Abstract
Clinical trials involving systemic neoadjuvant treatments in breast cancer aim to shrink tumors before surgery while simultaneously allowing for controlled evaluation of biomarkers, toxicity, and suppression of distant (occult) metastatic disease. Yet neoadjuvant clinical trials are rarely preceded by preclinical testing involving neoadjuvant treatment, surgery, and post-surgery monitoring of the disease. Here we used a mouse model of spontaneous metastasis occurring after surgical removal of orthotopically implanted primary tumors to develop a predictive mathematical model of neoadjuvant treatment response to sunitinib, a receptor tyrosine kinase inhibitor (RTKI). Treatment outcomes were used to validate a novel mathematical kinetics-pharmacodynamics model predictive of perioperative disease progression. Longitudinal measurements of presurgical primary tumor size and postsurgical metastatic burden were compiled using 128 mice receiving variable neoadjuvant treatment doses and schedules (released publicly at https://zenodo.org/records/10607753). A non-linear mixed-effects modeling approach quantified inter-animal variabilities in metastatic dynamics and survival, and machine-learning algorithms were applied to investigate the significance of several biomarkers at resection as predictors of individual kinetics. Biomarkers included circulating tumor- and immune-based cells (circulating tumor cells and myeloid-derived suppressor cells) as well as immunohistochemical tumor proteins (CD31 and Ki67). Our computational simulations show that neoadjuvant RTKI treatment inhibits primary tumor growth but has little efficacy in preventing (micro)-metastatic disease progression after surgery and treatment cessation. Machine learning algorithms that included support vector machines, random forests, and artificial neural networks, confirmed a lack of definitive biomarkers, which shows the value of preclinical modeling studies to identify potential failures that should be avoided clinically.