Given that toxicology studies the potential adverse effects of environmental exposures on various forms of life and that clinical toxicology typically focuses on human health effects, what can and should the relatively new term of "translational toxicology" be taken to mean?Our assertion is that the core concept of translational toxicology must incorporate existing principles of toxicology and epidemiology, but be driven by the aim of developing safe and effective interventions beyond simple reduction or avoidance of exposure to prevent, mitigate or reverse adverse human health effects of exposures.The field of toxicology has now reached a point where advances in multiple areas of biomedical research and information technologies empower us to make fundamental transitions in directly impacting human health. Translational toxicology must encompass four action elements as follows:1) Assessing human exposures in critical windows across the lifespan2) Defining modes of action and relevance of data from animal models3) Use of mathematical models to develop plausible predictions as the basis for4) Protective and restorative human health interventions.in-utero development.The discussion focuses on the critical window of Exposure assessment, basic toxicology and development of certain categories of mathematical models are not new areas of research; however overtly integrating these in order to conceive, assess and validate effective interventions to mitigate or reverse adverse effects of environmental exposures is our novel opportunity. This is what we should do in translational toxicology so that we have a portfolio of interventional options to improve human health that include both minimizing exposures and specific preventative/restorative/mitigative therapeutics. In the current genomics era, gene-environment interactions provide the key to understanding health and disease. Human exposures to chemicals, physical agents and social factors are inevitable and determining what their subtle biological effect means to human disease is difficult. Absence of evidence of (effect or harm) is not evidence of absence (of effect or harm), particularly if adverse outcomes are ecologically apparent in environmental settings or in experimental animals following known exposures. To minimize adverse health outcomes, regulators, commercial entities, health care providers and the general public need to know what exposures pose a significant risk that merits intervention(s) to either reduce exposure or mitigate effects.Multiple factors in the environment impact human development and subsequent health and disease. It has long been appreciated that vitamins, minerals and other essential nutrients play an important role in fetal growth and development. For example, the essential role of folate (folic acid) in pregnancy and human development is well known. But apart from a modest number of other well-known deficiencies, there is still limited understanding of the impact of micronutrient deficiencies or inadequacies on the fetus and subsequent long-term health outcomes . AdditioThe appreciation of maternal stress and other aspects of the social environment on the fetus has only recently gained some mechanistic explanation. Animal research suggesting transgenerational epigenetic programming of genes  has been seen as an attractive and plausible explanation. Recent reports in humans and nonhuman primates show that epigenetic effects may be sufficient explanations for such social effects. Radtke et al.  analyzedin-utero development and how to plausibly mitigate adverse health effects of these exposures particularly in terms of endocrine/metabolic, neurodevelopment and reproductive consequences across the ensuing lifespan.At present there is still a critical gap between laboratory toxicology research and testing  and epidemiological and ecosystem studies, which examine exposed populations for disease. The current bipartite approach fails to make adequately overt the link between exposure(s) and clinical outcome(s). In fact, most such claims of cause-and-effect are no better than a tentative association of exposure and effect. So we are typically left with both, a) inadequate evidence of a plausible explicit risk due to an exposure, and b) inadequate evidence that there is no plausible explicit risk due to an exposure and therefore limited intervention possibilities. It is our objective to discuss current knowledge from research toxicology and epidemiological studies on the occurrence of adverse events triggered during critical life-span periods focusing on If chemical exposures and stress influence the occurrence of endocrine mediated diseases, what is the potential public health impact? Golden  compreheEndocrine and metabolic disorders: childhood obesity As the world has moved from agrarian, to industrial, then information ages, the level of sedentary activities open to humans have increased exponentially, which has contributed to a global rise in obesity rates, affecting both low and high income countries, as well as creating wide variations within countries. In high income countries, the poor population is most affected while in low income countries, the most affected are the middle class • early development  and active  health risk mitigation/intervention strategies can be developed for exposed individuals.What evidence and modes of action link exposure to endocrine disruptors to endocrine or other human diseases? An essential missing link between endocrine disruptor testing and screening and epidemiology/population-based exposure assessments is individualized assessments of exposures and effects that are plausibly linked via known modes-of-action. Because metabolomic methods allow a broad look at multiple potentially perturbed metabolic pathways (and implictly different modes-of-action), and multiple biospecimens can be assayed , this may prove to be the preferred core analytical method for defining these individualized exposure-effect relationships.Numerous biological processes and multiple levels of biological organization could be adversely impacted by exposures to exogenous chemicals and thereby affect fetal-neonatal development and measurable endpoints  and into the circulation under homeostatic conditions. This process is dramatically enhanced during stress situations and induced mobilization regimens . Recent Evidence suggests haematopoietic stem cells (HSCs) can migrate to injured liver and influence tissue repair. However, Kavanaugh et al.  found thAs a result of extensive collection of genome-wide transcriptional expression data from cultured human cells treated with bioactive small molecules, "The Connectivity Map  has been assembled by use of simple pattern-matching algorithms . This syThe types of advances being made are illustrated by recent work in hepatocellular carcinoma (HCC), the fifth most common cancer worldwide. HCC is more prevalent in men than women and recent genetic studies have revealed a causal role for androgen receptor (AR) in hepatocarcinogenesis, but the underlying molecular mechanism remains unclear. Feng et al.  used genThe field of toxicogenomics is undergoing remarkable expansion due to advances in genomic technologies as well as an expanding set of concepts about how environmental agents may impact gene regulation and heritability of traits. The epigenetic bases for heritable changes in gene expression  are becoming more certain as mechanisms such as DNA methylation, histone modifications, non-coding RNAs, and changes in expression or activity of histone acetylases (HAT) and histone deacetylases (HDAC) in the regulation of gene expression patterns are elaborated . It is bThe global prevalence of obesity is increasing across most ages in both sexes. Ng et al.  found thMathers et al.  summarizTransient environmental influences, such as perinatal nutritional stress, may induce deleterious metabolic symptoms that last for the entire life of individuals, implying that epigenetic modifications play an important role in this process. Jousse et al.  investigHistone modifications are thought to regulate chromatin structure, transcription and other nuclear processes. Histone methylation was originally believed to be an irreversible modification that could only be removed by histone eviction or by dilution during DNA replication. However, the isolation of two families of enzymes that can demethylate histones has changed this notion . The bioO-GlcNAcylation, which is a nutrient-sensitive sugar modification, participates in the epigenetic regulation of gene expression. Thus, O-GlcNAc cycling may serve as a homeostatic mechanism linking nutrient availability to higher-order chromatin organization . The widTo elucidate the role of age-related epigenetic changes in healthy ageing and potential longevity, Bell et al.  studied Translatable biomarkers  or biomarker equivalency/ pairings  must be utilized but prudently. To advance understanding of whether exposures have effects that may be a risk, various molecular and imaging biomarkers have been developed, proposed and used in both laboratory and epidemiological settings. A critical shortcoming in this tactic is that a biomarker result is interpreted as a validated proxy for a clinical outcome. This assumption or interpretive leap is virtually always wrong. In human health research, the outcomes that truly matter are clinical endpoints . Short of directly measuring clinical endpoints, surrogate endpoints can be measured if such surrogate endpoints have been validated. At a minimum for biomarkers to be plausibly interpreted as indicators of clinical endpoints, such biomarkers must be explicitly validated as predictors of surrogate endpoints. There are numerous such sets of endpoints and biomarkers that are used in medical practice with varying degrees of reliability. To illustrate, a few common examples would be as follows:Clinical endpoint: sepsisSurrogate endpoint: bacteremiaBiomarker: feverClinical endpoint: prostate cancerSurrogate endpoint: microscopic pathologyBiomarker: prostate specific antigen (PSA)Clinical endpoint: bone fracturesSurrogate endpoint: bone mineral densityBiomarker: osteocalcin (OC), trimeric carboxyterminal telopeptide (ICTP).In environmental health research, we cannot have control over several key components in the "usual" human health research setting. Key characteristics of both the exposure  and the exposed subject  are not controlled by the investigator. So, for environmental health research where the aim is to assess possible human health effects of exogenous exposures, how can we approximate a thorough validation process of linking biomarker(s) to surrogate endpoint(s) to clinical endpoint(s)? We must transform the usual logic of "translational" health research into an approach that "works" to move toxicology research into actionable environmental health discoveries.The aim of translational toxicology is to advance environmental health sciences in order to:1. Transform Research & Development programs, especially endocrine disrupter programs, to link them overtly to disease outcomes;2. Link target tissue/organ/system outcomes in animal models to animal biomarkers (mostly molecular) to human biomarkers to human target organ outcomes 3. Enhance predictive use of animal and human biomarker data sets by development of circumscribed computational  model development.We do need to consider that there may need to be sustained, continuing interventions for certain adverse effects/disease predispositions that are the result of environmental exposures. Nevertheless, key windows for interventions are likely to be the same as those in which adverse effects are elicited. Thus, in utero/neonatal/early childhood, adolescent/peri-pubertal and then menopausal transition in women may be particularly responsive since organizational/re-organizational processes are biologically dynamic in those intervals.What are the prospects for screening pregnant women for exposures of concern and then implementation of mitigation strategies? Perhaps the current compliance of obstetrical practices in terms of testing in prenatal care is a guide. Siddique et al.  examined"Fetal therapy is broadly defined as any intervention administered to or via the mother with a primary indication to improve perinatal or long-term outcomes for the fetus or newborn." . Due to Two studies by Ibanez et al. ,97 suggeWe need to broadly reorient perspectives to make toxicology and/or environmental health an active human health-promoting process. We cannot continue to rely on the existing dichotomy; on one hand, we have laboratory-based molecular, cellular and animal models data while on the other hand we have epidemiological and exposure assessment data. We are convinced that linking these types of data and scientific insights can be done and this is the crux of moving toxicology into an active translational research and interventional science.Hormone signaling pathways may serve as mediators of reproductive and developmental effects and earliest indication of exposure. These early exposures may have later effects which may differ across the lifespan depending on other critical hormonal activities in the body.Exposures are inevitable and the body either builds or has resilience or resistance to the adverse effects, or due to earlier exposures losses its ability to resist and succumbs to disease. The earlier exposures that cause the body to lose its ability to avoid disease in response to environmental factors needs to be evaluated.Stem/progenitor cell populations must be a key component to recovery/resilience to insults and provide a capacity to recover/respond/heal either from the exposure of interest or to multiple future or concurrent insults later in development or across the lifespan.Lab animals, ecological (wildlife) exposures, companion animals, and livestock can serve as bio-monitors and formal ways of getting observations from these populations into the knowledge base on human relevance need to be adopted.A number of contemporary analytical techniques are available to detect and quantify exposures and effects. These methodological tools are widely called "biomarkers" and cover a rather wide range of techniques/technologies from DNA sequences of individual genes, to FACS of cell subpopulations, to 3-D reconstruction of tissues and organs from pathology slides, to whole body imaging with CT and/or fMRI, etc. Techniques such as "shotgun" proteomics and metabolomics offer further broad scope approaches for assessing responses of cells, tissues or organisms to external signals or stressors. Appropriate recognition of how biomarkers relate to disease outcomes in humans is critical to moving environmental toxicology from its current state to producing effective intervention strategies.How do we best develop and gain insight by comparisons of critical windows in animal/cellular models to understand the human consequences for effects and the opportunities for protective interventions?Because exposures occur to many individual compounds, classes of compounds and combinations (mixtures) of compounds and raise legitimate concern, translational links need to rely on various types of biomarkers that address two types of causal toxicopathologic pathways.1. The one (or ones) that are known modes of action of the compound(s) such as most of the EPA Endocrine Disruptor Screening Program Tier 1 Screening Assays .2. The possibility of unknown modes of action such as most of the EPA Endocrine Disruptor Screening Program Tier 2 Testing Assays  or use oNumber 1 is the "silver bullet" or "searching for the lost keys under the lamp-post" while number 2 is "casting the broad net upon the waters" or "searching in the dark." Both need to be done. Number 1 because it relies on using all that we know to trace a straight line between exposure, effect and prospects for mitigation; number 2 because chemicals  have actions in multiple molecular/cellular sites, and biological organisms and components are rife with pleiotropic and redundant systems. So, techniques that broadly ask what effects might result from exposures are essential for translational toxicology. The sorts of techniques that can "cast a broad net" to possibly let us see (previously) unknown modes of action include metabolomics, some forms of proteomics, assays of mutagenic and epigenetic effects, stem cell/progenitor cell/cell fate/cell sorting methods, histomorphometry and advanced microscopy techniques, circulating molecules , anatomical and functional morphology imaging methods. These approaches must be core components of the research and development strategy if translational environmental health is to advance and favorably impact public health.1. The pregnant woman and her fetus are exposed to many chemicals. These chemicals include environmental chemicals, dietary components, over-the-counter drugs, prescription drugs, substances of abuse  and herbal and related products.2. Any of these may affect the fetus via many potential modes of action such as epigenetic, mutational, endocrine, stem cell, and a multitude of other signaling pathways .3. We will depend upon use of biomarkers to assess actions of those compounds and to establish meaning for clinical outcomes. Readily measured biomarkers will have to be linked to surrogate outcomes which have to be representative of clinical outcomes.4. In order to give substance to the term "translational", we must develop ethical and effective interventions to complement exposure reduction so that the adverse health effects of exposures can be prevented, reversed or mitigated.a-DMRs: Chronological age; AEDs: Antiepileptic drugs; AFC: Antral follicle count; AMH: Antimullerian hormone; APAP: Acetaminophen (paracetamol); ap-DMRs: Age-related phenotypes; AR: Androgen receptor; BM: Bone marrow; BPA: Bisphenol A; CCRK: Cell cycle-related kinase; CDC: Centers for Disease Control; CNS: Central nervous system; CpGs: Cytosine-phosphate-guanine; CT: Computerized tomography; CXCR4+: C-X-C chemokine receptor type 4; DMRs: Differentially methylated regions; EDSTAC: Endocrine Disruptor Screening and Testing Advisory Committee; FACS: Fluorescence activated cell sorting; FDA: Food and Drug Administration; DHA: Docosahexaenoic acid; DNA: Deoxyribonucleic acid; DSM: Diagnostic and Statistical Manual of Mental Disorders; EDCs: Endocrine-disrupting chemicals; ETS: environmental tobacco smoke; F1-CD: Control diet; F1-LPD: Low-protein-diet; FFQ: Food frequency questionnaire; fMRI: functional magnetic resonance imaging; GH/IGH: Growth Hormone/Insulin-like growth factor 1; GR: Glucocorticoid receptor; HAT: Histone acetylases; HCC: Hepatocellular carcinoma; HDAC: Histone deacetylases; HFD: High-fat-diet; HPAA: Hypothalamic-pituitary-adrenal axis; HSC: Hematopoietic stem cells; ICTP: Trimeric carboxyterminal telopeptide; INFANIB: Infant Neurological International Battery; IQ: Intelligence quotient; LBW: Low-birthweight; LT-HSC: Long-term repopulation of hematopoietic stem cells; Lys: Lysine; MgSO4: Magnesium sulfate; miRNA: Micro-ribonucleic acid; MRI: Magnetic resonance imaging; NAC: N-acetylcysteine; NHANES: National Health and Nutritional Examination Survey; NHIS: National Health Interview Survey; OC: Osteocalcin; O-GlcNAc: O-GlcNAcylation; OGTT: Oral glucose tolerance test; OR: Odds ratio; OTC: Over the counter; PBDEs: Polybrominated diphenyl ethers; PCOS: Polycystic ovary syndrome; PET: Positron emission tomography; PFCs: Perfluorinated compounds; PP: Precocious pubarche; PSA: Prostate specific antigen; RNA: Ribonucleic acid; RT-PCR: Reverse transcriptase polymerase chain reaction; SCLs: Salivary cotinine levels; SDF-1: Stromal-cell-derived-factor-1; SES: Socio-economic status; siRNAs: Short inhibitory ribonucleic acids; TCF: T-cell factor; TCSCs: Tissue-committed stem cells; TEDX: The Endocrine Disruption Exchange; USPSTF: U.S. Preventive Services Task Force; VCAM-1: Vascular cell adhesion protein 1.All authors  declare that they have no competing interests. Quintiles, Inc. [C.H.] is a pharmaceutical services company that conducts pharmaceutical and biotechnology research and product development for numerous sponsors but does not own pharmaceutical or biotechnology products. Integrated Laboratory Systems, Inc. [M.W. and D.A.] is a research and testing services company that does not own pharmaceutical or biotechnology products.All authors researched and wrote the debate. All authors provided critical reviews and revisions of the manuscript. All authors read and approved the final manuscript.CH – MD, PhD: Executive Director, Cardiovascular and Metabolic Unit, Quintiles, Inc., Morrisville, NC, USA; Department of Obstetrics & Gynecology, Duke University Medical Center; Department of Mathematics, North Carolina State University; Department of Pathology/Comparative Medicine, Wake Forest UniversityMW –PhD: Chief Scientist, Integrated laboratory Systems, Inc., Research Triangle Park, NC, USA.DA – PhD: Chief of Staff, Integrated laboratory Systems, Inc., Research Triangle Park, NC, USA.IO – DVM, PhD: Advanced Leadership Fellow, Harvard University, Cambridge, MA, USA.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/2050-6511/14/51/prepub


Breast cancer remains a significant scientific, clinical and societal challenge. This gap analysis has reviewed and critically assessed enduring issues and new challenges emerging from recent research, and proposes strategies for translating solutions into practice.More than 100 internationally recognised specialist breast cancer scientists, clinicians and healthcare professionals collaborated to address nine thematic areas: genetics, epigenetics and epidemiology; molecular pathology and cell biology; hormonal influences and endocrine therapy; imaging, detection and screening; current/novel therapies and biomarkers; drug resistance; metastasis, angiogenesis, circulating tumour cells, cancer ‘stem’ cells; risk and prevention; living with and managing breast cancer and its treatment. The groups developed summary papers through an iterative process which, following further appraisal from experts and patients, were melded into this summary account.de novo or acquired resistance and how to target key nodes in these dynamic processes; (6) developing validated markers for chemosensitivity and radiosensitivity; (7) understanding the optimal duration, sequencing and rational combinations of treatment for improved personalised therapy; (8) validating multimodality imaging biomarkers for minimally invasive diagnosis and monitoring of responses in primary and metastatic disease; (9) developing interventions and support to improve the survivorship experience; (10) a continuing need for clinical material for translational research derived from normal breast, blood, primary, relapsed, metastatic and drug-resistant cancers with expert bioinformatics support to maximise its utility. The proposed infrastructural enablers include enhanced resources to support clinically relevant in vitro and in vivo tumour models; improved access to appropriate, fully annotated clinical samples; extended biomarker discovery, validation and standardisation; and facilitated cross-discipline working.The 10 major gaps identified were: (1) understanding the functions and contextual interactions of genetic and epigenetic changes in normal breast development and during malignant transformation; (2) how to implement sustainable lifestyle changes  and chemopreventive strategies; (3) the need for tailored screening approaches including clinically actionable tests; (4) enhancing knowledge of molecular drivers behind breast cancer subtypes, progression and metastasis; (5) understanding the molecular mechanisms of tumour heterogeneity, dormancy, With resources to conduct further high-quality targeted research focusing on the gaps identified, increased knowledge translating into improved clinical care should be achievable within five years. Globally, breast cancer is the most frequently diagnosed cancer in women, with an estimated 1.38 million new cases per year. Fifty thousand cases in women and 400 in men are recorded each year in the UK alone. There are 458,000 deaths per year from breast cancer worldwide making it the most common cause of female cancer death in both the developed and developing world 77]). IntExploring the diversity and inter-tumour heterogeneity of breast cancer has led to the development of a novel classification that integrates genomic and transcriptomic information to classify 10 subtypes with distinct clinical outcomes . Triple-Breast development is critically reliant upon cell polarity , choreogHypoxia reflects dynamic microenvironmental conditions in solid tumours, limits responses to radiotherapy  and someIt is not known how many breast epithelial cell subpopulations function as stem cells  or progenitor cells (which proliferate expansively) -106. Clein vivo may not be active in ‘mammosphere’ cultures. There is no clear consensus on markers that define functional breast CSC in mouse and human. Indeed, they may not represent a fixed subpopulation, but instead exist in specific niches in flexible equilibrium with non-CSCs, with the balance depending on interactions between them as well as external selective pressures [Current cancer stem cell (CSC) assays have limitations: dormant cells cannot be detected and cell subpopulations that give rise to clones ressures -109. Undressures  and its Several large-scale, cross-sectional, integrated molecular studies have established comprehensive molecular portraits of invasive primary breast cancers -114. Thein situ (DCIS), an increased understanding is required of molecular markers of prognosis, thus providing key information to avoid overtreatment. We need to know which DCIS lesions will recur if adequate surgery is performed with wide, clear margins. Biological markers of DCIS should aim at defining which lesions are likely to progress, in order to avoid radiotherapy or even surgery if the risk of invasive cancer is sufficiently remote [For ductal carcinoma y remote . MarkersPaget’s venerable ‘seed and soil’ analogy - recognising that tumour-initiating cells require a permissive host environment to thrive - is beginning to be deciphered at the molecular level. . The comStromal changes predict early progression of disease  and in-dThere is a need for better biomarkers of hypoxia including gene expression profiles  serum prTumours have an increased dependence on aerobic glycolysis. We need to understand how hypoxia affects the tumour metabolome and thus may determine therapeutic responses . The depThere is increased understanding of stem cell hierarchies and their potential roles in breast development -131, but-/lo cells (putative CSCs) in the bone marrow is an independent adverse prognostic indicator in patients with early stage breast cancer [Blood-borne tumour cells are routinely identified in breast cancer patients but their scoring can depend upon the method used . Their rt cancer . A popult cancer , which mThis key hallmark of breast cancer occurs when cancer cells access lymphatic and vascular systems, enabling dissemination via lymph nodes and then via the venous and arterial vascular system to distant organs. Once the disease has spread, it becomes life-threatening and patients require systemic treatment. Metastatic relapse typically occurs many months to decades after surgery, thus we need a greater understanding of the processes that occur following tumour cell dissemination, including the phenomenon of dormancy. Recent mathematical modelling using relapse data has provided interesting insights and proposals for hypothesis testing . CTCs anIn addition, seminal research using animal models has identified tumour and host genes associated with metastatic capacity , and also organotropism -151. TheReversible EMT, regulated by many factors including transforming growth factor beta (TGFβ) signalling, Slug and Snail transcription factors and hypoxia may be linked to invasion, dissemination and drug resistance -156. TheIt is unclear whether CTCs originate from primary tumours, micro-metastases or multiple primary and secondary sites. Indeed, CTCs from distant metastases can potentially reseed the primary tumour ,160. MorTo enable further progress, systems and protocols for isolating and characterising CTCs need to be rigorously defined and standardised, with an analysis of whether all systems identify/isolate the same cells The use of ctDNA is increasing as a potentially useful further source of information on breast cancer biology and response to therapy -166. miRMetastasis is the major cause of treatment failure, but it is far from clear why some patients with apparently similar disease succumb and not others . We needWe need to understand how the host microenvironment at secondary sites influences tumour cell survival and to define similarities and differences between ‘permissive’ microenvironments in organs favoured by breast cancer cells such brain, bone or liver. We have learned a good deal since the last gap analysis about the ‘vicious cycle’ of bone metastasis, whereby tumour cell interactions within this unique microenvironment mutually promote metastatic outgrowth and bone remodelling via hormonal, immunological and inflammatory mediators. These findings need to be translated into new therapies targeting both tumour and host components  with theCurrent clinical therapies for breast cancer are offered on an individual patient basis via a multidisciplinary team and comprise surgery, radiotherapy and drug therapies targeting oncogenic processes. Selection of therapy is based on Level 1 evidence from large RCTs or meta-analyses of such RCTs -177. IncImmunohistochemical (IHC) analyses for selecting therapeutic options generally lack reproducibility and standardization resulting in poor concordance between laboratories. The Quality Assurance programme for ER, PR and human epidermal growth factor receptor 2 (HER2) in the UK has to some extent addressed this, but for other biomarkers, including Ki67, there clearly remain problems. We need to develop standardised protocols for better quantification of biomarkers , especiaHealth inequalities remain in relation to treatment. Older people diagnosed with cancer are more likely to experience undertreatment, potentially having poorer clinical outcomes than younger women for example ,181. IndSurgery remains the primary treatment for most women, with breast conservation (plus whole breast radiotherapy) providing similar outcomes to mastectomy. Following mastectomy, breast reconstruction should be considered, although uptake is incomplete. Axillary surgery has moved from clearance via node sampling techniques to sentinel node biopsy as the preferred means for assessment of axillary metastasis in early breast cancer. Neoadjuvant therapy, initially implemented to down-stage inoperable cancers, is increasingly used to assess drug efficacy in individuals and to reduce the extent of surgery required in good responders .Radiotherapy is both clinically effective and cost-effective in the adjuvant and palliative settings. The Oxford overview of adjuvant radiotherapy trials  showed aTrials of partial breast irradiation evaluating intraoperative radiotherapy in comparison to external beam radiotherapy ,195 or bClinical decision-making tools to support individualised treatment can influence patients’ treatment choices and experiences  and commA significant number of patients are overtreated to achieve the improved survival overall in early breast cancer, since we cannot define individual risks of disease recurrence or sensitivity to treatment. For survivors, the long-term side effects of treatment may be significant; individualised treatment so that patients only receive the treatment they require to achieve cure remains elusive. This is relevant to surgery, radiotherapy, chemotherapy and endocrine therapy.With the widespread adoption of sentinel node biopsy (SNB)-limiting surgery to the axilla has substantially reduced arm morbidity . A detaiFor postoperative radiotherapy after breast-conserving therapy, we do not have reliable ways of identifying low risk, particularly in elderly patients for whom radiotherapy might be omitted. While even low-risk patients have an approximately 50% reduction in first recurrence , the absFurther work is required to clarify whether the response to neoadjuvant chemotherapy can be used to guide the selection of patients for regional nodal irradiation  or whethUnderstanding the optimal treatment strategies for an individual patient remains elusive. A number of genomic  and immunohistochemical (for example IHC 4) tests have been developed to predict prognosis and latterly, response to chemotherapy; however, prospective trial evidence is still awaited . RecentlIncreased understanding of the dynamic changes that occur over time is critical and will require repeated assessment of tumour profiles. Genomic tests predict response to endocrine or chemotherapy and those at highest risk of relapse -212, butAs a result of improved outcome for patients with metastatic breast cancer (MBC), central nervous system (CNS) metastatic disease is an increasing therapeutic challenge . OptimalBisphosphonates reduce the risk of developing breast cancer in osteoporotic and osteopenic women by approximately 30% and the risk of recurrence in early breast cancer when used at the time of diagnosis ,216.The The impact of bone-targeted therapy on extra-skeletal metastases and locoregional relapse also highlights the need to better understand experimental observations concerning reseeding of tumours from dormant cells within the bone microenvironment . Additioin situ vaccine [The role of localised treatment of oligometastatic disease for example in the form of selective stereotactic body radiotherapy, radiofrequency ablation or surgery is currently unclear. The impact of irradiating the primary tumour, biological communications between treated primary site and distant metastases and whether radiation therapy can convert the primary tumour into an  vaccine  are relain vivo real time biosensors of tumour biology to capture transient changes in the tumour microenvironment that drive metastasis.The molecular basis of chemo-radiosensitivity, biomarkers  of tumour and/or normal tissue sensitivity is required to allow selection of patients who may benefit from adjuvant radiotherapy and avoid toxicity to those who will not. Explanations for the mechanism(s) of favourable impacts of locoregional control from radiotherapy (RT) on survival are needed  and may Even shorter-dose fractionation schedules (that is one week of whole breast radiotherapy) might achieve equivalent locoregional control with comparable toxicity ,226. ParMultiple lines of clinical and translational evidence have increased our knowledge of the risk of recurrence, particularly for ER+ve disease ,234-236.Comprehensive guidelines to define endocrine resistance have now been agreed . ClinicaThe multiple cell-signalling changes driving resistance and associated disease progression, nevertheless reveal potential cancer cell vulnerabilities  for examSeveral molecularly targeted therapies have been licensed since the last gap analysis including lapatinib and pertuzumab in HER2+ cancers  and the For HER-2 positive disease, dual HER-receptor blockade is more effective than monotherapy and may help prevent or overcome resistance ,263. TwoResistance to targeted signal transduction agents is common, arising via multiple mechanisms including utilisation of compensatory feedback loops or alternative signalling pathways. Systems biology applications have begun to describe these dynamic changes ,268, andRobust guidelines (akin to REMARK) are not yet employed in studies assessing the efficacy of novel therapeutics. Such rigour is essential to ensure that both appropriate models and quantitative outputs are fully utilised. The best drug combinatorial approaches could then be developed based on mechanistic insight into opportunities afforded by synthetic lethality ,270. Morin vivo; this is exacerbated by our incomplete appreciation of networks, cross-talk and redundancy in cell signalling. Given that multiple inhibitors of specific pathways are now available (for example PI3K/PKB/mTOR), harmonised approaches to prioritisation of specific inhibitors/inhibitor classes and of research objectives in clinical trials are required.We lack a comprehensive understanding of the exact mechanisms (both on- and off-target) by which drugs exert anti-cancer effects There is incomplete understanding of the role of diverse gene expression, epigenetic, protein and non-coding RNA changes in the heterogeneous manifestations of clinical resistance, . There iThere is a need to understand the clinical impact of additional hormone receptors besides ERα, especially the progesterone receptor (PR): whilst PR is prognostic, the TEAM study has not demonstrated a predictive value . SimilarIt is not clear whether there are differences in ER+ve premenopausal vs. postmenopausal endocrine resistance . As withIt is important to define the contribution of CSCs to relapse on endocrine therapy, determine their sensitivity to existing agents or identify the unique signalling pathways that sustain their clonogenic potential. Diagnostic or prognostic tests based on ‘whole’ tumour samples may fail to address these potentially significant minority subpopulations of cells.The few prospective studies to date have demonstrated that changes in management for one in six patients could be advised based on changes in breast cancer biomarkers on relapse, particularly ER, PR and HER2 -281. ConDespite high-level evidence for isolated treatment situations (for example adjuvant treatment with AIs) ,285,286,Models are needed for the longitudinal study of hypoxic ‘microniches’ to inform timing of delivery of sequential targeted therapies or chemotherapy with radiation; to test real-time robotically controlled RT delivery to motion-affected hypoxic regions of primary breast tumours; and RT in combination with novel agents targeting pH regulatory mechanisms. Similarly, novel early-phase clinical trials of preoperative RT + targeted therapy or neoadjuvant hormonal therapy with baseline on-treatment biopsies for markers and gene signatures of radiosensitivity (the window of opportunity design) could complement the development of trials of stereotactic body RT to primary + neoadjuvant systemic therapy for limited-volume metastases in liver and bone.Practical considerations include the risk/benefit of combining signalling inhibitors with anti-hormones, sequencing of tamoxifen and AIs  and targAlthough phenotypically similar to BRCA1 mutant breast cancers, TNBC are heterogeneous and lack of expression of ER, PR and HER2 is not a good predictor of homologous recombination repair (HRR) status  Prognostin vitro and in vivo models are required to understand the cellular and molecular complexities of pathological angiogenesis and lymphangiogenesis, tumour cell intravasation, extravasation, organ colonisation and strategies for effective therapeutic interventions [Current understanding the role of lymphangiogenesis in metastasis  is limited . In contventions .Anti-angiogenic therapies have been extensively trialled but have not yet lived up to their promise, with bevacizumab no longer approved for breast cancer by the FDA -302. TumAlthough generally considered to be immunosuppressive, some chemotherapeutic agents  may involve an immune element; thus the combination of immunotherapy and chemotherapy becomes a real possibility ,307. In Cancer immunotherapy is gaining ground, whether antibody-based or cell-based, with an increasing emphasis on targeting the tumour microenvironment (for example macrophages or cancer-associated fibroblast (CAFs)) with DNA vaccines . In addiCancer and its treatment have a considerable and long-term impact on everyday life -313. ConA recent framework publication highlights the importance of providing support to enable people to self-manage their aftercare . PatientQuality of life in women with metastatic breast cancer is poor  with manThe impact of medical management on quality of life and decision making regarding palliative chemotherapy ,324 and The main physical symptoms associated with breast cancer treatment are fatigue, pain, hot flushes, night sweats, cognitive and sexual problems and lymphoedema. Some interventions have demonstrated benefit with specific side effects -331. MetGroup interventions are less effective in reducing anxiety and depression than individualised interventions such as cognitive behaviour therapy (CBT); , but do CBT reduces fatigue , insomniMuch evidence demonstrates the benefits of physical activity for breast cancer patients . RCTs shThe translation of physical activity research into clinical practice is a challenge. Currently, exercise-based cancer rehabilitation is not routinely incorporated into breast cancer care. However, from the National Cancer Survivorship Initiative, Macmillan Cancer Support is evaluating around 12 physical activity programmes and evaluating physical, psychological and cost benefits. One exercise intervention during therapy reassessed participants after five years and showed that those from the exercise group were still incorporating approximately 2.5 hours more physical activity a week and were more positive than control patients . FurtherWhile the problems are well recognised, there is inadequate clinical translation: for example, recognising the benefits of physical activity requires incorporating and testing intervention(s) in clinical practice. There is also a lack of representation and sensitivity to the needs of diverse groups. Similarly, the impact of breast cancer goes beyond the patient; more attention should be paid to their families, partners and children.CBT is becoming integrated into clinical practice with training for clinical nurse specialists but there is still a need to consider how CBT and other interventions can be better integrated to widen access. Novel interventions must be developed and validated using methods based upon sound theoretical principles, with demonstrable effectiveness  that can be deployed as widely as possible to maximise benefit. A clear understanding of the components of interventions that promote uptake, adherence and long-term benefit is required. Funding for research into living with and managing the consequences of breast cancer and its treatment is very limited, adversely impacting the building of research capacity and expertise.Establishing a multidisciplinary research consortium to develop a theoretical framework to inform research addressing the needs of those living with and managing the broad ranging consequences of breast cancer and its treatment would inform choice of outcome measures, innovative approaches to intervention design and testing. Alternative trial designs to RCTs need to be considered that incorporate patient preferences. It would also be of great benefit to the field to draw up guidance on implementing successful evidence into clinical practice.Longitudinal studies are required to assess the recovery of health and wellbeing and the long-term adjustment of women and men who have a diagnosis of breast cancer. This will allow investigation of how unmet psychosocial needs and psychological morbidity during diagnosis and treatment relate to quality of life, sexuality, physical wellbeing and the effects of other illnesses later in life. The long-term impacts of breast cancer and therapy on everyday life need further investigation . There aThere is insufficient epidemiological data on the problems of women who have recurrence and metastatic disease. Research into integrated oncology and palliative care models are needed to determine which approaches improve quality of life, psychological wellbeing, palliation of symptoms, treatment decisions and end of life care. The needs of the families of women with advanced metastatic cancer and how to support them and their carers most effectively are unclear. Decision making at the end of life and the development of tools to assist women and healthcare professionals to choose appropriate treatment and place of death is needed.Specialist breast care nurses have also been found to enhance the supportive care of women with metastatic breast cancer. . HoweverDevelopment of mindfulness and third-wave approaches (for example Acceptance and Commitment Therapy) may be effective. More RCTs of theory-based interventions for treatment-related symptoms and innovative trial designs are needed  to support women to manage their everyday lives. Interventions to address specific psychological needs such as low self-confidence and fear of recurrence also need to be tested. Interventions are required to support women to increase their physical activity, reduce the risk of recurrence and examine the impact on late effects. The frequency, intensity, type and timing of physical activity for maximum benefit needs to be established. Effective means are required to support women to manage impaired sexuality/sexual function, altered body image, lymphoedema, weight gain , fear ofThere is now a greater appreciation of the importance of employing appropriate human cancer cells. . CommonlBetter representation of breast cancer subtypes is required. Material from normal mammary tissue, premalignant breast conditions, different ER+ve (and rare) subtypes of breast cancers and ideally metastases from all major sites are needed to cover the full spectrum of breast cancer development and progression. Primary or minimally passaged cell cultures will avoid issues of misidentification, contamination or long-term culture artefacts. Ideally, a central repository of well-annotated human primary breast cancer cells, associated host cells and cell lines should be available to researchers linked to a searchable, open-access database. Maintaining breast tumour tissue in culture with its essential characteristics intact will enable prognostic screening and testing of potential therapeutic agents.in vitro models. [Reliable cell-type-specific markers are required and it is also important to be able to recognise cancer stem cell subpopulations (or transient phenotypes). Identification of promoters for distinct cell subpopulations will enhance the number and scope of available  models.  and enab models. . IdeallyThree-dimensional culture models can recapitulate the tissue architecture of the breast and its characteristic invasion patterns ,365 espeIn the last five years there has been an expansion in the use of orthotopic  breast cancer xenografts  and signExpansion of PDX models will be required to cover all the main breast cancer phenotypes  and to ain vitro. Improved tumour models and methods are required to understand the localised and possibly transient factors involved in temporal and spatial heterogeneity that promote invasion and metastasis.Invasive behaviour does not occur uniformly or synchronously within a tumour  and thisNovel agents designed for systemic administration are rarely tested against established invasive/metastatic disease in preclinical animal models ,383. TheIn around 20% of women, complete resection of primary tumours does not prevent distant metastases because dissemination has already occurred. In these cases, agents targeting cell motility or invasion may have limited value. It is therefore critical that preclinical models used for testing such therapies incorporate established micrometastases . Similarin vivo biosensors of tumour biology offer novel opportunities for significant progress.Preclinical or clinical trials focused on tumour shrinkage are not appropriate for testing the efficacy of anti-invasive or anti-metastatic agents that may reduce metastasis without significantly impacting primary tumour growth . Such apex vivo targeting studies, employing signalling analyses and imaging systems to track resistance mechanisms and progression.While challenging, establishing cell lines, tissue slice models and PDX from relapsed and resistant cancers should be the ultimate goal in order to provide a window on the mechanisms that occur in patients where therapies fail. This would also allow in vitro, either by transfection of potential signalling molecules such as HER2 or from continuous exposure to anti-endocrine agents. Extensive panels of relapsed human tumour cell lines are required to reflect the heterogeneity of clinical resistant disease. This will allow assessment of the impact of genetic background, duration, sequence and type of endocrine agent (including AI) and rational evaluation of agents to reverse resistance [in vitro with clinical resistance.Preclinical endocrine resistant models have largely been derived from ER+ve MCF7 cells sistance . It is cBiobanking has substantially improved and is seen as a significant outcome of the last gap analysis  but the Increased use of clinical relapse material will determine the relevance of preclinical findings and identify potential candidates for detailed mechanistic evaluation in appropriate tumour model systems. Ultimately the goal is to determine if patients can be better stratified to allow rational, personalised choices for further therapy. This aspiration requires better integration between clinicians and scientists, trial providers and pharmaceutical companies and would benefit from data sharing. Tissue-based analyses from clinical trials need to be expanded to incorporate all of the next generation sequencing studies for research. These initiatives need to be co-ordinated with cancer registry/ British Association of Surgical Oncology (BASO) breast cancer data.Blood samples for early diagnosis, monitoring treatment response, early indicators of disease relapse  are imperative as our ability to generate new biomarkers through emerging technologies increases. These include detection of CTCs, miRNAs, ctDNA, exosomes, and so on. Serum HER2 measurement may be another promising biomarker with prognostic and predictive value -398.With the exception of ER and HER2, the availability of biomarkers to accurately identify which patients will receive benefit from targeted treatment, and indicators of patients at high risk of progression or relapse remains limited. Further advances in molecularly targeted and anti-endocrine therapy require clinically applicable predictive biomarkers to enable appropriate patient recruitment and to track responses to treatment ,400. Thenot respond to trastuzumab (primary resistance) in addition to the development of secondary acquired resistance. Discriminatory biomarkers are required for combination therapies such as lapatinib and trastuzumab in HER2-positive breast cancers. We lack preclinical data that can predict which combination of anti-HER2 therapies is optimal. There is also a need for biomarkers that can identify patients who may be more suitably treated with a tyrosine kinase inhibitor (TKI) rather than trastuzumab or combination anti-HER2 therapy. New irreversible TKIs currently in clinical trials, (for example afatinib and neratinib) have shown increased potency in preclinical studies - could these now become the mainstay for HER2-positive tumours?Validation of predictive markers for drug response could be better facilitated by the routine inclusion of such approaches into clinical trials rather than retrospective analyses of archived material. Any new biomarkers should have well-defined cut-off points, be thoroughly validated and robust. We require biomarkers to identify patients who will PIK3CA mutations) and proteomic (for example PTEN loss) biomarkers impact the efficacy of specific PI3K pathway inhibitors in the clinical setting is limited. Further preclinical research on the functional proteomic effects of genomic abnormalities in the PI3K pathway in breast cancer is essential.Knowledge of the therapeutic benefits of mTOR inhibitors and of newer PI3K pathway inhibitors in breast cancer subtypes is rudimentary and we have no biomarkers that can be used to optimise their therapeutic index. In addition, knowledge of how important genomic  is routinely applied to the early detection and follow-up of breast cancers, there is a need to increase the use of functional screening techniques to better understand tumour heterogeneity, identify features associated with response or resistance to treatment and more rapidly translate promising new preclinical methodologies to clinical evaluation. It is important to evaluate emerging imaging biomarkers of primary and metastatic breast cancer and there is a requirement for new, more specific and clinically translatable radiotracers for positron emission tomography/single-photon emission computed tomography (PET/SPECT) ,402. We Imaging may also be able to report on intratumoural heterogeneity and identify the most significant region (for example more aggressive/invasive areas via diffusion-weighted magnetic resonance imaging (MRI)), to more accurately direct biopsies or radiotherapy. EMT could be addressed by the increased use of cluster, histogram and/or texture analyses, but it will be necessary to define the correct metrics to assess and quantify such phenotypes . It woulA key achievable goal is to non-invasively evaluate predictive biomarkers of therapeutic responses. Increased adoption of more clinically relevant orthotopic xenograft and transgenic murine models of primary and metastatic breast cancer will demand robust preclinical imaging approaches. The use of such models in imaging-embedded trials of novel agents will improve the accuracy of preclinical data, accelerating the development of promising drugs, or enabling early closure of suboptimal programmes. Such refined preclinical trial designs will also prove highly informative in establishing combination and/or sequential treatment regimes.de novo resistant cancers and investigate how such resistance can be counteracted. These approaches are particularly relevant for therapeutic strategies that target cancer stem cells, residual (dormant) cancer cells or influence the tumour microenvironment. Future trial design will also have to incorporate dynamic strategies, such as using the response to short-term treatment to guide the use of additional preoperative treatment. Given the increasing focus on small target populations (for example molecular subtypes of breast cancer), clinical trial strategies for effective patient stratification or selection based on molecular characteristics are required to allow routine integration into large-scale clinical trials. In addition, the relatively long period between surgery and relapse in breast cancer patients impacts negatively on the economic feasibility of such clinical trials. New thinking will be required to modify clinical trial design, and to consider biomarkers that relate to invasive and metastatic phenotypes, for example as in trials with denosumab where the development of skeletal-related events (SRE) was an accepted and measurable endpoint [Clinical trial design should be adapted to use preoperative and neoadjuvant models to allow novel therapies to be tested in patients ,407, ideendpoint .There is a need to incorporate standardised patient-reported outcome measures (PROMs) both within clinical trials and in everyday clinical practice. Currently, many trial reports are reliant on the common terminology criteria for adverse events (CTCAE) gradings about side effects, which show alarming discrepancies with data actually collected from patients .Further research is needed to support the use of decision aids around surgery and treatment and to define any benefits. There is also a need for prospective research to identify consequences of treatment and the impact of co-morbidities on the lives of women with breast cancer so that future patients can consider these as part of their decision making. The experiences of minority ethnic groups, younger (<45 years) and older (>70 years) women in relation to their treatment choices and management need further research. Addressing non-adherence to endocrine therapy and understanding the biological mechanisms of significant side effects such as menopausal symptoms are poorly understood. The value of incorporating lifestyle recommendations as part of routine care and its impact on recovery and quality of life should be further explored.in vitro/in vivo/ex vivo model development, serial clinical sample collection, advanced bioinformatic/systems biology analysis, clinical biomarker validation and ‘bench to bedside’ drug development. Stronger multidisciplinary collaborations between laboratory scientists, clinicians, bioinformaticians and engineers (and in turn with funding bodies and industry) must be encouraged. Much better integration of computer science, database engineering, data analytics and visualisation, hardware and software engineering within biological research will be essential to effectively read and translate increasingly complex data. Convincing drug companies of the benefits of a co-ordinated approach  in clinical trials of new drugs is problematic, and access of material for research purposes is limited. Companies must be convinced of the benefits of accurate biomarkers to allow for the better stratification of patients. Even though this will limit their target population, this should be offset by higher response rates and faster regulatory approval.Increased resources are required to support core  as well as new ‘omics technologies; to develop improved Continued support is required for basic biological research and understanding of cell signalling processes with emphasis on interactions, cross-talk and microenvironmental regulation. It is important that approaches in this area are linked to systematic investigations and precise analyses of cell responses to a wide range (and combination) of inhibitors, tested in clinically relevant breast cancer model systems. A key element is open discussion and learning from negative results to avoid unnecessary duplication of research. Sharing of information, best practice, optimised model systems, technologies and resources is essential, perhaps through developing web-based analysis portals. Such approaches are needed to integrate and interpret diverse sources of data to understand the plasticity of signalling emerging during treatment though to resistance Figure .A co-operative network of advanced radiotherapy facilities, analogous to the Experimental Cancer Medicine Centres is needed to ensure adequate patient numbers for clinical trials. Engaging patients and healthcare teams is critical to enable complex biological studies . Lack of academic clinicians (particularly in radiation oncology), radiobiology and physics staff nationally and rising service pressures on NHS staff are all detrimental to delivery of clinical translational research.While substantial advances have been made in breast cancer research and treatment in the last five years, there remain significant gaps in translating this newly acquired knowledge into clinical improvements.Understanding the specific functions and contextual interactions of genetic and epigenetic advances and applying this knowledge to clinical practice, including tailored screening, will require deeper understanding of molecular mechanisms and prospective clinical validation. Even with clinically actionable tests, decision making, support for patients and their families and overcoming the barriers to lifestyle change  alongside chemopreventive strategies are required to optimise health outcomes.de novo or acquired resistance. This will significantly improve patient stratification for existing therapies and identify key nodes in these dynamic processes as potential new therapeutic targets. Validated markers of these processes  will benefit from synergies between laboratory and clinical interactions. Improved understanding of the interactions, duration, sequencing and optimal combinations of therapy should allow better stratification of patients and reduce overtreatment (or undertreatment) enhancing prevention or survival while reducing morbidity.Genomic profiling of sequential clinical samples  is required to identify specific biomarkers of inter-/intra-tumour spatial and temporal heterogeneity, metastatic potential, sensitivity to radiotherapy and different forms of chemotherapy, Further genetic, epigenetic and molecular profiling of breast cancers and their associated stroma would be significantly enhanced by expanded panels of cell lines representing all major breast cancer subtypes and three-dimensional tumour-host heterotypic co-culture systems. This would enable increased understanding of the molecular drivers behind specific cancer subtypes and their role  in treatment resistance and metastasis. Deciphering tumour-stromal interactions incorporating metabolic and immunological host mechanisms and intracellular/extracellular signalling pathways would have therapeutic implications for prevention and therapy. Advanced high-content analytical methods will enable consideration of additional key cancer ‘hallmarks’ beyond proliferation (for example cell motility and invasion) and enable screening for inhibitors under more physiologically relevant conditions. Better preclinical animal models  are required. Such models would enable testing of hypotheses derived from clinical observations and rigorous target validation and evaluation of novel therapies in the metastatic setting (and where desirable in immunocompetent hosts).Underpinning these advances, optimised multimodality imaging for diagnosis and therapeutic monitoring should enable better evaluation of primary and metastatic disease. Clinically annotated tissues for translational research must be linked to bioinformatics as key contributors to interdisciplinary research, essential for rapid future advances. Increasing numbers of women and men are surviving breast cancer. Alongside advances in understanding the disease and using that knowledge for prevention, earlier detection and successful treatment of breast cancer, interventions to improve the survivorship experience require innovative approaches to address the consequences of diagnosis and treatment.Top 10 gaps:1. Understanding the specific functions and contextual interactions of genetic and epigenetic changes in the normal breast and the development of cancer2. Effective and sustainable lifestyle changes  alongside chemopreventive strategies3. Tailored screening approaches including clinically actionable tests4. Molecular drivers behind breast cancer subtypes, treatment resistance and metastasisde novo or acquired resistance; how to target the key nodes in these dynamic processes5. Mechanisms of tumour heterogeneity, tumour dormancy, 6. Validated markers of chemosensitivity and radiosensitivity7. Interactions, duration, sequencing and optimal combinations of therapy for improved individualisation of treatment8. Optimised multimodality imaging for diagnosis and therapeutic monitoring should enable better evaluation of primary and metastatic disease9. Interventions and support to improve the survivorship experience including physical symptoms such as hot flushes and lymphoedema10. Clinically annotated tissues for translational research including tumour, non-tumour and blood based materials from primary cancers, relapsed and metastatic diseaseProposed strategic solutions:For significant progress to be made in treating and supporting those impacted by breast cancer (and ultimately preventing and overcoming this disease) basic and translational research scientists in academia and industry, funding bodies, government and patients need to work together to achieve the following key strategic solutions1. To reverse the decline in resources targeted towards breast cancer research, funding must be increased and strategically directed to enhance our current knowledge, develop the talent pool, and apply evidence-based findings to improve clinical care2. A fully cohesive and collaborative infrastructure must be developed to support breast cancer research; this requires improved access to appropriate, well-annotated clinical material including longitudinal sample collection with expert bioinformatics support and data sharing.in vitro and in vivo models are required for evaluation of new therapies together with validated biomarkers, which should then be embedded in clinical practice.3. Building on sound investment and infrastructure, all stakeholders  must work together on the clinical development and translation of research knowledge to patient benefit. For example, enhanced, clinically relevant, 4. Research funders, government and industry should provide innovative programmes to encourage collaborative cross-disciplinary working practices, including the training of more physician-scientists and integration of physical sciences, technology and engineering.5. Improving clinical trial methodologies, including patient involvement, recognising that a changing global environment is required to ensure that all clinical developments can be tested and ultimately implemented for patient benefit.in situ; DDR: DNA damage response; DNA: Deoxyribonucleic acid; DTC: Disseminated tumour cell ; ECM: Extracellular matrix; EMT: Epithelial-mesenchymal transition; ER: Oestrogen receptor; FGF: Fibroblast growth factor; FGFR1: Fibroblast growth factor receptor 1; FNA: Fine-needle aspiration; FOXA1: Forkhead box protein A1; GEM: Genetically engineered mouse; GWAS: Genome-wide association studies; HER2: Human epidermal growth factor receptor 2; HER3: Human epidermal growth factor receptor 3; HRR: Homologous recombination repair; HRT: Hormone replacement therapy; HSP90: Heat shock protein 90; IBTR: Ipsilateral breast tumour recurrence; ICGC: International Cancer Genome Consortium; ICOGs: Illumina collaborative oncological gene-environment study; IGF1: Insulin-like growth factor 1; IHC: Immunohistochemical; iPS: Induced pluripotent stem cells; LC-MS: Chromatography-mass spectrometry; MBC: Metastatic breast cancer; miRNA: Micro RNA; MRI: Magnetic resonance imaging; NMR: Nuclear magnetic resonance; panHER: Representing the whole HER family; PARP: Poly (ADP-ribose) polymerase; PDX: Patient-derived xenografts; PET/SPECT: Positron emission tomography/single-photon emission computed tomography; PI3K: Phosphatidylinositide-3 kinase; PIK3CA: Gene encoding PI3 kinase alpha; PKB: Protein kinase B; PR: Progesterone receptor; PROMs: Patient-reported outcome measures; RCT: Randomised controlled trial; RECIST: Response evaluation criteria in solid tumors; RNA: Ribonucleic acid; RT: Radiotherapy; SERMs: Selective oestrogen receptor modulators; siRNA: Short inhibitory RNAs; SNB: Sentinel node biopsy; SNP: Single nucleotide polymorphism; SRE: Skeletal-related events; START A: Standardisation of Breast Radiotherapy (START) trial A; START B: Standardisation of Breast Radiotherapy (START) trial B; TCGA: The Cancer Genome Atlas; TGFβ: Transforming growth factor beta; TKI: Tyrosine kinase inhibitor; TMA: Tissue microarray; TNBC: Triple-negative breast cancer; VEGF: Vascular endothelial growth factor; WHI: Women’s Health Initiative.AI: Aromatase inhibitor; AR: Androgen receptor; ATM: Ataxia telangiectasia mutated; BASO: British Association of Surgical Oncology; CAF: Cancer-associated fibroblast; CBT: Cognitive behavioural therapy; CDK10: Cyclin-dependent kinase 10; CHEK2: CHK2 checkpoint homolog; CHK2: Checkpoint kinase 2; CNS: Central nervous system; CSC: Cancer stem cell; CTC: Circulating tumour cell (in blood); CTCAE: Common terminology criteria for adverse events; ctDNA: Circulating tumour DNA; DCIS: Ductal carcinoma Dr Galina Velikova: Chair of a working group of the National Cancer Survivorship Initiative led by Macmillan Cancer Support.Drs Helen Bryant and Dr Nicola Curtin: hold patents for PARP inhibitors.Professor William Gallagher: co-Founder and part-time Chief Scientific Officer of OncoMark, a molecular diagnostics company.Dr Martin Leach: director of Specialty Scanners plc, developing MRI-based diagnosis and treatment systems.Dr Sacha Howell: Advisory Board honoraria from AstraZeneca, Roche, Novartis, Genomic Health and Celgene.Dr Robert Stein: shareholder in GlaxoSmithKline and chief investigator of the OPTIMA study; travel funds received from Celgene, Roche, BristolMeyersSquibb, SanofiAventis and Novartis; Advisory Board fees from Novartis, Amgen, GSK, Roche and AstraZeneca.Dr Nigel Bundred has received paid honoraria from Genomic Health.The remaining authors declare that they have no competing interests.≠ denotes current Breast Cancer Campaign Scientific Advisory Board membership. # denotes current Breast Cancer Campaign Board of Trustees membership. Chairs: SAE# and AMT# conceived the overall strategy, designed the workshop formats and authored the manuscript on the basis of the final reports submitted by the nine working groups. Group Leaders: RBC, IDSS, DGE*≠, CF≠,WMG≠, AH≠, IH*≠, LJJ*, SPL, SPR≠, PS*≠, and VS* led their respective groups with the help of the Deputy Group Leaders, co-ordinated responses from a pre-circulated questionnaire, and wrote and submitted final reports. Deputy Group Leaders: EOA, NJB a, JMF*≠, JMWG*, AJH*, MH, AK, JRM*, PM*≠, ES, MJS*≠, ER, and RN* supported the activities of the Group Leaders in contributing to collating workshop presentations and discussions and producing the final reports from each group. Working group members: SA*, ASA , JA*, FB*, JPB*, KB*≠, NJBb, HEB≠, JMB, AMC*, JSC*, CEC*, GJRC*, AC, NJC, LVD*≠, SWD, DFE, DME, DRE*, JE, DFF*, MGC, AJG, VG, AMG, BTH, SH, SJH≠, GH, NHW, MSH, BJ, TJK, CCK, IHK*, MOL, DJM, JFM*≠, LAM, SGM≠, JEM, DWM, WRM, JRM, SMM*, JPBOC, ROC*, CP, PDPP*, EAR≠, JMS*, RS≠, JS, CHS, ANJT, GV, RAW*, CJW, KJW≠ and LSY all participated in/contributed to the gap analysis workshops, discussions and in generating the respective reports. NJBa Nigel J Bundred. NJBb Nicola J Brown. All authors read and approved the final manuscript.*denotes recipient of Breast Cancer Campaign funding in the last five years.


Cilia, suggests that not only do cilia touch, they may even stick together for a long time [The primary cilium has been much celebrated for its central role as a sensory organelle. Whether we consider odorants binding to odorant receptors in olfactory cilia or light stimulating rhodopsin in the retinal outer segment, core ciliary structures and G-protein coupled receptors like rhodopsin allow our senses to function. The importance of ciliary pathways in sensation is well illustrated in patients with Bardet-Biedl syndrome, whose ciliary defects are linked to anosmia and loss of retinal function . In addiong time .Drosophila suggested that a specialized ciliary diliation, a narrowing of the cilia, was organized by the intraflagellar transport (IFT-A) complex, and this ciliary specialization interacted with supporting cells in the chordotonal organ and was required for sensory function [Chylamydomonas induced to mating, the cilia can form agglutination structures critical to their mating function [Cilia are organized around the axoneme, with the centriole organizing the ciliary base see ,3, for r, for r3,function . Finallyfunction . Finallyfunction .So cilia appear to interact purposefully with cells and exosomes from their surrounding cellular neighbourhood. But what about touching each other?Lippincott-Schwartz and colleagues consider cilia-cilia pairing, first looking into the retina and liver. In the retina, they observe that the ciliary membrane of rod cells, enveloping both the connecting cilium and outer segment, are closely packed side-by- side in the photoreceptor layer. The close juxtaposition of outer segments suggested possible adhesion sites. In the liver cholangiocytes, cilia extend into the bile duct and may participate in bile flow and signalling. Some cilia appeared to participate in cilia-cilia contacts, especially in younger animals. Moving to a cell culture model, the authors find that when MDCK cells are induced to form 3D cysts, the cilia are oriented on the apical surface towards the lumen, and indeed form cilia-cilia contacts. In MDCK cell monolayers grown on filters, the cilia are longer (815) and cells are close packed (10 spacing). Here the cilia can form continuous arcs, or point contacts, and even cilia-cilia networks. In other cells, less tightly packed and with short cilia, the cilia-cilia contacts are less apparent.If the cilia-cilia contacts are important, a first guess is that they would be enduring, rather than transient. Indeed, the authors find that by filming of cells, that most showed contacts persisting for 2 hours, and over half of cell for up to 20 hours or longer. So cilia-cilia contacts can be stable; a first estimate is that 13% of cilia make contact. What sets the percentage and whether there are cell mechanisms that favor ciliary pairing would help us understand when and where the phenomena is important. One might guess that the density and organization of cells would be important to favor ciliary pairing. Some data suggest that ciliary length may be regulated once preciliated cells reach confluence and establish adherens junctions, possibly requiring the Par3-Par6-aPKC pathway ,10. We cChylamydomonas also uses glycoproteins for ciliary pairing, there is now question of which ciliary membrane protein(s) may mediate pairing. Inspection of the ciliary or FABB proteome may be a good place to look for candidates [In terms of how the ciliary arcs are formed, the authors consider whether a single cilium might bend into an arc; or if cilia from adjacent cells adhere; or if cilia from adjacent cells actually fuse! Using time-lapse microscopy, it became clear that ciliary contacts are established first, and then zipped up to form a stable pairing. Electron micrographs of the interaction was reminiscent of an adhesive pairing, so the authors considered whether known molecular pathways for adhesion were required. Using EGTA to chelate calcium, and DTT to dissolve disulphide bonds, neither disrupted ciliary pairing, suggesting that neither calcium-dependent cadherins nor disulphide-requiring Ig domains were strongly required. In contrast, treating cells with the mannosidase II inhibitor swainsonine to block oligosaccharide formation, the authors did observe a loss of the ciliary pairing phenomena. Other drugs perturbing glycoprotein formation like neuraminidase treatment or elastase treated failed to block pairing, but these experiments were technically less conclusive. Considering the ever-important cell cycle, it was clear that as cilated cells enter mitosis, they also showed a loss of ciliary pairing, further supporting the potential biological relevance of the pairing phenomena. Because ndidates .The studies here provide a provocative first glimpse of how glycoprotein contacts may link cilia-cilia pairings in cells, which could proceed from initial synaptic pairing to more stable, zipped-up associations. Additional genetic or molecular studies could inform and support the importance of these pairing for ciliary function. But the larger question is why cilia would use such contacts. Among the potential roles, a general function in intercellular communication between closely apposed cells or intracellular communication in tissues would be important. A somewhat similar mechanism may be provided by cytonemes, specific filopodial intercellular links , and muc


Despite the combination of light-microscopic immunocytochemistry, histochemical mRNA detection techniques and protein reporter systems, progress in identifying the protein composition of neuronal versus glial gap junctions, determination of the differential localization of their constituent connexin proteins in two apposing membranes and understanding human neurological diseases caused by connexin mutations has been problematic due to ambiguities introduced in the cellular and subcellular assignment of connexins. Misassignments occurred primarily because membranes and their constituent proteins are below the limit of resolution of light microscopic imaging techniques. Currently, only serial thin-section transmission electron microscopy and freeze-fracture replica immunogold labeling have sufficient resolution to assign connexin proteins to either or both sides of gap junction plaques. However, freeze-fracture replica immunogold labeling has been limited because conventional freeze fracturing allows retrieval of only one of the two membrane fracture faces within a gap junction, making it difficult to identify connexin coupling partners in hemiplaques removed by fracturing. We now summarize progress in ascertaining the connexin composition of two coupled hemiplaques using matched double-replicas that are labeled simultaneously for multiple connexins. This approach allows unambiguous identification of connexins and determination of the membrane “sidedness” and the identities of connexin coupling partners in homotypic and heterotypic gap junctions of vertebrate neurons. Vertebrate gap junctions consist of connexin proteins that assemble as hexamers to form connexon “hemichannels” that link across the extracellular space, forming leakless channels that permit the direct intercellular transport of water, ions and small molecules [≤450 Da  mice can be considered the “gold standard” for confirmation of specificity. Many of the antibodies that we use have been characterized for specificity by comparison of immunofluorescence and/or immunoblotting results in wild-type mice vs. mice with KO of the various connexins. For connexins relevant here, such characterization has included antibodies against Cx26 . Because of inherent limits of LM resolution, current immunocytochemical methods applied to complex CNS tissues are unable to discern whether specific connexins, reportedly identified either by diffuse cytoplasmic staining Colwell  or by thx, y and z axes are indicated in stereoscopic images by the inscribed three-dimensional box, which corresponds to a single “voxel” (volume pixel) at the resolution limit of confocal LM . Moreover, in the red wavelength  using knife-fractured single replicas (procedure described below) revealed that neuronal processes often had thin astrocyte “fingers” interposed, in this case with a small A:A gap junction labeled for both Cx26 and Cx30 , detection is common for multiple connexin mRNAs, including multiple glial connexin mRNAs in neurons  express only Cx45 and not Cx36 . These protocols included minimization of stress to animals and minimization of the number of animals used. One formaldehyde-fixed rat retina and several formaldehyde-fixed goldfish hindbrains were prepared for DR-SDS-FRL and DR-FRIL, as previously described , three cross sections of adult rat replica were prepared by DR-SDS-FRL and simultaneously double-labeled for Cx36 and Cx45. We found more than 160 gap junctions labeled for Cx36, 12 of which also contained Cx45. Eleven of those were found in the matched complementary replica . These connexins vary primarily in their phosphorylation sequences [Cx34.7 lacks a phosphorylation site for CaMKII , while bi- and trihomotypic gap junctions may provide for bidirectional signaling but with the added property of differential modulation of multiple conductance states for ions and small signaling molecules.DR-FRIL and DR-SDS-FRL have unambiguously revealed individual gap junctions expressing two connexins—on the one hand, forming bihomotypic and, on the other hand, forming heterotypic junctions. As a now widely recognized type of synapse between neurons in the mammalian CNS, the conductance properties of electrical synapses and their regulation take on new importance. The two different connexin distributions demonstrated by DR-FRIL  suggest the existence of previously unrecognized mechanisms for regulating gap junction conductance states. Bi- and trihomotypic gap junctions are likely to increase the complexity and enhance the quality of synaptic communication provided by gap junctions. Likewise, heterotypic gap junctions provide not only for differential modulation on opposite sides of the same gap junction but also for the possibility of electrical rectification in teleost CNS neurons. Because there appears so far to be only one connexin (Cx36) widely expressed in neurons in tetrapods, heterotypic coupling may seem at first glance to preclude rectification. However, functional asymmetry between apposed hemichannels could perhaps be achieved by differences in posttranslational modifications between these two channels. Supporting this possibility, Cx36-containing junctions have been shown to coexist at different degrees of phosphorylation in the retina (Kothmann et al. As powerful as FRIL has proven to be, there are two limitations that make it and DR-FRIL less inviting for the novice. First, freeze-fracture and FRIL require complex, costly equipment that is at the cutting edge of high-vacuum, cryopreservation and metal evaporation technologies. Second, with more than a dozen discrete steps, all of which must be performed flawlessly to obtain the matching complementary replicas, DR-FRIL is particularly demanding of its technological practitioners. Third, freeze-fracture electron microscopy requires considerable time to gain expertise in obtaining and interpreting FRIL images. The training period for FRIL is several years because the researcher must learn conventional electron microscopy as well as interpretation of tissue ultrastructure in freeze-fracture replicas before learning FRIL methods. In these days of automated molecular biology, few students are willing to make this long-term commitment. With few laboratories remaining that are capable of conducting FRIL and DR-FRIL, there is a narrowing window of opportunity for the application of simultaneous ultrastructural and immunocytochemical approaches, not just to gap junctions and mixed synapses at EM resolution but also to other key questions in neuroscience requiring this level of resolution.


MicroRNAs (miRs) have emerged recently as important regulators of gene expression in the cell. Frequently dysregulated in cancer, miRs have shed new light on molecular mechanisms of oncogenesis, and have generated substantial interest as biomarkers, and novel therapeutic agents and targets. Recently, a number of studies have examined miR biology in Ewing sarcoma. Findings indicate that alterations in miR expression in Ewing Sarcoma are widespread, involve both EWS/Ets oncogenic fusion-dependent and independent mechanisms, and contribute to malignant phenotypes. miRs with prognostic potential have been identified, and several preclinical studies suggest that miR manipulation could be therapeutically useful in this aggressive disease. These and future studies of miR biology stand to expand our understanding of Ewing sarcoma pathogenesis, and may identify new biomarkers and treatment options. MicroRNAs (miRs) represent a recently discovered novel class of cellular bioactive molecules with important functions in the regulation of gene expression in normal physiology and disease  by the action of a protein complex containing the Dicer gene product  have been proposed to drive the initiation and maintenance or tumors, but defining their identity and impact remains a challenge for cancer biologists  transcription (or transcription of the parent gene for miRs derived from protein-coding mRNAs), pri-miR to pre-miR processing, nuclear-cytoplasmic transport, pre-miR to (mature) miR processing, and stability/turnover. Thus far, in Ewing Sarcoma, evidence has been presented for regulation of precursor transcription and pre-miR to miR processing. With respect to transcriptional control, McKinsey et al.  showed tStudies have also provided evidence for alterations in miR processing in Ewing Sarcoma. De Vito et al.  identifiWhat have we learned from miR studies in Ewing Sarcoma thus far? We have gained new insight into disease biology, and identified new candidate biomarkers and therapeutic targets. MiRs represent a novel and unique mechanism of regulation of gene expression, which can affect protein levels without dramatic changes in mRNA levels. Thus, understanding of miR-mediated pathways can reveal new oncogenic mechanisms not easily accessible to other methodologies like RNA-based gene expression profiling. To this end, miR studies thus far have revealed a new mechanism for augmenting EWS/Fli1 protein levels (Riggi et al., The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In human cancer cells, a constitutive activation of MAPK, STAT3, β-catenin, and various other signaling pathways triggers multiple immunosuppressive cascades. These cascades result in the production of immunosuppressive molecules  and induction of immunosuppressive immune cells . Consequently, immunosuppressive conditions are formed in tumor-associated microenvironments, including the tumor and sentinel lymph nodes. Some of these cancer-derived cytokines and chemokines impair immune cells and render them immunosuppressive via the activation of signaling molecules, such as STAT3, in the immune cells. Thus, administration of signal inhibitors may inhibit the multiple immunosuppressive cascades by acting simultaneously on both cancer and immune cells at the key regulatory points in the cancer-immune network. Since common signaling pathways are involved in manifestation of several hallmarks of cancer, including cancer cell proliferation/survival, invasion/metastasis, and immunosuppression, targeting these shared signaling pathways in combination with immunotherapy may be a promising strategy for cancer treatment. By the time cancer cells are detected clinically, they have already evaded the immune-defense system . This may be achieved possibly by using chemotherapy, molecular targeted drugs, anti-tumor antibody, irradiation, cryoablation, radiofrequency ablation, or oncolytic viruses. (3) Development of methods to enhance dendritic cell (DC) functions: the methods include augmentation of antigen uptake, cross presentation, and T cell stimulation by using adjuvants, cytokines, or agonistic antibodies. We have previously developed several protocols for combined immunotherapy of in situ tumor destruction and subsequent DC activation. An example of this is the use of oncolytic HSV, which is capable of both direct tumor destruction and DC stimulation. Intratumoral administration of HSV not only inhibited the treated tumor but also suppressed untreated tumors at remote sites via induction of systemic anti-tumor T cells  Development of methods to reverse immunosuppression: Various immunomodulating reagents are being studied to evaluate their efficacy in recovering immunosuppressive condition in cancer patients. These reagents include antibodies , chemotherapy, and molecular targeted drugs.Analysis of mouse tumor models and human clinical trials using the identified tumor antigens revealed that following key points need to be addressed in order to regulate the anti-tumor immune network and develop effective immunotherapy Figure  Kawakam. (1) IdeIn this article, we will focus on the combined use of molecular targeted drugs with immunotherapy, that could possibly reverse immunosuppression and augment anti-tumor T cell responses.+ Tregs and Th2 cells into tumor and sentinel lymph nodes , and regulatory T cells (Tregs). Ultimately, cancer cells generate immunosuppressive microenvironments in tumor and sentinel lymph nodes , a molecule in MAPK signal pathway, was identified by systematic DNA sequencing of signaling molecules in human melanoma cells  accompanied by LGL lymphocytosis and autoimmune like syndrome such as pleuritis and colitis  is observed. We found that β-catenin directly promote transcription of immunosuppressive cytokine IL-10 in human melanoma (Yaguchi et al., When β-catenin-activated human melanoma cell lines were implanted in immunodeficient mice, human IL-10 in mouse serum was increased, and function of mouse DCs in spleens and tumors were impaired for T cell stimulatory activity probably due to increased human IL-10 which is capable of affecting mouse DCs (Yaguchi et al., in vivo activity should be carefully evaluated because it may also cause various adverse effects, including possible inhibition of anti-tumor immune responses. In this regard, mutated-molecule-specific inhibition such as that of the mutant BRAF-selective inhibitors is one of the promising strategies. Activation of STAT3 appears to shift immune response toward cancer’s advantage, thus, its inhibition is attractive for possible improvement of anti-tumor immune responses. Altogether, combination therapy using molecular targeted drugs and various immunotherapies such as cancer vaccines and check point blockade is a promising strategy to treat cancer patients. Future clinical trials may demonstrate the proof of concept of this strategy.As discussed in this article, altered activation of various oncogenes and signaling in both cancer cells and immune cells can be an attractive target to reverse immunosuppressive conditions in tumor-associated microenvironments of cancer patients. Signal inhibitors may augment current cancer immunotherapy, in addition to its possible direct anti-tumor effects through inhibition of cancer cell proliferation and invasion. However, its total However, there are several obstacles to overcome before the benefits of combination therapy can reach the patients. One such obstacle is scientific. Although quite a few signal inhibitors, immunotherapies, and combined therapies have shown promising results in experimental settings, mouse model, and human are different. A successful treatment in mouse models may not work in patients. Therefore, for the selection of appropriate molecular targets and inhibition methods, further understanding of human cancer immunopathology is deeply essential and urgently desired. Another obstacle is a pragmatic one, which may arise when individual therapies in a combination therapy are developed and/or owned by different companies. The issues of company regulations, patents, and logistics could become a barrier between research and clinical translation. The core idea of combination therapy is that by using multiple already-available therapies, cancer patients are able to gain greater-than-sum benefits. Therefore, it is crucial that institutions and companies to look beyond self-interests and work together to reach a common goal. Academic institution may mediate the cooperation between companies and provided combination therapies to patients.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Governments and philanthropic organizations collectively pour hundreds of millions of dollars annually into the prevention and treatment of a select group of life-threatening infectious diseases that includes malaria, HIV/AIDS, and tuberculosis. The merits of these high-profile programs are indisputable, yet emerging interest in traditionally neglected tropical diseases (NTDs) suggests that the lights of global awareness and medical treatment are now shining more brightly on lesser-known infections, which remain scourges for more than a billion persons worldwide Should SCA be considered an NTD? From the viewpoint of this hematologist, an NTD can be operationally defined as any serious medical affliction with the following characteristics: (1) worldwide distribution, typically affecting millions; (2) highest burden among the most impoverished and disadvantaged populations; (3) serious morbidity, diminished quality of life, and even mortality; (4) comorbidity for other life-threatening diseases; (5) relatively simple diagnostic testing; and (6) inexpensive treatment options. Although NTDs are usually infectious and communicable, perhaps those should not be strict requirements. Indeed, based on these criteria, SCA is long overdue for membership in this elite but tragic club of global medical maladies. Perhaps ironically, such a designation of SCA may allow this currently “invisible” lethal disease to become more noticeable as a “neglected” disease.SCA results from the homozygous inheritance of a single DNA mutation within the beta globin gene, leading to a glutamic acid to valine substitution within the hemoglobin tetramer, changing normal hemoglobin (HbA) into abnormal sickle hemoglobin (HbS). In deoxygenating conditions such as the venous circulation, HbS rapidly polymerizes within the erythrocytes, leading to intracellular tactoids that deform the red blood cells into the characteristic curved or sickled shape. Persons with SCA suffer a wide variety of serious disease complications: increased susceptibility to bloodstream infections, especially early fatal pneumococcal sepsis; chronic hemolytic anemia that features both intravascular and extravascular erythrocyte destruction; recurrent periodic acute vaso-occlusive events, including pain and acute chest syndrome; and chronic damage affecting almost every organ system.P. falciparum. The relative survival advantage of persons with HbAS, which results from a series of clever biochemical and genomic mechanisms that reduce malarial pathophysiology  now commemorates this recognition. In 2010, WHO issued a supplemental report on SCA that provided specific targets and goals for sub-Saharan countries, related to a national strategy for comprehensive care and treatment of this disorder Despite its origins in Africa and Arab-India, SCA is now recognized as a truly worldwide health problem. Tens of thousands of SCA births occur in the Middle East and across the Americas each year. Recent immigration patterns have now led to sizable sickle cell populations emerging in previously unaffected areas of the world, including Ireland, Scandinavia, Australia, and South Africa. Active research partnerships can begin with networking, as supported by the new Global Sickle Cell Disease Network Interventions for SCA must also include treatment of the underlying disease. The introduction of newborn screening and early life-saving interventions into sub-Saharan Africa will result in a large cohort of surviving children with SCA, which will only add to the healthcare burden of low-income countries Based on the six criteria proposed initially, there are compelling reasons to consider SCA an NTD. First, SCA has a worldwide distribution in Africa, Asia, and the Americas, with over 300,000 births occurring annually. Second, the highest burden of SCA falls on the poorest and most disadvantaged populations in sub-Saharan Africa and tribal Indian populations. Third, SCA causes serious morbidity and contributes substantially to under-5 mortality rates. Fourth, SCA is an important comorbid factor for other life-threatening diseases, especially malaria and invasive pneumococcal disease. Fifth, rapid and inexpensive testing at birth or in the neonatal period can accurately determine the presence of SCA. Sixth, simple interventions with penicillin prophylaxis, pneumococcal immunizations, and education can be life-saving and lead to improved survival. Most importantly, however, this life-threatening hematological disease has been long overlooked by almost all medical organizations and governments, and is only now receiving modest interest and attention as a substantial global healthcare issue. With better awareness and funding, SCA can change from an invisible killer of children to a neglected one, which will help promote the need for life-saving diagnostic and treatment efforts to reach affected infants and children. We hematologists should learn from NTD specialists and experts to develop strategies and policies that integrate testing and treatment