87

Breast Disease 26 (2006,2007) 8798

IOS Press

Tumor Dormancy and Cancer Stem Cells:

Implications for the Biology and Treatment of
Breast Cancer Metastasis
Alison L. Allana,b,c, , Sharon A. Vantyghem a,b,d, Alan B. Tucka,b,d,e and Ann F. Chambers a,b,d
a

London Regional Cancer Program, Schulich School of Medicine and Dentistry, University of Western Ontario,
London, Ont., Canada
b
Department of Oncology, Schulich School of Medicine and Dentistry, University of Western Ontario, London,
Ont., Canada
c
Department of Anatomy & Cell Biology, Schulich School of Medicine and Dentistry, University of Western
Ontario, London, Ont., Canada
d
Department of Pathology, Schulich School of Medicine and Dentistry, University of Western Ontario, London,
Ont., Canada
e
London Health Sciences Centre, London, Ont., Canada

Abstract. Breast cancer remains a leading cause of morbidity and mortality in women, mainly due to the propensity of primary
breast tumors to metastasize to regional and distant sites. Metastatic spread after the removal of a primary tumor can be
difficult to identify, creating uncertainty in patients with regards to possible cancer recurrence. This is a particular problem
in breast cancer, exemplified by the fact that recurrence can take place after decades of apparent disease-free survival. The
mechanisms underlying tumor dormancy in breast cancer remain poorly understood, and this presents significant challenges to
both experimental investigation and clinical management of breast cancer. This review will discuss what is currently known
about the metastatic process and tumor dormancy, consider the growing evidence that cancer stem cells may contribute to tumor
progression and dormancy, and speculate about the clinical importance and implications of this research.
Keywords: Breast cancer, metastasis, tumor dormancy, minimal residual disease, cancer stem cells

INTRODUCTION
Over the last several decades, tremendous research
advances have been made in the realms of breast cancer
detection and management of primary tumors. Despite
this, breast cancer remains a leading cause of morbidity
and mortality in women [57], mainly due to the propen Corresponding author: Alison L. Allan, Ph.D., Oncology Scientist, London Regional Cancer Program, Assistant Professor, Departments of Oncology and Anatomy & Cell Biology, Schulich
School of Medicine and Dentistry, University of Western Ontario,
790 Commissioners Road East, London, Ontario, Canada N6A 4L6.
Tel.: +1 519 685 8600 x55134; Fax: +1 519 685 8616; E-mail:
alison.allan@lhsc.on.ca.

sity of primary breast tumors to metastasize to regional

and distant sites such as lymph node, lung, liver, brain,
and bone [23,81]. When the primary tumor is detected and removed before metastasis occurs, prognosis is
good and the chance of disease-free survival is high.
However, if cancer cells have already begun to disseminate from the primary tumor and spread to other parts of
the body, current therapeutic strategies largely depend
on the use of systemic cytotoxic drugs that frequently
result in severe side-effects for the patient and, in many
cases, often do not yield long-term success. Moreover,
metastatic spread after the removal of a primary tumor
can be difficult to identify, creating uncertainty in patients with regards to possible cancer recurrence. This
is a particular problem in breast cancer, exemplified

0888-6008/06,07/$17.00 2006,2007 IOS Press and the authors. All rights reserved

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A.L. Allan et al. / Tumor Dormancy and Cancer Stem Cells

by the fact that recurrence can take place after decades

of apparent disease-free survival [70,110]. This observation, referred to as clinical tumor dormancy, is also supported by studies involving individuals undergoing autopsy for other (i.e. non cancer-related) causes
of death such as accidents or trauma [14,43]. These
studies, summarized by Black and Welsh [14], report
that carcinoma in situ can be found in the breasts of
39% of women age 4050 years, even though only 1%
of women are ever diagnosed with breast cancer during
life in the same age range. The mechanisms underlying tumor dormancy in breast cancer remain poorly
understood, and this presents significant challenges to
both experimental investigation and clinical management of breast cancer. This review will discuss what
is currently known about the metastatic process and tumor dormancy, consider the growing evidence that cancer stem cells may contribute to tumor progression and
dormancy, and speculate about the clinical importance
and implications of this research.

THE METASTATIC PROCESS

Metastasis is defined as the spread of cancer cells
from a primary site resulting in the establishment of
secondary tumors in distant locations [23,39,81]. It
is widely accepted that the metastatic process is comprised of a series of complex and sequential steps, and
cancer cells must successfully complete each step in
order to give rise to a metastatic tumor. These steps
include escape from the primary tumor (intravasation),
dissemination via the blood or lymphatic system, survival within the circulation, arrest and extravasation
into a secondary site, initiation of growth into micrometastases, and maintenance of growth as vascularized, clinically detectable macrometastases [23,39,67,
81,107,118].
Metastatic inefficiency
Considering the onerous nature of this multistep process, it is not surprising that several lines of experimental and clinical evidence indicate that metastasis
is an inherently inefficient process [21,24,25,66,112]
(Fig. 1). Experimental studies have shown that early
steps in hematogenous metastasis (intravasation, survival, arrest, and extravasation) can be remarkably efficient, with greater that 80% of cells successfully completing the metastatic process to this point. However, only a small subset of these cells (i.e. 2%, de-

pending on the experimental model) can initiate growth

as micrometastases, and an even smaller subset (i.e.
0.02%, depending on the experimental model) are
able to persist and grow into macroscopic tumors [21,
24,25,66]. It is therefore the later steps in metastasis
involving growth at the secondary site that have been
shown, at least in experimental models, to be highly
inefficient. Furthermore, it has been hypothesized that
these two steps (i.e. initial growth of micrometastases
and persistence/outgrowth of macrometastases) represent the critical decision-making stages for metastatic dormancy [48,54,66,73,75,76], and this idea is discussed in more detail later in this review. This hypothesis is also supported by clinical observations that,
despite the fact that cancer patients may have hundreds to thousands of single disseminated cancer cells
detectable in the bloodstream and sites remote from
the primary tumor [108], only a very small percentage progress to form overt macroscopic metastases [24,
112,113]. However, the physiological and/or pathological influences that definitively tip the balance between
dormancy and proliferation in secondary sites remain
poorly understood.
Organ-specific metastasis: Importance of seed and
soil
It is well established that certain types of cancers
have organ-specific preferences for metastatic growth,
and breast cancer favors metastasis to regional lymph
nodes, lungs, liver, bone, and brain [23]. In the 1920s,
James Ewing proposed that blood flow patterns alone
were sufficient to account for both the physical delivery of tumor cells to secondary organs and for patterns of organ-specific metastasis [38]. However, several theories have challenged this idea by proposing
that there are additional, molecular-level mechanisms
which explain why and how cancer cells can arrest and
grow in favorite metastatic sites. The most central of
these theories is the seed and soil theory of metastasis, first proposed in 1889 by Stephen Paget [79,80].
Paget predicted that a cancer cell (the seed) can survive and proliferate only in secondary sites (the soil)
that produce growth factors appropriate to that type of
cell, and this theory has largely withstood the test of
time [16,40,41,51,86]. In a meta-analysis of published
autopsy study data [113], Weiss showed that, in many
cases, metastases detected at autopsy were in proportion to the blood flow from the primary tumor site to
the secondary organ. However, in some cases, more
metastases (notably breast cancer metastasis to bone)

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89

Fig. 1. Metastasis is a very inefficient process. Experimental studies have shown that early steps in metastasis (intravasation, survival, arrest,
and extravasation) can be highly efficient, with greater than 80% of cells successfully completing the metastatic process to this point. However,
only a small subset of these cells (i.e. 2%, depending on the experimental model) can initiate growth as micrometastases, and an even smaller
subset (i.e. 0.02%, depending on the experimental model) are able to persist and grow into macroscopic tumors. Dormancy can occur at two
critical, rate-limiting stages of metastasis development in the secondary site, the single cell stage and the micrometastasis stage. Once individual
tumor cells arrive in the secondary site, they may experience one of three fates: they may proliferate to form micrometastases, they may die, or
they may remain viable but dormant. If these solitary cells do begin to proliferate and go on to form micrometastases, they may again experience
one of three fates at this next stage: they may continue to proliferate to form vascularized macrometastases, they may die, or they may persist as
dormant micrometastases, where dormancy at this stage is defined as a balance between proliferation and apoptosis within the cell population
such that there is no net increase in the size of micrometastases. Both solitary dormant cells and dormant micrometastases are believed to
contribute to clinical dormancy and cancer recurrence, potentially through mechanisms involving specific phenotypic characteristics of dormant
tumor cells and/or the influence of the microenvironment.

or fewer metastases were detected than would be expected by blood flow alone, indicating that the soil
or microenvironment in the secondary organ is likely
very important. In addition to mediating growth of tumor cells, it has been suggested that microenvironmental factors in the secondary site can also have significant influence on supporting tumor dormancy through

suppression of immune mechanisms, angiogenesis, and

alteration of growth-related signaling pathways [36,
36,37,42,54,60,78,99,110,115,120]. Thus, the role of
the microenvironment in the metastatic process is significant, particularly for the initiation/maintenance of
metastatic growth and perhaps for the persistence of
tumor dormancy within a secondary site.

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TUMOR DORMANCY
Experimental evidence for dormancy
As discussed above, studies involving experimental
models of metastasis have demonstrated that dormancy
can occur at two critical stages of metastasis development in the secondary site, the single cell stage and the
micrometastasis stage [48,54,73,75,76] (Fig. 1). Once
individual tumor cells arrive in the secondary site, they
may experience one of three fates: they may proliferate
to form micrometastases, they may die, or they may remain viable but dormant [23,66]. These dormant solitary cells are defined by a prolonged state of G 0 , where
there is an absence of either proliferation or apoptosis,
and this quiescence likely affords protection from many
conventional cytotoxic drugs which only target actively
cycling cells [48,66,76,77]. It is currently not known
if these solitary dormant cells represent a specialized
subpopulation of cells that are programmed to stay dormant, an unspecialized population of cells that are not
well suited to grow in the new microenvironment, or
a combination of both. If these solitary cells do begin
to proliferate and go on to form micrometastases, they
may again experience one of three fates at this next
stage: they may continue to proliferate to form vascularized macrometastases, they may die, or they may
persist as dormant micrometastases, where dormancy at this stage is defined as a balance between proliferation and apoptosis within the cell population such
that there is no net increase in the size of micrometastases [22,23,54]. It has been proposed that this type of
dormancy is associated with an inability to recruit new
blood vessels to support further tumor growth, potentially via the protective effect of microenvironmental
factors that prevent the angiogenic switch [43,49].
Both these dormant micrometastases and solitary dormant cells are each believed to contribute to clinical
dormancy and cancer recurrence, although the characteristics (and likely the mechanisms) that govern each
are distinctly different.
Experimental models of dormancy
There are significant challenges associated with
studying tumor dormancy experimentally, mostly related to the limited number of in vivo dormancy models
available and the biological and technical complexities associated with identifying, quantifying, and monitoring solitary dormant cells and tiny dormant mi-

crometastases longitudinally in a complex in vivo environment.

From a biological perspective, the inherently heterogeneous nature of cancer cells can introduce complications, since subpopulations of solitary dormant cells
and actively growing micrometastases can co-exist in
the same organ [21,52,66,76], and destruction of the
surrounding tissue by the proliferating subpopulation
can make it difficult to monitor the single cell population over time. Furthermore, tumor cell populations can
contain both non-angiogenic and angiogenic subpopulations [2,74]. Recently, an elegant study by Naumov
et al. [74] demonstrated that many established human
tumor cell lines which have previously been described
as non-tumorigenic (including the breast cancer cell
line MDA-MB-436) were in fact potentially tumorigenic, but dormant. If these cells were injected into
animals and allowed to grow for a period of time much
longer than a normal tumor growth assay (4 months to
> 12 months), spontaneous tumors eventually began to
develop after an initial dormancy period and a switch to
the angiogenic phenotype. Although this study was focused on primary tumor growth rather than metastasis,
it does provide a conceptual framework to approach unresolved questions regarding metastatic dormancy and
the role of angiogenesis in this process.
From a technical perspective, several studies have
been able to verify the presence of solitary dormant
cells in vivo using fluorescent markers, negative histological staining for proliferation and apoptosis markers
(i.e. Ki67, TUNEL), and/or sensitive imaging modalities [6,21,46,48,52,66,76,77,106]. However, it remains
extremely difficult to prove that such cells are truly
dormant or to elucidate the mechanisms underlying
this dormancy. The detection of dormant micrometastases is slightly less challenging than that of solitary
cell detection and tracking, although significant difficulties still exist. Technologies involving imaging of
luciferase-expressing tumor cells have permitted realtime monitoring of dormant tumor presence, viability, and analysis of the angiogenic switch [11]. Although this imaging modality will be extremely valuable for gaining a greater understanding of the biology
of tumor dormancy, it cannot be used for monitoring
of dormant micrometastases in patients. More clinically relevant imaging modalities such as high resolution magnetic resonance imaging (MRI) [52,53] and
three-dimensional high-frequency ultrasound [47] are
currently being developed for studying tumor dormancy in pre-clinical models, and show some promise for
future application in the clinic.

A.L. Allan et al. / Tumor Dormancy and Cancer Stem Cells

Clinical evidence for dormancy

Although clinical tumor dormancy may occur in all
cancers, the evidence is most predominant in nonHodgkins lymphoma [28,92], renal carcinoma [97],
melanoma [20], and breast cancer [70,110]. One of
the biggest challenges in studying tumor dormancy in
breast cancer patients is that until recently, this phenomenon has been defined clinically as the diseasefree period between treatment of the initial cancer and
recurrence, and therefore could only be applied to patients who underwent a recurrence. Thus, the identification of patients harboring dormant cancer for study
was close to impossible, and as a result the prevalence
of clinical dormancy is likely underestimated [110].
In fact, the persistence of disease at a low or undetectable level (so-called minimal residual disease)
may be a common feature of breast cancer. This is supported by the autopsy findings discussed earlier [14,43],
as well as the accumulating evidence that breast cancer
patients with apparently localized disease (i.e. no indication of metastatic spread by current clinical parameters) have individual tumor cells in their bone marrow
and/or blood [27,65,71,82,93,95,96]. The presence of
such cells in the bone marrow is particularly interesting from both a biological and clinical viewpoint, since
the bone represents one of the most common sites for
breast cancer metastasis [23,81]. Numerous studies
have shown that detection of isolated tumor cells in
the bone marrow is an independent prognostic factor,
and approximately 30% of breast cancer patients may
have micrometastatic disease in their bone marrow at
initial presentation. However, only 3050% of these
patients will go on to develop clinically evident metastases within 5 years [15,32,44,45,68,88,117]. From a
biological perspective, these observations suggest that
the progression of dormant minimal residual disease to
clinically relevant metastases depends on the specific
phenotypic characteristics of individual disseminated
cells, the influence of the microenvironment and/or individual patient characteristics (i.e. immune response),
or a complex interaction between the two. Thus, the
simple presence of these cells in the bone marrow is
unable to sufficiently reflect the biological heterogeneity and phenotypic programming of these cells, and
consequently unable to predict their individual potential to remain dormant or progress to clinically relevant
metastases. This heterogeneity has led to the hypothesis that only a small percentage of cells in a tumor cell
population are capable of re-initiating growth to form
metastases in distant sites, and that these cells may in
fact be cancer stem cells.

91

CANCER STEM CELLS, METASTASIS, AND

TUMOR DORMANCY
As discussed earlier in this review, metastasis is an
inefficient process, such that very few cells that leave
a primary tumor successfully form macrometastases in
distant sites. This, coupled with the inherently heterogeneous nature of solid tumors, suggests that only a small subset of cells can successfully navigate
the metastatic cascade and eventually re-initiate tumor growth to form life-threatening metastases. Consideration of perspectives from other research fields
may provide a valuable opportunity to challenge current paradigms surrounding what defines a successful metastatic cell. In particular, impressive advances
in the hematology field which have demonstrated the
critical role of stem cells in hematological malignancies [55] suggests that these same mechanisms could
also be central to the initiation and progression of solid tumors. While the idea of cancer stem cells has
been around for many years [56,87,91,100,116], two
pivotal studies have recently provided compelling evidence that these cells may exist in solid tumors of the
breast [10] and brain [103]. However, the role that cancer stem cells might play in tumor dormancy and the
metastatic process remains to be elucidated.
Theoretical perspectives on tumor cell heterogeneity
and the origin of the cancer stem cell
It has long been observed by tumor biologists that
even with immortalized cancer cell lines, large numbers
of cells (in the range of 10 5 106 ) need to be injected
to initiate a tumor in experimental animals, and even
then, only a very small proportion of these cells will
go on to form metastases [23,66,114]. Two general
theories have been suggested to explain why not every
cell within a tumor is capable of maintaining and/or
re-initiating tumor growth [94]. The stochastic theory predicts that every cell within a tumor is potentially tumor-initiating, but that progression to tumorigenic
growth is governed by rare stochastic events. This theory assumes that the tumor is comprised of a homogeneous cell population, and that tumorigenic mechanisms are operative in all cells. In contrast, the hierarchy theory predicts that only a limited number of cells
within a heterogeneous tumor are capable of initiating
tumorigenic growth, but this subset of cells all initiate
tumors at a high frequency. It has been suggested that
this phenotypically distinct subset of tumorigenic cells

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are stem-like cells, or cancer stem cells (CSCs) [10,

31,69,83,103,116].
The term cancer stem cell is an operational term
defined as a cancer cell that has the ability to both selfrenew to give rise to another tumorigenic cell, as well
as undergo differentiation to give rise to the phenotypically diverse (and non-tumorigenic) cell population
that makes up the rest of the tumor [9,13]. However,
the definitive cellular origin of the cancer stem cell has
remained elusive, and is currently the topic of intense
debate and experimental investigation. If these cells
arise from normal stem cells, then cancer cells could
appropriate the existing stem cell regulatory pathways
for self-renewal. On the other hand, if these cells arise
from mature, differentiated cells, oncogenic mutations
are required for de-differentiation and self-renewal [9,
13,83,94]. The fact that multiple mutations are necessary for a cell to become tumorigenic and metastatic [50] has implications for the cellular origin of cancer cells. It can be argued that mature cells have a
very limited lifespan, and thus it is unlikely that all
the necessary mutations could occur during the relatively short life of these cells. In contrast, the infinite self-renewal capacity of normal stem cells means
these cells may be the only cells that are around long
enough to accumulate the necessary mutations [9,13,
69,83,94]. There is some evidence to suggest that many
leukemias arise from mutation of normal hematopoietic stem/progenitor cells [58,85], although the same has
not yet been proven in solid cancers.
Stem cells give rise to all tissues during embryonic
development, and are important in the adult for maintaining tissue homeostasis. In the hematopoietic system, there are three different populations of multipotent stem/progenitor cells, including stem cells capable of long-term renewal, stem cells capable of shortterm renewal, and multipotent progenitors that cannot
self-renew but differentiate into the varied lineages in
the bone marrow [72,94]. Pluripotent stem cells possessing the capacity for self-renewal and the ability to
generate an organ-specific, differentiated population of
cells exist in other organs besides the hematopoietic
system, and the analysis of these normal stem cells
may provide insights into cancers arising in specific
tissues. For example, in the normal breast, three cell
lineages have been identified: myoepithelial cells that
form the basal layer, ductal epithelial cells that line
the lumen of the ducts, and milk-producing alveolar
cells [33,64,89,104]. Although most normal cells in the
breast have a limited capacity for self-renewal, recent
studies have demonstrated that a complete mammary

gland can be reconstituted from a single epithelial stem

cell [101]. Identifying the cell-of-origin of breast cancer will be important, since mutational transformation
of these different cells could result in tumors with different metastatic potential, i.e. the differentiation status
of the tumor-initiating cell could dictate the development of a well-differentiated, non-invasive tumor versus a poorly differentiated, highly aggressive tumor.
Furthermore, it has been hypothesized that transformation of different subsets of breast stem/progenitor cells
could be responsible for the diversity in breast cancer
phenotypes, including expression of the estrogen receptor in some subsets [34]. Finally, the cellular origin
of the cancer stem cell could be an important determinant of breast cancer cell dormancy, both from the perspective of phenotypically distinct regulatory pathways
of solitary cells, and/or the ability of cells to respond
to microenvironmental signals influencing dormancy.
Stem cell characteristics relating to dormancy and
metastasis
In addition to self-renewal, several other classical
properties of normal stem cells are strikingly reminiscent of the observed experimental and clinical behavior
of malignant breast cancer cells, including activation
of anti-apoptotic pathways, an increased capacity for
drug resistance, and the requirement for a supportive
niche or microenvironment to grow.
From an evolutionary point of view, normal stem
cells have a number of unique properties that help protect them from insult and ensure their long lifespan.
For instance, stem cells are thought to be more resistant to DNA damaging agents than differentiated cells
because of their ability to undergo asynchronous DNA
synthesis and their enhanced capacity for DNA repair.
During asynchronous DNA synthesis, the parental immortal DNA strand always segregates with the new
stem cell rather than with the differentiating progeny,
thus helping to protect the stem cell population from
DNA damage [1719,84,90,102]. Stem cells also express higher levels of anti-apoptotic proteins than differentiated cells, including members of the Bcl-2 family [111]. Furthermore, despite a limitless self-renewal
capacity, normal stem cells are relatively quiescent and
divide infrequently unless activated [29,30,83]. Since
many cancer drugs are designed to kill actively dividing
cells, cancer stem cells may escape cytotoxic drug targeting for the same reasons that solitary dormant tumor
cells do.

A.L. Allan et al. / Tumor Dormancy and Cancer Stem Cells

93

Fig. 2. Cancer stem cells, metastasis, and tumor dormancy. The inefficiency of the metastatic process, the inherently heterogeneous nature of
solid tumors, and the influence of the tumor microenvironment dictate that only a small subset of cells (shown in red) can successfully navigate
the metastatic cascade and eventually re-initiate tumor growth to form life-threatening metastases. The cancer stem cell theory also predicts that
only a limited number of cells within a heterogeneous tumor are capable of initiating tumorigenic growth, and that this phenotypically distinct
subset of cells are stem-like cells, or cancer stem cells (CSCs). Several classical properties of normal stem cells are strikingly reminiscent of
the observed experimental and clinical behavior of malignant breast cancer cells, including an unlimited capacity for self-renewal, activation of
anti-apoptotic pathways, increased drug resistance, and the requirement for a supportive niche or microenvironment to grow. Furthermore,
experimental models of tumor dormancy have demonstrated that these influences can also play significant roles in maintaining tumor dormancy
or triggering proliferation and disease progression. By applying the stem cell theory to breast cancer metastasis and tumor dormancy, it can be
hypothesized that the subset of cells within a primary breast tumor that are capable of initiating and maintaining metastatic growth in secondary
sites (shown in red) may in fact be cancer stem cells. Understanding the functional and mechanistic role that cancer stem cells play in determining
tumor dormancy and metastatic potential could have significant implications for the way we currently study, diagnose and treat breast cancer.

A particularly intriguing property of stem cells that

supports their possible role in cancer and metastasis is
their increased capacity for drug efflux and drug resistance via high expression of specific drug transporter
proteins [83]. The two transporters most extensively
studied in stem cells include ABCB1, which encodes
P-glycoprotein, and ABCG2, which encodes a protein
called breast cancer resistance protein (BCRP). These
two transporter proteins can help a cell efflux a large
number of different chemotherapeutic agents, includ-

ing several that are used to treat breast cancer, such

as paclitaxel and doxorubicin. Along with ABCC1,
ABCB1 and ABCG2 represent the three principal multidrug resistance (MDR) genes overexpressed in tumor
cells [35,59,83,98]. This drug resistance could be an
inherent feature of cancer stem cells, and could help
explain the high level of drug resistance in metastatic
disease.
Finally, the central role of the microenvironment in
regulating both normal stem cells and cancer cells sug-

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A.L. Allan et al. / Tumor Dormancy and Cancer Stem Cells

gests that similar mechanisms may be operational in

both situations [61]. In adults, normal stem cells reside
in a physiologically unique microenvironment called
the stem cell niche. This niche provides a physical
anchoring site for stem cells via adhesion molecules
linking the stem cells to the extracellular matrix. The
niche also generates extrinsic factors that control stem
cell number, growth, and differentiation [62,63,105,
119]. Under normal physiological conditions, the niche
provides fine control over proliferation, typically maintaining cells in G0 and/or balancing proliferation and
apoptosis such that the stem cell population remains at
a constant size [12,26,109,121]. However, some proliferation is required in order to maintain ongoing tissue
regeneration, and it has been suggested that one of the
functions of the stem cell niche is to prevent tumorigenesis by tightly controlling this stem cell proliferation.
If signaling pathways in the niche are dysregulated, it
may be converted into a microenvironment that favors
uncontrolled proliferation and expansion of the stem
cell population. Correspondingly, it could be hypothesized that cancer stem cells remain dormant in metastatic sites (either as solitary cells or dormant micrometastases) until they are activated by inappropriate signaling
from the microenvironment [61,116]. Currently, the
similarities between stem cell niches in different tissues
remains poorly understood, in particular with regards
to whether tissue-specific stem cells can be regulated
by stem cell niches in other organs. This knowledge
will have important and provocative implications for
understanding metastatic growth in secondary sites, including the possibility that breast cancer stem cells may
favor growth in the bone marrow because it provides a
particularly cultivating stem cell niche.

CLINICAL IMPLICATIONS
The cancer stem cell hypothesis has fundamental
implications for therapy and prognosis of breast and
other solid cancers [1,8,9,29,116]. A central question
raised by this model is whether or not current therapeutic drugs are in fact targeting the right cells. The
majority of research surrounding cancer biology and
the development of new therapeutics is focused around
the gold standard of pre-clinical drug efficacy; the
ability to shrink a tumor in a mouse. Similarly, testing of new therapeutics in Phase II clinical trials has a
measured outcome of tumor shrinkage. However, if a
tumor is maintained by a small subpopulation of cancer stem cells that are inherently resistant to therapeu-

tic agents, then this observed tumor shrinkage may reflect selective killing of the more differentiated, nontumorigenic cells that make up the bulk of the tumor
while leaving the cancer stem cells viable and able to
continue to maintain and/or re-initiate tumor growth at
a metastatic site. If only a rare subpopulation of cells
is responsible for tumor maintenance and progression,
then the goal of therapy should be to identify and characterize this population and subsequently develop therapies that target and eliminate it. However, current therapeutic strategies fail to account for potential molecular
and proliferative differences between different subpopulations of tumor cells, and this may explain why the
majority of therapies fail in the metastatic setting.
In addition to treatment implications, the cancer stem
cell model could also have significant connotations for
prognosis of breast cancer [810,29,104,116]. One
of the paradigms of cancer treatment is that remission
generally becomes more difficult to achieve with each
relapse, and the diagnosis of metastatic disease significantly lowers the chance of survival. This suggests that
the cancer cell population evolves to be increasingly
aggressive over time, perhaps because, as therapeutic
agents selectively kill off the non-tumorigenic cells, the
cancer stem cell subpopulation makes up an increasing
proportion of the metastatic tumor. Indeed, studies by
Al-Hajj et al. [10] suggest that that the cancer stem
cell content within a breast tumor could have prognostic significance, although further research is needed to
conclusively prove this.
Finally, the use of DNA and tissue microarrays for
identification of novel prognostic markers and/or new
therapeutic targets for breast cancer has generally failed
to account for the cellular heterogeneity present within tumors. Since the expression patterns of normal
stem cells can vary significantly from their differentiated counterparts [7], then it is probable that cancer
stem cells also have different expression characteristics
than the bulk of the non-tumorigenic cell population.
Thus, expression analysis of isolated, enriched populations of cancer stem cells could potentially uncover
better prognostic markers and more effective therapeutic targets than the current practice of analyzing mixed
populations of cells present in breast tumor tissue.

CONCLUSIONS AND FUTURE DIRECTIONS

The majority of breast cancer deaths occur as a result
of metastatic disease rather than from the effects of the
primary tumor. Furthermore, elucidation of the mech-

A.L. Allan et al. / Tumor Dormancy and Cancer Stem Cells

anisms regulating clinical tumor dormancy and those

involved in disease relapse remain two of the most important and provocative challenges in cancer biology.
The inefficiency of the metastatic process, the inherently heterogeneous nature of solid tumors, and the influence of the tumor microenvironment dictate that only a
small subset of cells (potentially cancer stem cells) can
successfully navigate the metastatic cascade and eventually re-initiate tumor growth to form life-threatening
metastases. Moreover, experimental models of tumor
dormancy have demonstrated that these influences can
also play significant roles in maintaining tumor dormancy or triggering proliferation and disease progression (summarized in Fig. 2). In breast cancer patients,
it is believed that metastatic cancer cells may remain
dormant for decades until some unknown mechanism
triggers them to proliferate and progress to clinically relevant metastases. However, increasing support
for the cancer stem cell hypothesis alternatively suggests that the dormant disseminated cells in this patient
population may actually arise from non-tumorigenic
cells, and it is only when cancer stem cells disseminate
(and/or respond to a favorable stem cell microenvironment) that they subsequently self-renew and patients relapse with metastatic disease. Understanding the functional and mechanistic role that cancer stem cells may
play in determining tumor dormancy and metastatic potential could therefore have significant implications for
the way we currently study, diagnose, and treat breast
cancer.

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ACKNOWLEDGEMENTS
We thank members of our laboratory and our collaborators for their research work and helpful discussions. Some of the studies described in this review
were supported by grant #42511 from the Canadian Institutes of Health Research (to AFC and ABT). A.L.A.
is supported by the lmperial Oil Foundation. S.A.V. is
supported by a Rethink Breast Cancer Career Development Award. A.F.C. is the recipient of a Canada Research Chair in Oncology and an award from the Lloyd
Carr-Harris Foundation. Wherever possible we have
cited review articles, and we refer the reader to these
for citations of primary papers. We apologize to the
authors whose work we could not cite directly because
of space restrictions.

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