5 -(2, 4-dimethoxy-5 -( trifluoromethylphenylsulphonamido )phenyl-5-oxopentyl)-1 ,3,8- riazaspiro( 4.5)decane-2,4-dione RS- 102221: a selective 5-HT2C receptor antagonist), administered directly into the dorsal striatum. Intra-striatal injection of DOI did not affect temporal discrimination. Systemically administered DOI disrupted temporal discrimination; this effect was not attenuated by intra-striatal injection of MDL-100907 or RS102221, suggesting that the 5-HT2 receptors that mediate DOI's effect on temporal discrimination are not located in the dorsal striatum. Experiments 5 and 6 examined the effects of intra-striatally administered DOI, MDL-100907 and RS-102221 on temporal differentiation. In experiment 5, systemic injection of DOI significantly reduced T50. This effect was antagonized by systemically administered MDL-100907. In experiment 6, intra-striatally administered DOI had no significant effect on T50 or the Weber fraction. Intra-striatal injections of MDL-100907 and RS-102221 did not alter temporal differentiation, and failed to reverse the effects of systemically administered DOI. The results suggest that the 5-HT2 receptor population responsible for DOI’s effect on temporal differentiation is not located in the dorsal striatum. Experiment 7 examined the effect of a 5-HT1A and a 5-HT2A receptor agonist on another widely-used temporal differentiation schedule, the fixed interval peak procedure. The 5-HT1A receptor agonist 8-hydroxy-2-( di-n-propylamino) tetralin (8-0H-DPAT) and the 5-HT2A/2C receptor agonist DOI had similar effects on performance: both agonists displaced the peak function to the left and reduced the peak time, tpeak. The effect of 8-0H-DPAT was antagonized by the selective 5-HT1A receptor antagonist N-[2-( 4-[2-methoxyphenyl]- 1-piperazinyl)ethyl]-N-2-pyridinylcyclohexane-carboxamide (WAY- 100635), and the effect of DOI by the 5-HT2A receptor antagonist ketanserin, respectively. These results, taken together with previous findings with the free-operant psychophysical procedure, suggest that 5-HT1A and 5-HT2A receptors mediate similar effects on temporal differentiation. The final chapter (Chapter 8) summarizes the findings from the project, and discusses their implications for the putative role of 5-HT in interval timing and for current theoretical accounts of timing. It is argued that current models of timing behaviour that assume the existence of a unitary 'pacemaker-driven' internal clock may have difficulty accommodating the finding that the same drug can have qualitatively different effects on temporal discrimination and temporal differentiation. Some possible directions for future research in this area are also discussed.

The heat shock response was originally described as a phenomenon of inducible gene expression in Drosophila in response to hyperthermia, but has rapidly become recognised as a ubiquitous response by virtually all cell types to a wide variety of environmental stresses. Much of the early work on heat shock protein (hsp) structure and function concentrated on the analysis of heat shock gene expression in Drosophila, but it soon became clear from studies involving higher eukaryotes and prokaryotes that the heat shock response is highly conserved and a high degree of homology in the nucleic acid sequence of related heat shock genes is evident in all species from bacteria to man. Over the past decade, the study of heat shock protein expression has diversified into broad areas of biological research. The importance of heat shock proteins as molecular chaperones which mediate the folding and assembly of polypeptide chains has led to a reexamination and broadening of our understanding of the principles of protein folding and transport. In immunology, heat shock proteins have been shown to act as major antigens involved in the immune response to pathogens, and mechanisms involving heat shock proteins have been implicated in the pathogenesis of a variety of autoimmune diseases, including rheumatoid arthritis and systemic lupus erythematosus. At the conception of this research, evidence existed that expression of heat shock proteins was related to the differentiation of cells, including haemopoietic cells, and abnormal expression in some tumour cells had been reported, although not in leukaemic cells. It was against this background that the ideas for this research project were conceived. Based in the Department of Haematology at Warwick Hospital, I had access to samples from leukaemic patients, providing an opportunity to examine heat shock protein expression in malignant cells from these patients. As the project evolved, the significance of lisp expression was addressed by studying the relationship between heat shock protein expression and apoptosis. This mode of cell death has recently been shown to be crucial in carcinogenesis. A tumour is known to develop if the balance between cell division and cell death by apoptosis is disturbed, permitting a potentially malignant clone of cells to escape elimination. In addition, most, if not all, the cytotoxic drugs used to target malignant cells are known to exert their effects via the induction of apoptosis. The expression of genes which influence the susceptibility of cells to chemotherapy-induced apoptosis may therefore have a bearing upon the efficacy of chemotherapeutic regimens. Since heat shock proteins have been shown to protect cells against apoptosis induced by a variety of stresses, their expression in leukaemic cells is particularly worthy of investigation, both in terms of leukaemogenesis and the response of leukaemic cells to chemotherapy. This research project has therefore evolved to question the role of heat shock proteins in the biology and treatment of leukaemia and to establish their role in the control of apoptosis, with particular reference to the stress response of cells exposed to the chemotherapeutic agents used in the treatment and clinical management of these malignancies.

This thesis concentrates on the treatment of women with breast cancer in the 19th and 20th century. It analyses written published patient narratives linking them with clinical developments. Medical history holds a rich source of information providing the view of the clinician. This includes case reports and case series from one surgeon or one hospital for the earlier period of the study and has progressed to the double blind randomised controlled trial that dominates comparative research today. There is an imbalance in the material available for the analysis of patients’ perceptions of their treatment. The patient view is not represented well in the history of medicine. This thesis attempts to provide a more complete assessment of the developments in breast cancer treatment by including the patient’s view. Three narratives provide an insight into the perception of women who were treated with breast cancer prior to the introduction of anaesthesia and infection control. The novelist, Fanny Burney (1752-1840), underwent a mastectomy in 1811. In a letter to her sister she wrote about her experience providing details of her diagnosis and treatment. In comparison, Emily Gosse (1806-1857) refused a mastectomy for her breast cancer and sought alternative treatment with caustics. Her husband, Phillip Gosse and friend, Anna Shipton, wrote narratives about Emily’s suffering. A third narrative provides the view of a woman with breast cancer who received no treatment and died of metastatic breast cancer; Zelie Martin died in 1877. These narratives were linked to a case report by Lorenz Heister (1683-1758). Heister described the procedure for amputation of the breast in detail. His method prevailed until new scientific developments in surgery such as anaesthesia and infection control improved the short-term survival of patients and enabled surgeons to operate sooner with a greater attention to detail.

The aims of this thesis were to develop new dosage guidelines for epirubicin. In this thesis, a population analysis performed using a UK data set, including 109 patients with breast cancer treated with single-agent epirubicin, identified aspartate aminotransferase (AST) as the only covariate that had a clinically significant influence on epirubicin CL. The population model for epirubicin CL was as follows: CL (L/h) = 72.9 x (1- (0.135 x (In AST)). Inclusion of AST reduced the inter-individual variability in CL from 49 to 39 %. Using the population model, new dosage guidelines were proposed to achieve a target AUC of 4000 ng.h/ml, as identified from the literature. The following doses were predicted to achieve this exposure with the greatest precision: ASK150 U/L = 125 mg; AST 150-250 U/L = 90 mg; AST 250-500 U/L = 60 mg; AST> 500 U/L = 30 mg. In the UK data set, the new guidelines achieved the target with greater precision (root mean squared error (rmse) = 39.0 %) than the current UK guidelines, current USA guidelines or an earlier equation based on AST (raise = 63 %, 62 % and 59 %, respectively). Furthermore, as the proposed dosing guidelines do not require adjustment according to BSA, they could reduce dosage preparation time and minimise the potential for prescribing and dispensing errors. The predictive performance of the model was evaluated using two external data sets. In 18 patients with either breast cancer or hepatocellular carcinoma, the population model estimated CL values with poor precision (rmse = 82 %). Similarly, in a Swedish data set including 79 patients with breast cancer, the population model also estimated CL values with poor precision (rmse = 43 %). A comparison of CL values in patients with normal liver function showed that the median CL in patients from the Swedish data set was nearly twice that in the UK data set The Swedish and UK data sets were combined and a new population model using all the data was developed. Despite the increase in patient numbers, AST was still the only clinical factor that was identified as influencing epirubicin PK.