Review on different Multimodal Approaches for Multifactorial Cancer Disease

 

Dilip O. Morani1*, Bhushan Rane2

1Asst. Professor, Department of Pharmaceutics, Bombay Institute of Pharmacy and Research,

Dombivli - 421201, Maharashtra, India.

2Department of Pharmaceutics, Shri D.D. Vispute College of Pharmacy and Research Center,

Devad-Vichumbe, New Panvel - 410206, Maharashtra, India.

*Corresponding Author E-mail: dilip22morani@gmail.com

 

ABSTRACT:

In early-stage cancer, chemotherapy, radiotherapy or surgery is a common treatment. However, monotherapy results in medicine struggle besides later numerous series of treatment; it loses its effect in patients. The multimodal approach is an elementary principle for treating maximum tumor categories by confirmed existence benefits. The multidisciplinary approach comprises multimodality action and surgery followed by radiotherapy with or lacking chemotherapy or simultaneous chemoradiotherapy is mandatory for diverse forms of tumor. In all pathological states including cancer, combination approach is considered as future of therapeutics. Thus, grouping of multidrug treatment is utmost frequently utilized strategy in cancer treatment. While combining cancer treatment together with anticancer drugs overcomes the medicine fighting as well as provides synergistic result displaying delayed existence for patients. The drive of present review article is to 1) climax necessity and importance of multidisciplinary method in cancer treatment; 2) discuss part of radiotherapy, chemotherapy, immunotherapy and their combinations.

 

KEYWORDS: Multimodal approach; Multifactorial cancer; Multimodality imaging; Multimodal care, Combination therapy.

 

 


INTRODUCTION:

Cancer is a multifaceted disease that includes band beginning initial bulk reduction to a severe incapacity multiple symptoms mismatched with life. Cancer is a multipart condition that occurs in many patients where the source of the ailment is still unknown. Moreover, it is also present in various chronic conditions like kidney disease, obstructive pulmonary disease, as well as AIDS1-2. Cancer is a degenerative condition categorized by changed digestion, enhanced swelling and reduction in value of natural life.

 

 

This disease that has frustrated several investigators as well as clinicians from many years since it is many times irreversible and thus lead to increased mortality and morbidity3-4. Further, cancer is a varied disorder having various tumors originates in different portions of body. It is a disease associated with different etiology, epidemiology and therapy. For a favourable prognosis, premature discovery as well as handling of cancer is crucial factors. In developed countries, life expectancy is rapidly growing and population is aging leading to a noteworthy rise in number of people annually diagnosed with cancer because many kinds of tumors are age dependent. A conflict on cancer was announced and individuals pass away after courageous fights and in war, dreadful trials were often accepted5. Cancer is unique of main foremost origin of demise internationally and quantity of cancer instances is enhancing worldwide. The figure of cancer deaths globally predictable to rise through 45% from 7.9 million in 2007 to 11.5 million in 2030 according to [WHO] World Health Organization6 and total sum of new instances of cancer may expect to growth from 11.3 million in 2007 to 15.5 million in 2030. Various efforts have been ended to prevent, diagnose and treat cancer.

 

Cancer is a multifaceted disorder and record of literature indicates that it is an outcome of altered metabolism and decreased energy-protein consumption7-9. Decreased energy-protein consumption may be owing to number of aspects like pain, stress, depression, surgery, radiation, chemotherapy and underlying cancer itself10-11. Various revisions have also established that tumor as well as tumor microenvironment yield proinflammatory cytokines which lead to altered patient digestion. Variations in nutrient digestion like fat, glucose also protein digestion can be caused due to chronic inflammation. However, altered glucose and insulin levels contribute to proinflammatory carcinogenic atmosphere. Furthermore, the understandings of cancer causes will continue to enlarge and will expectantly in future can assist in improvement of treatment.

 

In western countries, approximately one sector of entirely demises is as a result of cancer. Half of cancer cases drop some body weight; one third drops additional 5% of their actual body weight. Upon diagnosis, the occurrence of bulk drop varies greatly with the tumor site. In cases with solid tumors, the highest occurrence of bulk drop is seen. In cancer patients, complete occurrence of bulk drop may increase as tall as 86% in past 1-2 weeks of life12.

 

Multifactorial Cancer Disease:

The pathophysiology of tumor is categorized by adverse energy as well as protein equilibrium which is determined by mixture of increased digestion and reduced diet consumption13-15. This includes multifaceted interaction among tumor and the host. Further, there are also mechanical factors that lead to reduce intake of food. The following patient factors in cancer mainly affect pathophysiology of patient.

 

Stage:

In general, majority of cancer cases are aged ended 70 years. From stage of 50, aging is related through drop of skeletal muscle. The mechanism behind this is many and includes decrease in spreading of stages of anabolic hormones like testosterone. Generally, there is an undesirable equilibrium amongst total body protein synthesis and deprivation. This phenomenon not only existing in skeletal muscle of aged cancer cases but then also may be aggravated through occurrence of current general swelling.

Physical exercise:

In cancer patients, measured mean bodily movement level was found to be much lower as compared with healthy adults of similar age16. It is well understood that absence of bodily movement will result in deconditioning as well as weakening in skeletal muscle mass. Further, physical movement can to produce to loss of anabolic stimulation. Thus, it is important to maintain modest stages of bodily movement. Nevertheless, it is likely to enhance physical activity through special nutritional complement comprising eicosapentaenoic acid (EPA). Physical activity is an important component of quality of life (QOL) and slightly renovation of it towards normal level can guide to improvement in QOL for tumor cases.

 

Protein digestion:

It is observed that 2.6 gm of muscle protein catabolize to yield 1 gm of fibrinogen emphasizing noteworthy discrepancy amongst important amino acid configuration of muscle and acute phase proteins17. The bent to reduction of skeletal muscle build may be owing to straight stimulation of catabolic pathways inside skeletal muscle via cytokines. In cancer patients, ubiquitin proteasome pathway (UPP) is stimulated and that act as vital controller of several cellular roles and its whole inhibition would be injurious.

 

Mechanical factors:

Cancer associated weight loss may be encouraged and preserved by decreased meal consumption18. Powered gastrointestinal irregularities can affect in decreased meal consumption and loss of appetite. Cancer patients may suffer from various conditions like pain, nausea, fatigue, constipation and malabsorption19. However, these signs are straight result of tumor attack. All the multiple factors which affect pathophysiology of tumor cases are characterized in Figure 1.

 

Figure 1: Multiple factors of cancer disease

 

The mortalities because of cancer disease have not progressed in previous some periods and still chemotherapy persists up-to-date standard of treatment. Though chemotherapy is cytotoxic at high dosage, its achievement is limited by adverse reactions and attained medicine confrontation which limits the maximum administered dose. Thus, different approaches like combination therapy, modern imaging techniques, multimodal imaging, multimodal care and theragnostic may be utilized to detect and treat diverse kinds of cancer are represented in Figure 2.

 

 

Figure 2: Diverse methods of cancer therapy

 

Combination Therapy:

Current treatment for cancer includes grouping of surgery, chemotherapy as well as radiotherapy. Surgery may treat confined tumors while chemotherapy and radiotherapy may have effectiveness in shrinking tumors20. Thus, these therapy opportunities may offer long period existence or may permit patients to drive into diminution21. However, occasionally patients can live for ages prior to cancer noticed again but inappropriately, further frequently than not, this is a deadly result22. Hence, one characteristic of cancer investigation which is presently being examined that why this happens and how it will be prevented from reoccurring even when treatment was effective and patient is in remission. So, development of therapy practice which encompasses to target multiple levels of tumor like beginning, movement as well as expansion of metastasis as a therapy is very essential in enhancing patient existence.

 

Tumor immunotherapy is an important aspect in tumor therapy which has many advantages23.

1.       It encompasses antigen presenting cells which become mature after appearance of antins and travel to lymph nodes which in turn induces natural killer (NK) cell as well as T cell reactions in lymphoid organs. At last, such T cells leave lymph node and enter into tumor bed activating immune response and effecting in antitumor result24

2.       Immunotherapeutic mediators involved melanoma distinction antigens like tyrosinase and cancer testes antigens25.

3.       Immunostimulatory monoclonal antibodies are utilised containing antagonist antibodies like cytotoxic T lymphocyte and agonist antibodies targeting CD4026.

4.       Moreover, cytokines like interleukin and interferon may similarly be delivered for immunotherapy27.

 

 

The rationales behind combination therapy are many and the trail has revealed better efficacy among radio, chemo and immunotherapy for multimodality treatment28.

 

Combination of hyperthermia therapy:

Hyperthermia therapy that is radiotherapy and chemotherapy have been combined for cancer disease. It is competent alternative therapy as its origin’s cancer reoxygenation. Enhancement in oxygenation is appeared when tumors heated between 39-43º C29. After heating, resultant reoxygenation can latter meant for 24 hours30. The chance of a positive reaction to radiation treatment can be improved via improvement of tumor oxygenation31. Additionally, hyperthermia combination has been exposed on the way to build tumors more delicate to chemotherapy and radiotherapy32. For example, grouping therapy of liposomal doxorubicin, paclitaxel and limited breast hyperthermia, 75% subsistence has been described to be improved by 5 years33.

 

Hyperthermia also triggered denaturation as well as accumulation of proteins which impact DNA restoration as well as cell cycle directive and changed vascularity for increase blood movement and medicine transfer and controlled the countenance of genes that yield household of heat shock proteins (HSPs)34. The overexpression of HSPs remains related to thermoresistance35. Suppression of HSPs gene expression is considered as multimodality treatment that inspired T cell immune response36. For example, gold nanoparticles might be utilised by way of photothermal mediators in grouping through immunotherapy37.

 

Mixture of anti-angiogenesis treatment:

This therapy inhibits the cancer growth by hindering development of novel blood vessels38. It is entailed in chronic inflammatory conditions and tissue regeneration. Cancer may get benefit from novel blood vessels for nutrients as well as oxygen and permit tumor cells to grow, conquer adjacent tissue and metastasis39. Angiogenesis inhibitor affects through signs narrated to development of novel blood vessels that is a form of chemical. Here are 2 types of inhibitors-indirect and direct angiogenesis inhibitor. Indirect angiogenesis inhibitor lumps synthesis of angiogenic proteins by cancer cells as well as blocks the receptor expression on endothelial cells while direct inhibitor restrains the vascular endothelial cells response to pro-angiogenic proteins40.

 

This treatment is associated with radiotherapy, chemotherapy or immunotherapy for synergistic or additive result41. This therapy normalizes tumor vessels, subjects to reduced vascular leakage, lowers intratumoral tissue pressure and enhanced therapeutic agent’s transport. By reduced intratumoral burden, this therapy increases oxygen stream in cancer as well as commands to tumor sensitivity to ionizing radiation. Enhancement in oxygenation and blood movement commands to developed volume of oxygen, glucose and amine acids that will support T cells to retain action in immunotherapy. In a trail, this treatment was grouped by hormonal treatment on patients through hormone receptor positive breast cancer who obtained first line bevacizumab and taxane comprising regimen42.

 

Mixture of photodynamic treatment:

Photodynamic treatment (PDT) uses a specific kind of light and photosensitizing agent to treat cancer. When photosensitizing mediator gets collected in tumor at equal period laser or another light basis is transported to parts. Then photosensitizer becomes stimulated after ground to excited level as well as liberates energy via again arriving to ground level. Further, energy is allocated to oxygen and effects in creation of reactive oxygen species (ROS) which results in cellular toxicity43. Paophyrin is utmost usually utilized as photosensitizer. The other examples of photosensitizers are chlorin, bacteriochlorin, phthalocyanine, chlorophyll derivative, purpurin etc. Among these, haematoporphyrin, methyl tetrahyroxyphenyl chlorine, 5-aminolevulinate and 5-aminolevulinic acid have been approved for clinical use44.

 

By generation of ROS, PDT kills the cancer cells and hurts tumor linked vasculature subjecting to nutrient deficiency and tumor hypoxia. It also declines immunosuppressive outcome and starts immune reaction in contrast to cancer cells45. However, majority of photodynamic narrated multimodality therapy are still in progress in animal models46.

 

Mixture of gene treatment:

It is new therapy which involves primer of genetic substance (DNA or RNA) within person’s cells to oppose against disorder. Viral paths have been extensively utilised to carry genes into tumor cells47. Also, it stimulates immune response, overwhelmed cell confrontation and prepare cancer cells delicate to treatments like chemotherapy as well as radiotherapy48. Generally, this therapy can be joint through all other above therapies such as immunotherapy, chemotherapy, hyperthermia therapy, PDT and anti-angiogenesis treatments by directing definite steps of tumor cells and promoting efficiency of other treatments. Currently, several clinical tests for gene treatment single lacking blend through further treatments is in progress49. One instance of grouping gene treatment was done by herpes simplex virus-thymidine kinase on prostate cancer patients50.

 

Phototheral therapy:

In this case, nanoparticles (NPs) fixed inside tumors produce heat in reply to exogenously functional laser light and may similarly considered as self-determining approach for discriminatory tumor therapy. Gold NPs are important carriers of PTT as it offers several advantages.

1.     Biocompatibility

2.     Effective light to heat translation

3.     Capacity to captivate near-infrared (NIR) light that pierces into the tissue more extensively than other light wavelengths51.

 

Gold NPs facilitated PTT has likewise assessed by grouping through further treatments like immunotherapy and gene treatment for increased antitumor effects. Thus, such combination may open thrilling chances for multimodal tumor therapy and may eventually guide to enhanced patient conclusions. NPs finished of numerous ingredients may be utilised for PTT52-54 but gold-based NPs (AuNPs) contain either partially or entirely gold and served as guide therapeutic stage as they offer various advantages. For applications in photothermal claims, AuNPs should have certain strategy principles like having tunability, plasmon resonance, photothermal alteration efficacy55-56 and encapsulation efficiency. Depending on these criteria, nanorods, nanoshells, nanocages as well as nanostars have been utilised by way of furthermost regular photothermal transducers. Firstly, AuNPs must be planned to fascinate light inside first (650-850 nm) or subsequent (950-1350 nm) NIR gap as such light wavelengths may deeply and harmlessly enter strong tissue so that AuNPs surrounded inside tumors. Secondly, AuNPs must show tall photothermal alteration efficacy that may be uttered via the structural dimensions such as size as well as shape of AuNP’s. Also, size as well as shape of AuNPs impact its capacity to pierce solid tumors and discharge from vasculature which will influence accomplishment of PTT as it may influence how heat is allocate through the tumor57-58.

 

Multimodal Approaches for other diseases:

Hanmi Pharmaceutical Company has filed a patent for the use of newly developed antihypertensive and antilipidemic drugs in combination therapy for coronary artery disease59.

 

Bliziotis and colleagues performed a meta-analysis in 2005 comparing the impact of beta lactam monotherapy against aminoglycoside and combination therapy on the formation of resistance60.

 

When used alone, bisoprolol often has less successful blood pressure-lowering effects; but, when combined with an ACE inhibitor, it produces outstanding results61.

 

The medication with the most researched combination of aspirin and clopidogrel also has the best risk-benefit ratio of any currently marketed medication62.

 

Many treatment therapies are available for treatment of RA which only gives symptomatic relief and can be overcome by using new drug combination. Many combination therapies are available in market which is not specific or the drugs used just increase the efficacy or potency of other drug63.

 

A minimum of 5 to 15% of individuals on netilmicin, tobramycin, or amikacin will experience renal function impairment; however, this is typically reversible, and the percentage may even be higher for those on Gentamicin. With the advancement of knowledge on the safety and effectiveness of using netilmicin and other antibiotics on an individual basis during the past several years, a new approach to the epidemiology of serious infection has arisen. In most cases, patients with severe systemic infections need to take antibiotics in combination. Netilmicin is often used in conjunction with a range of other antibiotics, including imipenem, pipericillin, ciprofloxacin, minocycline, ceftazidime, cefotaxime, cefoxitin, vancomycin, ceftriaxone, and clindamycin, to broaden the empirical therapy's antibacterial spectrum in a synergistic way and guarantee that at least one agent will cover the pathogen64.

 

Because combination therapy permits the use of lower doses of each antihypertensive drug, compensatory stimulation may be reduced. It is also possible that the second combination drug may counteract this stimulation65.

 

It is uncommon to achieve a decent control of blood pressure with monotherapy alone. The majority of patients experiencing high blood pressure problems will require combination medication therapy in order to meet their therapeutic objectives. When opposed to monotherapy, combination therapy has the advantage of synergistically enhancing each drug's hypertensive effects and potentially reducing side effects if each drug is given at a lower dose66.

 

Since no medication has been demonstrated to offer total pain relief. For certain patients, combination therapy of medicines with distinct modes of action and locations of action may be required. Patients that do not react to monotherapy or who are unable to take a given medicine to its maximum dosage because of side effects may benefit from rational multimodal polypharmacy. It is anticipated that a mix of fresh and enhanced medication discoveries will eventually result in pain relief that is both efficient and enhances quality of life67.

 

Currently, the notion of poly-pharmacology includes both the binding of a single medication to several targets within a network and the action of multiple drugs on distinct targets independently. Drug therapies with many targets can take many different forms, including polypharmacy or combination therapy, when multiple medications are used to act on different receptors to produce a combined pharmacological effect. Wonder medications known as multifunctional pharmaceuticals are ones that have the ability to treat several targets with a single medication68.

 

CONCLUSION:

The major obstacles for growth of useful treatment therapies for cancer are confrontation to chemotherapy and tumor recurrence. Currently, these aspects of cancer are most difficult to treat. Cancer is a multifaceted multifactorial syndrome which may be effectively treated and managed by multimodal approach. Such approach may include clinician, pharmacist, dietitian and physiologist that targets premature discovery along with management of cancer. This multidisciplinary team may also develop modified therapy strategy which includes pharmaceutical and no pharmaceutical approaches. Further, multimodal treatment may be incorporated on nanostructure design empowering of destroying cancer cells with grouping of chemotherapy, radiotherapy and theragnostic.

 

ACKNOWLEDGEMENTS:

All individuals listed as authors have contributed extensively to the work.

 

CONFLICTS OF INTEREST:

Authors state no conflicts of attention.

 

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Received on 15.05.2024         Modified on 09.07.2024

Accepted on 19.08.2024   ©Asian Pharma Press All Right Reserved

Asian J. Pharm. Tech. 2024; 14(3):264-270.

DOI: 10.52711/2231-5713.2024.00043