Yannan Nancy Dou - Academia.edu (original) (raw)
Papers by Yannan Nancy Dou
International Journal of Pharmaceutics, Jul 1, 2015
Journal of Controlled Release, Dec 1, 2015
Journal of Controlled Release, Jul 1, 2018
Journal of Controlled Release, Mar 1, 2017
Journal of Controlled Release, Jun 1, 2015
Existing paradigms in nano-based drug delivery are currently being challenged. Assessment of bulk... more Existing paradigms in nano-based drug delivery are currently being challenged. Assessment of bulk tumor accumulation has been routinely considered an indicative measure of nanomedicine potency. However, it is now recognized that the intratumoral distribution of nanomedicines also impacts their therapeutic effect. At this time, our understanding of the relationship between the bulk (i.e., macro-) tumor accumulation of nanocarriers and their intratumoral (i.e., micro-) distribution remains limited. Liposome-based drug formulations, in particular, suffer from diminished efficacy in vivo as a result of transport-limiting properties, combined with the heterogeneous nature of the tumor microenvironment. In this report, we perform a quantitative image-based assessment of macro- and microdistribution of liposomes. Multi-scalar assessment of liposome distribution was enabled by a stable formulation which co-encapsulates an iodinated contrast agent and a near-infrared fluorescence probe, for computed tomography (CT) and optical microscopy, respectively. Spatio-temporal quantification of tumor uptake in orthotopic xenografts was performed using CT at the bulk tissue level, and within defined sub-volumes of the tumor (i.e., rim, periphery and core). Tumor penetration and relative distribution of liposomes were assessed by fluorescence microscopy of whole tumor sections. Microdistribution analysis of whole tumor images exposed a heterogeneous distribution of both liposomes and tumor vasculature. Highest levels of liposome uptake were achieved and maintained in the well-vascularized tumor rim over the study period, corresponding to a positive correlation between liposome and microvascular density. Tumor penetration of liposomes was found to be time-dependent in all regions of the tumor however independent of location in the tumor. Importantly, a multi-scalar comparison of liposome distribution reveals that macro-accumulation in tissues (e.g., blood, whole tumor) may not reflect micro-accumulation levels present within specific regions of the tumor as a function of time.
Journal of Controlled Release, 2018
Journal of controlled release : official journal of the Controlled Release Society, Jan 29, 2017
Significant heterogeneity in the tumor microenvironment of human cervical cancer patients is know... more Significant heterogeneity in the tumor microenvironment of human cervical cancer patients is known to challenge treatment outcomes in this population. The current standard of care for cervical cancer patients is radiation therapy and concurrent cisplatin (CDDP) chemotherapy. Yet this treatment strategy fails to control loco-regional disease in 10-30% of patients. In order to improve the loco-regional control rate, a thermosensitive liposome formulation of CDDP (HTLC) was developed to increase local concentrations of drug in response to mild hyperthermia (HT). The HTLC formulation in combination with local HT demonstrated a significant therapeutic advantage in comparison to free drug and Lipoplatin™ in ME-180 and SiHa xenograft models of human cervical cancer, as well as in four distinct cervical patient-derived xenograft models. Differential response to HTLC+HT treatment was observed between the ME-180 and SiHa tumor models. Tumor doubling time, in vitro cell sensitivity, and tumor ...
Journal of controlled release : official journal of the Controlled Release Society, Mar 10, 2017
Thermosensitive liposomes have been put forward as a strategy to improve upon the limited tumor d... more Thermosensitive liposomes have been put forward as a strategy to improve upon the limited tumor drug availability associated with conventional non-thermosensitive liposomes. ThermoDox® is the first and only thermosensitive liposome formulation to reach clinical development. The initial Phase III clinical trial on ThermoDox® (i.e. HEAT trial) evaluating the combination of ThermoDox® and radiofrequency ablation (RFA) in comparison to RFA alone for treatment of inoperable hepatocellular carcinoma (HCC) failed to reach its primary endpoint in progression-free survival (PFS). Nevertheless, a subgroup analysis demonstrated a marked improvement in PFS and a significant improvement in overall survival (OS) for patients who underwent RFA treatment for at least 45min. Potential reasons for failure of the HEAT trial have been summarized in this review and include issues with clinical trial design, lack of supporting preclinical data, and improvements in the control arm (i.e. RFA alone). In rec...
Journal of drug targeting, Nov 16, 2016
Treatment efficacy of a heat-activated thermosensitive liposome formulation of cisplatin (CDDP), ... more Treatment efficacy of a heat-activated thermosensitive liposome formulation of cisplatin (CDDP), known as HTLC, was determined in xenograft models of non-small-cell lung carcinoma. The short-term impact of local hyperthermia (HT) on tumor morphology, microvessel density and local inflammatory response was also evaluated. The HTLC formulation in combination with local HT resulted in a significant advantage in therapeutic effect in comparison with free drug and a non-thermosensitive liposome formulation of CDDP (i.e. Lipoplatin(TM)) when administered at their maximum tolerated doses. Local HT-induced widespread cell necrosis and a significant reduction in microvessel density in the necrotic regions of tumors. CD11b-expressing innate leukocytes were demonstrated to infiltrate and reside preferentially at the necrotic rim of tumors, likely as a means to phagocytose-damaged tissue. Colocalization of CD11b with a marker of DNA damage (i.e. γH2AX) revealed a small portion of CD11b-expressi...
Journal of controlled release : official journal of the Controlled Release Society, Jan 25, 2015
Functional and molecular imaging has become increasingly used to evaluate interpatient and intrap... more Functional and molecular imaging has become increasingly used to evaluate interpatient and intrapatient tumor heterogeneity. Imaging allows for assessment of microenvironment parameters including tumor hypoxia, perfusion and proliferation, as well as tumor metabolism and the intratumoral distribution of specific molecular markers. Imaging information may be used to stratify patients for targeted therapies, and to define patient populations that may benefit from alternative therapeutic approaches. It also provides a method for non-invasive monitoring of treatment response at earlier time-points than traditional cues, such as tumor shrinkage. Further, companion diagnostic imaging techniques are becoming progressively more important for development and clinical implementation of targeted therapies. Imaging-based companion diagnostics are likely to be essential for the validation and FDA approval of targeted nanotherapies and macromolecular medicines. This review describes recent clinic...
International journal of pharmaceutics, Jan 21, 2015
Pentamidine isethionate, widely used for the treatment of parasitic infections, has shown strong ... more Pentamidine isethionate, widely used for the treatment of parasitic infections, has shown strong anticancer activity in cancer cells and models of melanoma and lung cancer. Systemic administration of pentamidine is associated with serious toxicities, particularly renal, affecting as many as 95% of patients (O'Brien, Dong et al., 1997). This work presents the development of a liposome pentamidine formulation for greater tumor accumulation and lower drug exposure to vulnerable tissues. Liposomes formulated with saturated/unsaturated phospholipids of different chain lengths, varying cholesterol content, and surface PEG were explored to understand the effects of such variations on drug release, encapsulation efficiency, stability and in vivo performance. Saturated phospholipids with longer chain lengths, higher cholesterol content and PEG resulted in greater stability. The optimal formulation obtained showed significantly lower clearance rate (3.6 ± 1.2mL/h/Kg) and higher AUC0-inf (...
Journal of controlled release : official journal of the Controlled Release Society, Jan 8, 2015
Existing paradigms in nano-based drug delivery are currently being challenged. Assessment of bulk... more Existing paradigms in nano-based drug delivery are currently being challenged. Assessment of bulk tumor accumulation has been routinely considered an indicative measure of nanomedicine potency. However, it is now recognized that the intratumoral distribution of nanomedicines also impacts their therapeutic effect. At this time, our understanding of the relationship between the bulk (i.e., macro-) tumor accumulation of nanocarriers and their intratumoral (i.e., micro-) distribution remains limited. Liposome-based drug formulations, in particular, suffer from diminished efficacy in vivo as a result of transport-limiting properties, combined with the heterogeneous nature of the tumor microenvironment. In this report, we perform a quantitative image-based assessment of macro- and microdistribution of liposomes. Multi-scalar assessment of liposome distribution was enabled by a stable formulation which co-encapsulates an iodinated contrast agent and a near-infrared fluorescence probe, for ...
Journal of Controlled Release, 2014
Cisplatin (CDDP) has been identified as the primary chemotherapeutic agent for the treatment of c... more Cisplatin (CDDP) has been identified as the primary chemotherapeutic agent for the treatment of cervical cancer, but dose limiting toxicity is a key issue associated with its clinical application. A suite of liposome formulations of CDDP has been developed in efforts to reduce systemic toxicity, but their therapeutic advantage over the free drug has been modest due to insufficient drug release at the tumor site. This report describes the development of a novel heat-activated thermosensitive liposome formulation containing CDDP (HTLC) designed to release approximately 90% of the loaded drug in less than 5min under mild heating conditions (42°C). Physico-chemical characteristics of HTLC were assessed in terms of gel to liquid crystalline phase transition temperature (Tm), drug loading efficiency, particle size, and stability. The pharmacokinetic profile and biodistribution of HTLC in non-tumor-bearing mice were evaluated over a 24h period. A sophisticated spatio-temporal elucidation of HTLC release in tumor-bearing mice was achieved by way of real-time monitoring using a magnetic resonance (MR) imaging protocol, wherein a custom-built laser-based conformal heat source was applied at the tumor volume to trigger the release of HTLC co-encapsulated with the MR contrast agent gadoteridol (Gd-HP-DO3A). MR thermometry (MRT) demonstrated that a relatively uniform temperature distribution was achieved in the tumor volume using the external laser-based heating setup. In mice bearing subcutaneously-implanted ME-180 cervical tumors, the combination of HTLC and heat resulted in a 2-fold increase in tumor drug levels at 1h post-administration compared to HTLC without heating. Furthermore, the overall tumor accumulation levels for the HTLC groups (with and without heat) at 1h post-injection were significantly higher than the corresponding free CDDP group. This translated into a significant improvement in therapeutic efficacy evaluated as tumor growth delay (p<0.05) for the heated HTLC treatment group compared to the unheated HTLC, heated or unheated free CDDP, and saline groups. Overall, findings from this study demonstrate that a heat-activated, triggered release formulation of CDDP results in a significant enhancement in the therapeutic index of this drug.
Journal of visualized experiments : JoVE, Jan 13, 2015
Liposomes have been employed as drug delivery systems to target solid tumors through exploitation... more Liposomes have been employed as drug delivery systems to target solid tumors through exploitation of the enhanced permeability and retention (EPR) effect resulting in significant reductions in systemic toxicity. Nonetheless, insufficient release of encapsulated drug from liposomes has limited their clinical efficacy. Temperature-sensitive liposomes have been engineered to provide site-specific release of drug in order to overcome the problem of limited tumor drug bioavailability. Our lab has designed and developed a heat-activated thermosensitive liposome formulation of cisplatin (CDDP), known as HTLC, to provide triggered release of CDDP at solid tumors. Heat-activated delivery in vivo was achieved in murine models using a custom-built laser-based heating apparatus that provides a conformal heating pattern at the tumor site as confirmed by MR thermometry (MRT). A fiber optic temperature monitoring device was used to measure the temperature in real-time during the entire heating per...
JCO Precision Oncology, 2024
In oncology drug development, using biomarkers to select a study population more likely to benefi... more In oncology drug development, using biomarkers to select a study population more likely to benefit from a therapeutic effect is critical to increase the efficiency of a clinical trial in demonstrating effectiveness. This perspective delves into therapeutic product approvals that were tested in pivotal trials with all-comers populations, but ultimately received US Food and Drug Administration approval for use within specific patient subgroups identified by biomarkers. Despite initial designs for efficacy and safety assessments in overall populations, a favorable benefit-risk assessment was primarily established in biomarker-positive subgroups. Analyzing these cases, we summarize key considerations pivotal to totality of evidence for regulatory benefit-risk assessments for biomarker-defined subgroup versus all-comers approvals, including biological and clinical rationales, biomarker prevalence, safety data, overall trial design, and subgroup efficacy characterization. Furthermore, a decision tree is proposed to guide optimal clinical trial design, delineating between patient enrichment and stratification, accounting for key factors including biological and clinical rationale, marker type (discreate or continuous), prevalence, assay readiness, and turnaround times for marker assessment. Finally, a recommended approach for subgroup characterization involves prespecifying magnitude of improvement that would be considered clinically meaningful in the biomarker-negative subgroup, which can be supplemented with methodologies such as Bayesian to incorporate evidence from similar studies when available. In summary, this perspective underscores the importance of clinical trial innovations, statistical methodologies and regulatory considerations, to optimize biomarker-driven drug development for patients with cancer.
International Journal of Pharmaceutics, Jul 1, 2015
Journal of Controlled Release, Dec 1, 2015
Journal of Controlled Release, Jul 1, 2018
Journal of Controlled Release, Mar 1, 2017
Journal of Controlled Release, Jun 1, 2015
Existing paradigms in nano-based drug delivery are currently being challenged. Assessment of bulk... more Existing paradigms in nano-based drug delivery are currently being challenged. Assessment of bulk tumor accumulation has been routinely considered an indicative measure of nanomedicine potency. However, it is now recognized that the intratumoral distribution of nanomedicines also impacts their therapeutic effect. At this time, our understanding of the relationship between the bulk (i.e., macro-) tumor accumulation of nanocarriers and their intratumoral (i.e., micro-) distribution remains limited. Liposome-based drug formulations, in particular, suffer from diminished efficacy in vivo as a result of transport-limiting properties, combined with the heterogeneous nature of the tumor microenvironment. In this report, we perform a quantitative image-based assessment of macro- and microdistribution of liposomes. Multi-scalar assessment of liposome distribution was enabled by a stable formulation which co-encapsulates an iodinated contrast agent and a near-infrared fluorescence probe, for computed tomography (CT) and optical microscopy, respectively. Spatio-temporal quantification of tumor uptake in orthotopic xenografts was performed using CT at the bulk tissue level, and within defined sub-volumes of the tumor (i.e., rim, periphery and core). Tumor penetration and relative distribution of liposomes were assessed by fluorescence microscopy of whole tumor sections. Microdistribution analysis of whole tumor images exposed a heterogeneous distribution of both liposomes and tumor vasculature. Highest levels of liposome uptake were achieved and maintained in the well-vascularized tumor rim over the study period, corresponding to a positive correlation between liposome and microvascular density. Tumor penetration of liposomes was found to be time-dependent in all regions of the tumor however independent of location in the tumor. Importantly, a multi-scalar comparison of liposome distribution reveals that macro-accumulation in tissues (e.g., blood, whole tumor) may not reflect micro-accumulation levels present within specific regions of the tumor as a function of time.
Journal of Controlled Release, 2018
Journal of controlled release : official journal of the Controlled Release Society, Jan 29, 2017
Significant heterogeneity in the tumor microenvironment of human cervical cancer patients is know... more Significant heterogeneity in the tumor microenvironment of human cervical cancer patients is known to challenge treatment outcomes in this population. The current standard of care for cervical cancer patients is radiation therapy and concurrent cisplatin (CDDP) chemotherapy. Yet this treatment strategy fails to control loco-regional disease in 10-30% of patients. In order to improve the loco-regional control rate, a thermosensitive liposome formulation of CDDP (HTLC) was developed to increase local concentrations of drug in response to mild hyperthermia (HT). The HTLC formulation in combination with local HT demonstrated a significant therapeutic advantage in comparison to free drug and Lipoplatin™ in ME-180 and SiHa xenograft models of human cervical cancer, as well as in four distinct cervical patient-derived xenograft models. Differential response to HTLC+HT treatment was observed between the ME-180 and SiHa tumor models. Tumor doubling time, in vitro cell sensitivity, and tumor ...
Journal of controlled release : official journal of the Controlled Release Society, Mar 10, 2017
Thermosensitive liposomes have been put forward as a strategy to improve upon the limited tumor d... more Thermosensitive liposomes have been put forward as a strategy to improve upon the limited tumor drug availability associated with conventional non-thermosensitive liposomes. ThermoDox® is the first and only thermosensitive liposome formulation to reach clinical development. The initial Phase III clinical trial on ThermoDox® (i.e. HEAT trial) evaluating the combination of ThermoDox® and radiofrequency ablation (RFA) in comparison to RFA alone for treatment of inoperable hepatocellular carcinoma (HCC) failed to reach its primary endpoint in progression-free survival (PFS). Nevertheless, a subgroup analysis demonstrated a marked improvement in PFS and a significant improvement in overall survival (OS) for patients who underwent RFA treatment for at least 45min. Potential reasons for failure of the HEAT trial have been summarized in this review and include issues with clinical trial design, lack of supporting preclinical data, and improvements in the control arm (i.e. RFA alone). In rec...
Journal of drug targeting, Nov 16, 2016
Treatment efficacy of a heat-activated thermosensitive liposome formulation of cisplatin (CDDP), ... more Treatment efficacy of a heat-activated thermosensitive liposome formulation of cisplatin (CDDP), known as HTLC, was determined in xenograft models of non-small-cell lung carcinoma. The short-term impact of local hyperthermia (HT) on tumor morphology, microvessel density and local inflammatory response was also evaluated. The HTLC formulation in combination with local HT resulted in a significant advantage in therapeutic effect in comparison with free drug and a non-thermosensitive liposome formulation of CDDP (i.e. Lipoplatin(TM)) when administered at their maximum tolerated doses. Local HT-induced widespread cell necrosis and a significant reduction in microvessel density in the necrotic regions of tumors. CD11b-expressing innate leukocytes were demonstrated to infiltrate and reside preferentially at the necrotic rim of tumors, likely as a means to phagocytose-damaged tissue. Colocalization of CD11b with a marker of DNA damage (i.e. γH2AX) revealed a small portion of CD11b-expressi...
Journal of controlled release : official journal of the Controlled Release Society, Jan 25, 2015
Functional and molecular imaging has become increasingly used to evaluate interpatient and intrap... more Functional and molecular imaging has become increasingly used to evaluate interpatient and intrapatient tumor heterogeneity. Imaging allows for assessment of microenvironment parameters including tumor hypoxia, perfusion and proliferation, as well as tumor metabolism and the intratumoral distribution of specific molecular markers. Imaging information may be used to stratify patients for targeted therapies, and to define patient populations that may benefit from alternative therapeutic approaches. It also provides a method for non-invasive monitoring of treatment response at earlier time-points than traditional cues, such as tumor shrinkage. Further, companion diagnostic imaging techniques are becoming progressively more important for development and clinical implementation of targeted therapies. Imaging-based companion diagnostics are likely to be essential for the validation and FDA approval of targeted nanotherapies and macromolecular medicines. This review describes recent clinic...
International journal of pharmaceutics, Jan 21, 2015
Pentamidine isethionate, widely used for the treatment of parasitic infections, has shown strong ... more Pentamidine isethionate, widely used for the treatment of parasitic infections, has shown strong anticancer activity in cancer cells and models of melanoma and lung cancer. Systemic administration of pentamidine is associated with serious toxicities, particularly renal, affecting as many as 95% of patients (O'Brien, Dong et al., 1997). This work presents the development of a liposome pentamidine formulation for greater tumor accumulation and lower drug exposure to vulnerable tissues. Liposomes formulated with saturated/unsaturated phospholipids of different chain lengths, varying cholesterol content, and surface PEG were explored to understand the effects of such variations on drug release, encapsulation efficiency, stability and in vivo performance. Saturated phospholipids with longer chain lengths, higher cholesterol content and PEG resulted in greater stability. The optimal formulation obtained showed significantly lower clearance rate (3.6 ± 1.2mL/h/Kg) and higher AUC0-inf (...
Journal of controlled release : official journal of the Controlled Release Society, Jan 8, 2015
Existing paradigms in nano-based drug delivery are currently being challenged. Assessment of bulk... more Existing paradigms in nano-based drug delivery are currently being challenged. Assessment of bulk tumor accumulation has been routinely considered an indicative measure of nanomedicine potency. However, it is now recognized that the intratumoral distribution of nanomedicines also impacts their therapeutic effect. At this time, our understanding of the relationship between the bulk (i.e., macro-) tumor accumulation of nanocarriers and their intratumoral (i.e., micro-) distribution remains limited. Liposome-based drug formulations, in particular, suffer from diminished efficacy in vivo as a result of transport-limiting properties, combined with the heterogeneous nature of the tumor microenvironment. In this report, we perform a quantitative image-based assessment of macro- and microdistribution of liposomes. Multi-scalar assessment of liposome distribution was enabled by a stable formulation which co-encapsulates an iodinated contrast agent and a near-infrared fluorescence probe, for ...
Journal of Controlled Release, 2014
Cisplatin (CDDP) has been identified as the primary chemotherapeutic agent for the treatment of c... more Cisplatin (CDDP) has been identified as the primary chemotherapeutic agent for the treatment of cervical cancer, but dose limiting toxicity is a key issue associated with its clinical application. A suite of liposome formulations of CDDP has been developed in efforts to reduce systemic toxicity, but their therapeutic advantage over the free drug has been modest due to insufficient drug release at the tumor site. This report describes the development of a novel heat-activated thermosensitive liposome formulation containing CDDP (HTLC) designed to release approximately 90% of the loaded drug in less than 5min under mild heating conditions (42°C). Physico-chemical characteristics of HTLC were assessed in terms of gel to liquid crystalline phase transition temperature (Tm), drug loading efficiency, particle size, and stability. The pharmacokinetic profile and biodistribution of HTLC in non-tumor-bearing mice were evaluated over a 24h period. A sophisticated spatio-temporal elucidation of HTLC release in tumor-bearing mice was achieved by way of real-time monitoring using a magnetic resonance (MR) imaging protocol, wherein a custom-built laser-based conformal heat source was applied at the tumor volume to trigger the release of HTLC co-encapsulated with the MR contrast agent gadoteridol (Gd-HP-DO3A). MR thermometry (MRT) demonstrated that a relatively uniform temperature distribution was achieved in the tumor volume using the external laser-based heating setup. In mice bearing subcutaneously-implanted ME-180 cervical tumors, the combination of HTLC and heat resulted in a 2-fold increase in tumor drug levels at 1h post-administration compared to HTLC without heating. Furthermore, the overall tumor accumulation levels for the HTLC groups (with and without heat) at 1h post-injection were significantly higher than the corresponding free CDDP group. This translated into a significant improvement in therapeutic efficacy evaluated as tumor growth delay (p<0.05) for the heated HTLC treatment group compared to the unheated HTLC, heated or unheated free CDDP, and saline groups. Overall, findings from this study demonstrate that a heat-activated, triggered release formulation of CDDP results in a significant enhancement in the therapeutic index of this drug.
Journal of visualized experiments : JoVE, Jan 13, 2015
Liposomes have been employed as drug delivery systems to target solid tumors through exploitation... more Liposomes have been employed as drug delivery systems to target solid tumors through exploitation of the enhanced permeability and retention (EPR) effect resulting in significant reductions in systemic toxicity. Nonetheless, insufficient release of encapsulated drug from liposomes has limited their clinical efficacy. Temperature-sensitive liposomes have been engineered to provide site-specific release of drug in order to overcome the problem of limited tumor drug bioavailability. Our lab has designed and developed a heat-activated thermosensitive liposome formulation of cisplatin (CDDP), known as HTLC, to provide triggered release of CDDP at solid tumors. Heat-activated delivery in vivo was achieved in murine models using a custom-built laser-based heating apparatus that provides a conformal heating pattern at the tumor site as confirmed by MR thermometry (MRT). A fiber optic temperature monitoring device was used to measure the temperature in real-time during the entire heating per...
JCO Precision Oncology, 2024
In oncology drug development, using biomarkers to select a study population more likely to benefi... more In oncology drug development, using biomarkers to select a study population more likely to benefit from a therapeutic effect is critical to increase the efficiency of a clinical trial in demonstrating effectiveness. This perspective delves into therapeutic product approvals that were tested in pivotal trials with all-comers populations, but ultimately received US Food and Drug Administration approval for use within specific patient subgroups identified by biomarkers. Despite initial designs for efficacy and safety assessments in overall populations, a favorable benefit-risk assessment was primarily established in biomarker-positive subgroups. Analyzing these cases, we summarize key considerations pivotal to totality of evidence for regulatory benefit-risk assessments for biomarker-defined subgroup versus all-comers approvals, including biological and clinical rationales, biomarker prevalence, safety data, overall trial design, and subgroup efficacy characterization. Furthermore, a decision tree is proposed to guide optimal clinical trial design, delineating between patient enrichment and stratification, accounting for key factors including biological and clinical rationale, marker type (discreate or continuous), prevalence, assay readiness, and turnaround times for marker assessment. Finally, a recommended approach for subgroup characterization involves prespecifying magnitude of improvement that would be considered clinically meaningful in the biomarker-negative subgroup, which can be supplemented with methodologies such as Bayesian to incorporate evidence from similar studies when available. In summary, this perspective underscores the importance of clinical trial innovations, statistical methodologies and regulatory considerations, to optimize biomarker-driven drug development for patients with cancer.