6.5 Targeting the tumor microenvironment
12 min read•august 21, 2024
Plasma medicine targets the tumor microenvironment, a complex ecosystem surrounding cancer cells. By understanding its components, researchers can develop more effective plasma-based interventions to disrupt tumor growth, progression, and metastasis.
This approach focuses on modifying cellular components, , and soluble factors within the tumor microenvironment. Plasma-induced changes, including reactive oxygen and nitrogen species effects, can directly impact tumor cells and surrounding tissues.
Tumor microenvironment components
- Plasma medicine targets the complex ecosystem surrounding tumors known as the tumor microenvironment
- Understanding the components of the tumor microenvironment allows for more effective plasma-based interventions
- Targeting these components can disrupt tumor growth, progression, and metastasis
Cellular components
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- Tumor cells form the core of the tumor mass and drive disease progression
- Stromal cells support tumor growth and include cancer-associated fibroblasts and
- Immune cells infiltrate the tumor and can have both pro- and anti-tumor effects
- Endothelial cells form blood vessels that supply oxygen and nutrients to the tumor
Extracellular matrix
- Network of proteins and glycosaminoglycans that provides structural support to the tumor
- Composed primarily of collagen, fibronectin, and laminin
- Regulates cell behavior through biochemical and biomechanical cues
- Often altered in tumors, leading to increased stiffness and abnormal signaling
- Serves as a barrier to drug delivery and immune cell infiltration
Soluble factors
- Growth factors promote tumor cell proliferation and survival (EGF, VEGF)
- Cytokines mediate communication between cells in the tumor microenvironment (IL-6, TNF-α)
- Chemokines direct cell migration and recruitment of immune cells (CXCL12, CCL2)
- Metabolites influence cellular metabolism and signaling (lactate, glutamine)
- Enzymes remodel the extracellular matrix and facilitate tumor invasion (MMPs)
Plasma-induced changes
- Plasma medicine utilizes ionized gases to induce changes in the tumor microenvironment
- These changes can directly affect tumor cells and modulate the surrounding tissue
- Understanding plasma-induced changes is crucial for optimizing treatment strategies
Reactive oxygen species effects
- Plasma generates high concentrations of reactive oxygen species (ROS)
- ROS induce oxidative stress in tumor cells, leading to DNA damage and apoptosis
- Hydrogen peroxide (H2O2) and hydroxyl radicals (OH•) are key players in ROS-mediated effects
- ROS can activate redox-sensitive signaling pathways (NF-κB, MAPK)
- Excessive ROS production overwhelms cellular antioxidant defenses
Reactive nitrogen species effects
- Plasma produces reactive nitrogen species (RNS) alongside ROS
- Nitric oxide (NO) and peroxynitrite (ONOO-) are important RNS in plasma medicine
- RNS can induce nitrosative stress and protein modifications
- Nitric oxide modulates blood flow and vascular permeability
- RNS contribute to the formation of long-lived in plasma-activated liquids
Physical plasma interactions
- Plasma generates electric fields that can affect cell membrane potential
- UV radiation from plasma can cause direct DNA damage and activate cellular stress responses
- Thermal effects, although minimal in cold plasma, can contribute to localized tissue heating
- Plasma-induced shockwaves may disrupt cellular structures and enhance drug delivery
- Charged particles in plasma can interact with cell surfaces and induce electroporation
Direct tumor cell targeting
- Plasma medicine directly affects tumor cells through various mechanisms
- These effects can lead to tumor cell death or inhibition of proliferation
- Understanding direct tumor cell targeting helps optimize plasma treatment parameters
Apoptosis induction
- Plasma treatment triggers both intrinsic and extrinsic apoptotic pathways
- Mitochondrial membrane permeabilization leads to cytochrome c release and caspase activation
- Death receptor activation (Fas, TRAIL) initiates extrinsic apoptosis
- ROS-mediated damage to cellular components promotes apoptotic signaling
- Plasma-induced apoptosis can overcome resistance mechanisms in cancer cells
Cell cycle arrest
- Plasma treatment can induce cell cycle arrest at various checkpoints (G1/S, G2/M)
- Cyclin-dependent kinase inhibitors (p21, p27) are upregulated following plasma exposure
- DNA damage response activation leads to cell cycle arrest and repair attempts
- Prolonged cell cycle arrest can result in senescence or cell death
- Cell cycle arrest provides an opportunity for other therapies to target vulnerable cells
DNA damage response
- Plasma-generated ROS and RNS cause both single-strand and double-strand DNA breaks
- Activation of DNA damage response pathways (ATM, ATR) triggers checkpoint activation
- DNA repair mechanisms (NHEJ, HR) are initiated to address plasma-induced damage
- Persistent DNA damage can lead to genomic instability and cell death
- The DNA damage response can sensitize tumor cells to other genotoxic therapies
Stromal cell modulation
- Plasma medicine affects not only tumor cells but also stromal cells in the microenvironment
- Modulating stromal cells can disrupt tumor-supporting networks and enhance anti-tumor responses
- Understanding stromal cell modulation is crucial for developing comprehensive plasma therapies
Cancer-associated fibroblasts
- Plasma treatment can reprogram cancer-associated fibroblasts (CAFs) to a less tumor-supportive phenotype
- ROS-mediated signaling alters CAF secretome, reducing pro-tumorigenic factors (TGF-β, VEGF)
- Plasma-induced changes in CAF metabolism affect their ability to support tumor growth
- Extracellular matrix production by CAFs is modified, altering tumor stiffness and invasion
- Targeting CAFs with plasma can enhance drug delivery by reducing stromal barriers
Tumor-associated macrophages
- Plasma exposure can shift tumor-associated macrophages (TAMs) from M2 to M1 phenotype
- M1 polarization promotes anti-tumor immune responses and enhances T cell activation
- RNS generated by plasma modulate macrophage nitric oxide production and function
- Plasma treatment alters TAM cytokine profile, reducing immunosuppressive factors (IL-10, TGF-β)
- Targeting TAMs with plasma can overcome immunosuppression in the tumor microenvironment
Endothelial cells
- Plasma affects tumor-associated endothelial cells, modulating and vascular function
- ROS-induced oxidative stress can trigger endothelial cell apoptosis and vascular disruption
- Plasma treatment alters endothelial cell adhesion molecule expression, affecting immune cell trafficking
- Vascular permeability is increased by plasma, potentially enhancing drug delivery
- Modulating endothelial cells with plasma can normalize tumor vasculature and improve oxygenation
Extracellular matrix alterations
- Plasma medicine induces changes in the extracellular matrix (ECM) of the tumor microenvironment
- ECM alterations can affect tumor cell behavior, drug delivery, and immune cell infiltration
- Understanding plasma-induced ECM changes is essential for optimizing treatment strategies
Collagen modification
- Plasma-generated ROS and RNS can directly modify collagen structure and crosslinking
- Oxidative stress leads to collagen fragmentation and reduced mechanical strength
- Plasma treatment alters collagen fiber organization, affecting tumor stiffness and cell migration
- Modified collagen exhibits changed binding properties for growth factors and signaling molecules
- Collagen alterations can enhance drug penetration and immune cell infiltration into tumors
Proteoglycan degradation
- Plasma-induced oxidative stress leads to the degradation of proteoglycans in the ECM
- Heparan sulfate proteoglycans are particularly susceptible to ROS-mediated cleavage
- Degradation of proteoglycans releases sequestered growth factors and cytokines
- Altered proteoglycan composition affects cell-ECM interactions and signaling
- Proteoglycan degradation can reduce the barrier function of the ECM, enhancing therapeutic access
Matrix metalloproteinase activation
- Plasma treatment can activate latent matrix metalloproteinases (MMPs) through oxidation
- ROS-mediated activation of pro-MMPs leads to increased ECM remodeling
- Plasma-induced changes in pH can affect MMP activity and substrate specificity
- Activated MMPs degrade various ECM components, altering tissue architecture
- MMP activation can promote the release of bioactive molecules sequestered in the ECM
Immune system modulation
- Plasma medicine has significant effects on the immune system within the tumor microenvironment
- Modulating immune responses can enhance anti-tumor immunity and overcome immunosuppression
- Understanding immune system modulation is crucial for combining plasma therapy with immunotherapy
T cell activation
- Plasma treatment can enhance T cell activation and proliferation through various mechanisms
- ROS-mediated signaling promotes T cell receptor (TCR) clustering and activation
- Plasma-induced changes in antigen-presenting cells enhance T cell priming and activation
- Modulation of the tumor microenvironment by plasma can improve T cell infiltration and function
- Plasma treatment can overcome T cell exhaustion and reinvigorate anti-tumor immune responses
Dendritic cell stimulation
- Plasma exposure activates dendritic cells (DCs), enhancing their antigen-presenting capabilities
- ROS and RNS generated by plasma trigger DC maturation and upregulation of costimulatory molecules
- Plasma-induced cellular stress leads to the release of damage-associated molecular patterns (DAMPs)
- Activated DCs produce pro-inflammatory cytokines that promote T cell activation (IL-12, TNF-α)
- Plasma-stimulated DCs can more effectively cross-present tumor antigens to cytotoxic T cells
Cytokine profile changes
- Plasma treatment alters the cytokine profile in the tumor microenvironment
- Pro-inflammatory cytokines (IFN-γ, TNF-α) are upregulated, promoting anti-tumor immunity
- Immunosuppressive cytokines (IL-10, TGF-β) are often downregulated following plasma exposure
- Plasma-induced changes in cytokine production affect immune cell recruitment and function
- Modulation of the cytokine profile can shift the balance from immunosuppression to immune activation
Angiogenesis inhibition
- Plasma medicine can inhibit tumor angiogenesis, the formation of new blood vessels
- Targeting angiogenesis reduces tumor growth and metastasis by limiting nutrient and oxygen supply
- Understanding plasma-induced angiogenesis inhibition is crucial for developing effective treatments
VEGF signaling disruption
- Plasma treatment can directly oxidize and inactivate vascular endothelial growth factor (VEGF)
- ROS-mediated modifications of VEGF receptors impair ligand binding and signaling
- Plasma exposure alters endothelial cell gene expression, reducing VEGF receptor levels
- Disruption of VEGF signaling inhibits endothelial cell proliferation and migration
- Plasma-induced changes in the ECM affect VEGF sequestration and bioavailability
Endothelial cell apoptosis
- Plasma-generated ROS and RNS trigger apoptosis in tumor-associated endothelial cells
- Oxidative stress leads to mitochondrial dysfunction and activation of intrinsic apoptosis pathways
- Plasma treatment can sensitize endothelial cells to extrinsic apoptosis signals (TRAIL, FasL)
- Endothelial cell apoptosis results in vascular collapse and reduced tumor blood supply
- Selective targeting of tumor-associated endothelial cells can normalize vasculature
Pericyte detachment
- Plasma exposure can disrupt pericyte-endothelial cell interactions in tumor blood vessels
- ROS-mediated damage to adhesion molecules leads to pericyte detachment from vessel walls
- Plasma treatment alters pericyte signaling pathways, affecting their supportive functions
- Pericyte detachment results in increased vascular permeability and instability
- Targeting pericytes with plasma can enhance the effectiveness of anti-angiogenic therapies
Drug delivery enhancement
- Plasma medicine can improve drug delivery to tumors through various mechanisms
- Enhanced drug delivery leads to increased therapeutic efficacy and reduced side effects
- Understanding plasma-induced drug delivery enhancement is crucial for combination therapies
Increased membrane permeability
- Plasma-generated electric fields and charged particles induce temporary electroporation
- ROS-mediated lipid peroxidation alters cell membrane fluidity and permeability
- Plasma treatment can activate membrane channels and transporters, facilitating drug uptake
- Increased membrane permeability allows for better penetration of large molecular weight drugs
- Transient permeabilization can be achieved without compromising long-term cell viability
Nanoparticle-mediated delivery
- Plasma treatment can modify nanoparticle surface properties, enhancing cellular uptake
- ROS-induced changes in the tumor microenvironment improve nanoparticle penetration and retention
- Plasma-activated liquids can be used as carriers for nanoparticle-based drug delivery systems
- Synergistic effects between plasma and nanoparticles can enhance therapeutic outcomes
- Plasma-responsive nanoparticles can be designed for controlled drug release in treated areas
Synergistic effects with chemotherapy
- Plasma pre-treatment sensitizes tumor cells to subsequent chemotherapy
- ROS-mediated DNA damage enhances the effectiveness of DNA-targeting chemotherapeutic agents
- Plasma-induced changes in cell membrane permeability increase drug accumulation in tumor cells
- Modulation of the tumor microenvironment by plasma improves chemotherapy distribution
- Combination of plasma with chemotherapy can overcome drug resistance mechanisms
Hypoxia targeting
- Plasma medicine offers unique approaches to target hypoxic regions within tumors
- Addressing tumor hypoxia can improve treatment outcomes and reduce therapy resistance
- Understanding plasma-based hypoxia targeting is crucial for developing comprehensive cancer therapies
Oxygen generation
- Plasma treatment can directly generate oxygen species in the tumor microenvironment
- Decomposition of plasma-generated hydrogen peroxide leads to localized oxygen release
- Plasma-induced changes in tumor vasculature can improve oxygen delivery to hypoxic regions
- Increased oxygen levels enhance the effectiveness of radiation therapy and certain chemotherapies
- Plasma-generated oxygen species can directly oxidize and damage hypoxic tumor cells
HIF-1α pathway modulation
- Plasma-generated ROS interfere with hypoxia-inducible factor 1-alpha (HIF-1α) stabilization
- Oxidative modification of HIF-1α protein leads to its degradation, even under hypoxic conditions
- Plasma treatment alters the expression of HIF-1α target genes involved in angiogenesis and metabolism
- Modulation of the HIF-1α pathway can reverse hypoxia-induced therapy resistance
- Targeting HIF-1α with plasma complements other hypoxia-targeting strategies
Metabolic reprogramming
- Plasma exposure induces metabolic changes in tumor cells, affecting their adaptation to hypoxia
- ROS-mediated damage to mitochondria forces cells to rely more on glycolysis
- Plasma treatment can alter the expression of key metabolic enzymes (PDK1, LDHA)
- Metabolic reprogramming by plasma sensitizes hypoxic tumor cells to energy stress
- Combining plasma with metabolic inhibitors can exploit plasma-induced metabolic vulnerabilities
Plasma vs other tumor therapies
- Plasma medicine offers unique advantages and complementary effects to conventional cancer therapies
- Understanding how plasma compares and interacts with other treatments is crucial for clinical integration
- Combining plasma with established therapies can lead to improved outcomes and reduced side effects
Radiation therapy comparison
- Plasma and radiation therapy both generate ROS, but plasma offers more diverse reactive species
- Unlike radiation, plasma treatment does not cause long-term radioactivity in tissues
- Plasma can be more precisely targeted to superficial tumors compared to some forms of radiation
- Combination of plasma and radiation can lead to synergistic DNA damage and cell death
- Plasma pre-treatment can sensitize tumors to subsequent radiation therapy
Chemotherapy synergy
- Plasma enhances chemotherapy efficacy through increased drug delivery and cellular sensitization
- Unlike many chemotherapies, plasma treatment has minimal systemic side effects
- Plasma can overcome certain drug resistance mechanisms (P-glycoprotein inhibition)
- Combination of plasma and chemotherapy allows for lower drug doses, reducing toxicity
- Plasma-induced changes in the tumor microenvironment can improve chemotherapy distribution
Immunotherapy combination
- Plasma treatment can enhance the immunogenicity of tumors, complementing immunotherapy approaches
- Unlike some immunotherapies, plasma has direct cytotoxic effects on tumor cells
- Plasma-induced immunomodulation can overcome resistance to immune checkpoint inhibitors
- Combination of plasma and CAR-T cell therapy can improve T cell infiltration and function
- Plasma treatment can be used to generate in situ tumor vaccines, enhancing systemic immune responses
Clinical applications
- Plasma medicine is transitioning from preclinical research to clinical applications in oncology
- Understanding current clinical efforts is crucial for advancing plasma-based cancer treatments
- Careful consideration of treatment protocols and safety is essential for successful clinical translation
Current trials
- Phase I/II clinical trials are ongoing for plasma treatment of various solid tumors (melanoma, head and neck cancer)
- Studies are evaluating the safety and efficacy of different plasma devices and treatment regimens
- Combination trials with standard therapies (radiation, chemotherapy) are being conducted
- Early results show promising outcomes in terms of tumor regression and quality of life improvements
- Ongoing trials are helping to establish optimal treatment parameters and patient selection criteria
Treatment protocols
- Standardized protocols for plasma treatment are being developed based on preclinical and clinical data
- Treatment duration, frequency, and intensity are optimized for different tumor types and locations
- Combination protocols with other therapies are designed to maximize synergistic effects
- Patient-specific factors (tumor size, location, prior treatments) are considered in protocol design
- Quality control measures ensure consistent plasma generation and application across treatments
Safety considerations
- Careful monitoring of potential side effects and long-term consequences of plasma treatment
- Evaluation of plasma-induced damage to healthy tissues surrounding the tumor
- Assessment of potential genotoxic effects and secondary malignancy risks
- Development of safety guidelines for medical staff operating plasma devices
- Consideration of contraindications and exclusion criteria for plasma treatment in certain patient populations
Future directions
- The field of plasma medicine in oncology is rapidly evolving with new research and technological advancements
- Understanding future directions is crucial for researchers and clinicians in this field
- Continued innovation will lead to more effective and personalized plasma-based cancer treatments
Personalized plasma medicine
- Development of patient-specific plasma treatment plans based on tumor molecular profiling
- Integration of real-time monitoring systems to adjust plasma parameters during treatment
- Utilization of artificial intelligence to predict optimal plasma treatment strategies
- Combination of plasma with targeted therapies based on individual tumor characteristics
- Adaptation of plasma devices to treat different tumor types and locations more effectively
Combination therapies
- Exploration of novel combinations of plasma with emerging cancer therapies (PARP inhibitors, oncolytic viruses)
- Development of nanoparticle-plasma hybrid approaches for enhanced drug delivery and activation
- Investigation of plasma-induced tumor vaccines in combination with checkpoint inhibitors
- Evaluation of plasma treatment in neoadjuvant and adjuvant settings with surgery
- Optimization of treatment schedules for plasma-radiotherapy-chemotherapy triple combinations
Novel plasma devices
- Design of plasma devices for minimally invasive and endoscopic applications
- Development of implantable plasma generators for sustained local treatment
- Creation of plasma-activated biomaterials for post-surgical tumor bed treatment
- Engineering of plasma devices capable of generating specific reactive species profiles
- Integration of plasma technology with other energy-based modalities (ultrasound, photodynamic therapy)
Key Terms to Review (18)
Angiogenesis: Angiogenesis is the process through which new blood vessels form from existing ones, playing a critical role in growth and healing. This process is essential for tissue regeneration, as it supplies necessary nutrients and oxygen while removing waste products. Angiogenesis is also significant in various medical contexts, including wound healing, tumor development, and interaction with blood components, highlighting its versatility and importance in health and disease.
Biomarker analysis: Biomarker analysis refers to the systematic examination of biological markers, which are indicators that can be measured and evaluated as a sign of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention. This type of analysis is crucial for understanding the tumor microenvironment, as it helps identify specific molecules or pathways involved in cancer progression and response to treatment.
Chul-Soo Ahn: Chul-Soo Ahn is a prominent figure in the field of cancer research, particularly known for his work on targeting the tumor microenvironment to improve therapeutic outcomes. His research focuses on understanding how the complex interactions between cancer cells and their surrounding environment can be manipulated to enhance treatment efficacy and reduce resistance to therapies. By investigating the tumor microenvironment, Ahn aims to identify novel targets for intervention that could lead to more effective cancer treatments.
Cold atmospheric plasma: Cold atmospheric plasma refers to a partially ionized gas at room temperature that contains a mix of charged particles, neutral atoms, and molecules. Unlike thermal plasmas, which can reach very high temperatures, cold atmospheric plasma operates at ambient conditions, making it suitable for various medical applications, particularly in disinfection, sterilization, and tissue regeneration.
Dielectric Barrier Discharge: Dielectric Barrier Discharge (DBD) is a type of electrical discharge that occurs between two electrodes separated by a dielectric material, allowing the generation of non-thermal plasma at atmospheric pressure. This technique is significant because it enables stable plasma generation without the need for high voltages while producing reactive species useful for various applications such as medical treatments, surface modifications, and sterilization.
Extracellular Matrix: The extracellular matrix (ECM) is a complex network of proteins, carbohydrates, and other molecules that provide structural and biochemical support to surrounding cells. It plays a critical role in cell adhesion, communication, and differentiation, acting as a scaffold that influences tissue development and healing processes. The ECM is vital for promoting tissue regeneration and shaping the tumor microenvironment, affecting how cells behave in health and disease.
Histological Evaluation: Histological evaluation is the microscopic examination of tissue samples to assess their structure, composition, and cellular characteristics. This process is crucial in understanding the tumor microenvironment, as it helps identify various cellular components, such as cancer cells, stromal cells, and immune cells, providing insights into how these elements interact and influence tumor behavior.
Inflammation modulation: Inflammation modulation refers to the process of adjusting the inflammatory response within the body, typically to either enhance or suppress it for therapeutic purposes. This term is particularly relevant in contexts where the inflammatory response can contribute to disease progression, such as in tumors, where an altered immune environment can impact tumor growth and metastasis. By targeting inflammation, strategies can be developed to improve healing and reduce unwanted tissue damage or promote immune response against tumors.
MAPK Pathway: The MAPK (Mitogen-Activated Protein Kinase) pathway is a crucial intracellular signaling cascade that transmits signals from the cell surface to the nucleus, regulating various cellular processes such as growth, differentiation, and survival. This pathway plays a significant role in how cells respond to external stimuli, including growth factors and stress signals, and is tightly linked to various biological functions and diseases, especially in cancer progression and the tumor microenvironment.
Metastasis prevention: Metastasis prevention refers to strategies and interventions aimed at stopping cancer cells from spreading from the primary tumor to other parts of the body. Effective metastasis prevention is crucial in improving patient outcomes, as metastasis significantly worsens the prognosis and treatment options for cancer patients. By focusing on the tumor microenvironment and its interactions with cancer cells, researchers seek to develop therapies that can inhibit the processes that facilitate this spread.
Nf-kb pathway: The NF-κB pathway is a crucial signaling mechanism that regulates immune response, inflammation, and cell survival. It involves the activation of NF-κB transcription factors that, when stimulated, translocate to the nucleus and promote the expression of genes involved in inflammatory processes and cellular proliferation. This pathway plays a significant role in the tumor microenvironment, influencing cancer development and progression by modulating interactions between cancer cells and surrounding stromal cells.
Overall survival: Overall survival refers to the length of time from either the date of diagnosis or the start of treatment for a disease, such as cancer, that patients are still alive. It is a crucial metric in clinical studies and treatment evaluations, as it helps determine the effectiveness of therapies and interventions by measuring how long patients live after receiving specific treatments.
Plasma-activated medium: A plasma-activated medium is a solution or gel that has been treated with cold plasma to enhance its biological properties, making it beneficial for various therapeutic applications. This activation process generates reactive species that can stimulate cellular processes and improve healing, making it a key player in promoting tissue regeneration and targeting tumor environments.
Reactive Species: Reactive species are highly reactive molecules that can participate in various chemical reactions, often resulting from the ionization of gases in plasma. They play a crucial role in plasma medicine by interacting with biological tissues and pathogens, leading to sterilization, disinfection, and promotion of healing processes.
Tumor ablation: Tumor ablation is a medical procedure that involves the targeted destruction of tumor cells using various techniques to eliminate or reduce the size of the tumor. This process can effectively remove or shrink tumors, making it a crucial strategy in cancer treatment that leverages methods like heat, cold, chemicals, and even plasma-based technologies to achieve desired outcomes.
Tumor response rate: Tumor response rate refers to the percentage of patients whose tumors show a significant reduction in size or complete disappearance following treatment. It is an important metric used to evaluate the effectiveness of cancer therapies, particularly in assessing how well treatments target and impact the tumor microenvironment, which plays a crucial role in cancer progression and response to therapy.
Tumor-associated macrophages: Tumor-associated macrophages (TAMs) are immune cells that are present within the tumor microenvironment, often contributing to tumor growth and progression. These macrophages can exhibit pro-tumorigenic properties, such as promoting angiogenesis, suppressing anti-tumor immune responses, and facilitating metastasis. Their dual role as both defenders against pathogens and potential enablers of cancer makes them a critical focus in the study of tumor biology and therapy.
Vladimir Khailova: Vladimir Khailova is a prominent figure in the field of Plasma Medicine, particularly known for his research on the interaction of cold plasma with biological tissues and its implications for cancer therapy. His work emphasizes the importance of targeting the tumor microenvironment to enhance the effectiveness of plasma-based treatments, paving the way for innovative therapeutic approaches in oncology.