TUGAS AKHIR MODUL 6

PEMODELAN MATEMATIKA DAN METODE NUMERIK

Disusun Oleh
Gayuh Adya Pratama, S.Pd
19051818010858

PROGRAM PENDIDIKAN PROFESI GURU DALAM JABATAN ANGKATAN IV

PROGRAM SERTIFIKASI PENDIDIKAN MATEMATIKA

UNIVESITAS MUHAMMADIYAH MALANG

2019
1. Carilah sebuah artikel jurnal imternasional (3 tahun terakhir) yang menggunakan
pemodelan matematika, Buatlah resume artikel tersebut dengan menyebutkan langkah-
langkah pemodelan sesuai yang telah Anda pelajari,

2. Lingkungan sekitar dapat menjadi inspirasi dalam mendesain soal matematika,

termasuk lingkungan sekolah,
a. Dengan mengacu pada kriteria yang telah dibahas pada modul 6,2, buatlah
sebuah soal bertipe pemodelan matematika sederhana untuk pembelajaran
matematika di sekolah,
b. Dengan mengikuti model siklus pemodelan matematika yang telah dibahas dalam
modul, selesaikan soal yang telah didesain pada poin a,
c. Masing-masing siswa mungkin akan memberikan jawaban yang bermacam-
macam dan perlu diprediksi sebelum menggunakan soal tersebut dalam proses
pembelajaran, Oleh karena itu, berikan beberapa alternatif lain cara
menyelesaikan soal tersebut, gunakan juga software matematis jika
memungkinkan,
3. Nilai Viskositas air dapat ditentukan dengan menggunakan tabel berikut ini:

T(ºC) (10-3 Ns/m2)

0 1,792
10 1,308
30 0,801
50 0,549
70 0,406
90 0,317
100 0,284

Perkirakan harga viskositas air  pada temperatur 40o menggunakan polinom Newton,
1. Judul artikel jurnal internasional (artikel jurnal terlampir):
Mathematical Modeling of the Effects of Tumor Heterogeneity on the Efficiency
of Radiation Treatment Schedule
Author: Farinaz Forouzannia1 · Heiko Enderling2, Mohammad Kohandel1
Bull Math Biol (2018) 80:283–293 https://doi.org/10.1007/s11538-017-0371-5
Received: 17 November 2016 / Accepted: 22 November 2017 / Published online: 7
December 2017 © Society for Mathematical Biology 2017

Hasil Resume:
Penelitian ini berfokus pada radioterapi menggunakan energi dosis tinggi
untuk membasmi dan mengendalikan sel kanker tumor. Berbagai jadwal perawatan
telah dikembangkan dan dicoba dalam uji klinis, namun masih ada kendala
signifikan untuk meningkatkan fraksinasi radioterapi. Metode penelitian ini
mengembangkan model matematika dua kompartemen untuk menganalisis efek
radiasi terapi pada dua subpopulasi fenotipik yang berbeda dari radioresisten dan
sel kanker adiosensitif. Pada kanker payudara, populasi ini telah diidentifikasi oleh,
masing-masing, CD44highCD24low (CD +; biomarker positif) dan CD44lowCD24high
(CD−; biomarker negatif), yang juga merupakan penanda batang kanker.
Lebih lanjut, penelitian ini menggunakan parameter estimasi. Simulasi
stokastik dan deterministik telah dibandingkan dengan dua set percobaan data
untuk mendapatkan nilai yang sesuai untuk parameter model. Studi eksperimental
pada sel pemicu kanker payudara (mis., CSC) dan uji pembentukan mammosphere
(MFA) data mengkalibrasi fraksi CSCs biomarker positif. Setelah dilakukan
pemodelan, dan menggunakan parameter estimasi, dan diilustrasikan dengan
gambar, hasil penelitian menunjukkan bahwa sel-sel tumor resisten dan sensitif
dianggap memiliki radiosensitivitas yang berbeda. Dengan demikian, total populasi
sel pada waktu t diberikan oleh N (t) = NS (t) + NP (t) (selanjutnya, NS ≡ NS + NRS
dan NP ≡ NP + NRP kecuali dinyatakan lain); populasi sel setelah terpapar
pengobatan selama periode waktu τ.
Kesimpulan pada penelitian ini adalah model matematika dua kompartemen
telah dikembangkan untuk menilai efek heterogenitas tumor dan fraksinasi
radioterapi pada respon pengobatan. Simulasi model menunjukkan bahwa
radioterapi dapat mengubah dan meningkatkan heterogenitas tumor fraksi sel
resisten. Studi selanjutnya dapat lebih meningkatkan kompleksitas biologis dengan
mempertimbangkan peningkatan pembaruan diri populasi resisten sebagai respons
 terhadap radiasi (Gao et al. 2013). Jika dosis radiasi total tidak cukup untuk
memberantasnya tumor, pengayaan dalam sel induk kanker dapat menyebabkan
kekambuhan dan kekambuhan tumor. Karena itu, jika kontrol total tumor tidak
dapat dicapai terapi yang optimal harus seimbang berkurangnya beban tumor dan
pencegahan pertumbuhan subpopulasi yang paling resisten.
2. Lingkungan sekitar dapat menjadi inspirasi dalam mendesain soal matematika,
termasuk lingkungan sekolah,
a. Soal pemodelan matematika sederhana
“Sebuah kapal terlihat dari atas mercusuar yang tingginya 40 meter. Ujung depan
kapal teramati dengan sudut depresi 45°, sedangkan ujung belakangnya 30°. Jika
kapal bergerak dengan arah menuju mercusuar, panjang kapal tersebut adalah...
meter.”

b. Pada kasus soal pada poin (a), berdasarkan Modul 6 Kegiatan Belajar 2,
permasalahan pada soal tersebut dinamakan dengan permasalahan dengan
“situasi nyata”. Langkah selanjutnya adalah siswa diharapkan mampu
menganalisis permasalahan tersebut, kemudian siswa dapat membuat
“pemodelan nyata” sebagai dasar untuk menyusun dalam bentuk “pemodelan
matematis”. Berdasarkan pemodelan yang sudah disusun, kemudian diharapkan
siswa dapat menyelesaikan persoalan dengan ”perhitungan matematis”. Berikut
adalah solusi penyelesaian dari permasalahan yang disajikan.
 Diketahui: ∠𝐸𝐷𝐵 = 45° , ∠𝐸𝐷𝐶 = 30°, dan tinggi mercusuar = 40 m
Sehingga: ∠𝐴𝐷𝐵 = 45°
∠𝐴𝐷𝐶 = 60°
Diperoleh:
𝐴𝐵
tan 45° = 𝐴𝐷
𝐴𝐵
1= 40
40 = 𝐴𝐵 “Perhitungan matematis”
𝐴𝐶
dan tan 60° = 𝐴𝐷
𝐴𝐶
√3 = 40
40√3 = 𝐴𝐶
Jadi, panjang kapal adalah (BC) = AC-AB
= 40√3 - 40
= 40(√3 − 1) meter
c. Alternatif yang dimungkinkan siswa dalam menjawab.

𝐴𝐶
tan 60° = 𝐴𝐷
𝐴𝐶
√3 = 40
40√3 = 𝐴𝐶

𝐴𝐵
dan tan 45° =
𝐴𝐷
𝐴𝐵
1= 40
40 = 𝐴𝐵
Jadi, panjang kapal adalah (BC) = AC-AB
= 40√3 - 40
= 40(√3 − 1) meter

3. Perkiraan harga viskositas air  pada temperatur 40o menggunakan polinom Newton
sebagai berikut.

Solusi ST-1

𝑓(𝑥1 ) − 𝑓(𝑥0 ) 1,308 − 1,792

𝑓(𝑥1 , 𝑥0 ) = = = −0,04840
𝑥1 − 𝑥0 10 − 0

𝑓(𝑥2 ) − 𝑓(𝑥1 ) 0,801 − 1,308

𝑓(𝑥2 , 𝑥1 ) = = = −0,02535
𝑥2 − 𝑥1 30 − 10

𝑓(𝑥3 ) − 𝑓(𝑥2 ) 0,549 − 0,801

𝑓(𝑥3 , 𝑥2 ) = = = −0,01260
𝑥3 − 𝑥2 50 − 30

𝑓(𝑥4 ) − 𝑓(𝑥3 ) 0,406 − 0,549

𝑓(𝑥4 , 𝑥3 ) = = = −0,00715
𝑥4 − 𝑥3 70 − 50
 𝑓(𝑥5 ) − 𝑓(𝑥4 ) 0,317 − 0,406
𝑓(𝑥5 , 𝑥4 ) = = = −0,00445
𝑥5 − 𝑥4 90 − 70

𝑓(𝑥6 ) − 𝑓(𝑥5 ) 0,284 − 0,317

𝑓(𝑥6 , 𝑥5 ) = = = −0,00330
𝑥6 − 𝑥5 100 − 90

Iterasi x f(x) ST-1

0 1,792 -
0 0,04840
10 1,308 -
1 0,02535
30 0,801 -
2 0,01260
50 0,549 -
3 0,00715
70 0,406 -
4 0,00445
90 0,317 -
5 0,00330
6 100 0,284

Solusi ST-2

𝑓(𝑥2 , 𝑥1 ) − 𝑓(𝑥1 , 𝑥0 ) −0,02535 − (−0,04840)

𝑓(𝑥2 , 𝑥1 , 𝑥0 ) = = = 7,68 𝑥 10−4
𝑥2 − 𝑥0 30 − 0

𝑓(𝑥3 , 𝑥2 ) − 𝑓(𝑥2 , 𝑥1 ) −0,01260 − (−0,02535)

𝑓(𝑥3 , 𝑥2 , 𝑥1 ) = = = 3,19 𝑥 10−4
𝑥3 − 𝑥1 50 − 10

𝑓(𝑥4 , 𝑥3 ) − 𝑓(𝑥3 , 𝑥2 ) −0,00715 − (−0,01260)

𝑓(𝑥4 , 𝑥3 , 𝑥2 ) = = = 1,36 𝑥 10−4
𝑥4 − 𝑥2 70 − 30

𝑓(𝑥5 , 𝑥4 ) − 𝑓(𝑥4 , 𝑥3 ) −0,00445 − (−0,00715)

𝑓(𝑥5 , 𝑥4 , 𝑥3 ) = = = 6,75 𝑥 10−5
𝑥5 − 𝑥3 90 − 50

𝑓(𝑥6 , 𝑥5 ) − 𝑓(𝑥5 , 𝑥4 ) −0,00330 − (−0,00445)

𝑓(𝑥6 , 𝑥5 , 𝑥4 ) = = = 3,83 𝑥 10−5
𝑥6 − 𝑥4 100 − 70

Iterasi X f(x) ST-1 ST-2

0 1,792 - 7,68E-
0 0,04840 04
10 1,308 - 3,19E-
1 0,02535 04
30 0,801 - 1,36E-
2 0,01260 04
50 0,549 - 6,75E-
3 0,00715 05
70 0,406 - 3,83E-
4 0,00445 05
90 0,317 -
5 0,00330
6 100 0,284
Solusi ST-3
𝑓(𝑥3 , 𝑥2 , 𝑥1 ) − 𝑓(𝑥2 , 𝑥1 , 𝑥0 ) 3,19 𝑥 10−4 − (7,68 𝑥 10−4 )
𝑓(𝑥3, 𝑥2 , 𝑥1 , 𝑥0 ) = =
𝑥3 − 𝑥0 50 − 0
= −8,99 𝑥 10−6
𝑓(𝑥4 , 𝑥3 , 𝑥2 ) − 𝑓(𝑥3 , 𝑥2 , 𝑥1 ) 1,36 𝑥 10−4 − 3,19 𝑥 10−4
𝑓(𝑥4, 𝑥3 , 𝑥2 , 𝑥1 ) = =
𝑥4 − 𝑥1 70 − 10
= −3,04 𝑥 10−6
𝑓(𝑥5 , 𝑥4 , 𝑥3 ) − 𝑓(𝑥4 , 𝑥3 , 𝑥2 ) 6,75 𝑥 10−5 − 1,36 𝑥 10−4
𝑓(𝑥5, 𝑥4 , 𝑥3 , 𝑥2 ) = =
𝑥5 − 𝑥2 90 − 30
= −1,15 𝑥 10−6
𝑓(𝑥6 , 𝑥5 , 𝑥4 ) − 𝑓(𝑥5 , 𝑥4 , 𝑥3 ) 3,83 𝑥 10−5 − 6,75 𝑥 10−5
𝑓(𝑥6, 𝑥5 , 𝑥4 , 𝑥3 ) = =
𝑥6 − 𝑥3 100 − 50
= −5,83 𝑥 10−7
Iterasi X f(x) ST-1 ST-2 ST-3
0 1,792 - 7,68E- -8,99E-
0 0,04840 04 06
10 1,308 - 3,19E- -3,04E-
1 0,02535 04 06
30 0,801 - 1,36E- -1,15E-
2 0,01260 04 06
50 0,549 - 6,75E- -5,83E-
3 0,00715 05 07
70 0,406 - 3,83E-
4 0,00445 05
90 0,317 -
5 0,00330
6 100 0,284

Solusi ST-4
𝑓(𝑥4 , 𝑥3 , 𝑥2 , 𝑥1 ) − 𝑓(𝑥3, 𝑥2 , 𝑥1 , 𝑥0 )
𝑓(𝑥4, 𝑥3, 𝑥2 , 𝑥1 , 𝑥0 ) =
𝑥4 − 𝑥0
−3,04 𝑥 10−6 − (−8,99 𝑥 10−6 )
= = 8,50 𝑥 10−8
70 − 0
𝑓(𝑥5 , 𝑥4 , 𝑥3 , 𝑥2 ) − 𝑓(𝑥4, 𝑥3, 𝑥2 , 𝑥1 )
𝑓(𝑥5, 𝑥4, 𝑥3, 𝑥2 , 𝑥1 ) =
𝑥5 − 𝑥1
−1,15 𝑥 10−6 − (−3,04 𝑥 10−6 )
= = 2,37 𝑥 10−8
90 − 10
𝑓(𝑥6 , 𝑥5 , 𝑥4 , 𝑥3 ) − 𝑓(𝑥5, 𝑥4, 𝑥3, 𝑥2 )
𝑓(𝑥6, 𝑥5, 𝑥4, 𝑥3, 𝑥2 ) =
𝑥6 − 𝑥2
−5,83 𝑥 10−7 − (−1,15 𝑥 10−6 )
= = 8,04 𝑥 10−9
100 − 30
 Iterasi x f(x) ST-1 ST-2 ST-3 ST-4
0 1,792 - 7,68E- -8,99E- 8,50E-
0 0,04840 04 06 08
10 1,308 - 3,19E- -3,04E- 2,37E-
1 0,02535 04 06 08
30 0,801 - 1,36E- -1,15E- 8,04E-
2 0,01260 04 06 09
50 0,549 - 6,75E- -5,83E-
3 0,00715 05 07
70 0,406 - 3,83E-
4 0,00445 05
90 0,317 -
5 0,00330
6 100 0,284

Solusi ST-5
𝑓(𝑥5 , 𝑥4 , 𝑥3 , 𝑥2 , 𝑥1 ) − 𝑓(𝑥4, 𝑥3, 𝑥2 , 𝑥1 , 𝑥0 )
𝑓(𝑥5, 𝑥4, 𝑥3, 𝑥2 , 𝑥1 , 𝑥0 ) =
𝑥5 − 𝑥0
2,37 𝑥 10−8 − 8,50 𝑥 10−8
= = −6,81 𝑥 10−10
90 − 0
𝑓(𝑥6 , 𝑥5 , 𝑥4 , 𝑥3 , 𝑥2 ) − 𝑓(𝑥5 , 𝑥4, 𝑥3, 𝑥2 , 𝑥1 )
𝑓(𝑥6, 𝑥5, 𝑥4, 𝑥3, 𝑥2 , 𝑥1 ) =
𝑥6 − 𝑥1
8,04 𝑥 10−9 − 2,37 𝑥 10−8
= = −1,74 𝑥 10−10
100 − 10
Iterasi x f(x) ST-1 ST-2 ST-3 ST-4 ST-5
0 1,792 - 7,68E- -8,99E- 8,50E- -6,81E-
0 0,04840 04 06 08 10
10 1,308 - 3,19E- -3,04E- 2,37E- -1,74E-
1 0,02535 04 06 08 10
30 0,801 - 1,36E- -1,15E- 8,04E-
2 0,01260 04 06 09
50 0,549 - 6,75E- -5,83E-
3 0,00715 05 07
70 0,406 - 3,83E-
4 0,00445 05
90 0,317 -
5 0,00330
6 100 0,284

Solusi ST-6
𝑓(𝑥6, 𝑥5 , 𝑥4 , 𝑥3 , 𝑥2 , 𝑥1 ) − 𝑓(𝑥5, 𝑥4, 𝑥3, 𝑥2 , 𝑥1 , 𝑥0 )
𝑓(𝑥6, 𝑥5, 𝑥4, 𝑥3, 𝑥2 , 𝑥1 , 𝑥0 ) =
𝑥6 − 𝑥0
−1,74 𝑥 10−10 − 6,81 𝑥 10−10
= = 5,07 𝑥 10−12
100 − 0
 Itera
x f(x) ST-1 ST-2 ST-3 ST-4 ST-5 ST-6
si
0 1,79 - - -
2 0,0484 7,68E- 8,99E- 8,50E- 6,81E- 5,07E-
0 0 04 06 08 10 12
10 1,30 - - -
8 0,0253 3,19E- 3,04E- 2,37E- 1,74E-
1 5 04 06 08 10
30 0,80 - -
1 0,0126 1,36E- 1,15E- 8,04E-
2 0 04 06 09
50 0,54 - -
9 0,0071 6,75E- 5,83E-
3 5 05 07
70 0,40 -
6 0,0044 3,83E-
4 5 05
90 0,31 -
7 0,0033
5 0
10 0,28
6 0 4
Dengan demikian persamaan polinomnya adalah:

𝑝6 (𝑥) = 𝑎0 + 𝑎1 (𝑥 − 𝑥0 )+𝑎2 (𝑥 − 𝑥0 )(𝑥 − 𝑥1 ) + 𝑎3 (𝑥 − 𝑥0 )(𝑥 − 𝑥1 )(𝑥 − 𝑥2 )

+ 𝑎4 (𝑥 − 𝑥0 )(𝑥 − 𝑥1 )(𝑥 − 𝑥2 )(𝑥 − 𝑥3 )
+ 𝑎5 (𝑥 − 𝑥0 )(𝑥 − 𝑥1 )(𝑥 − 𝑥2 )(𝑥 − 𝑥3 )(𝑥 − 𝑥4 )(𝑥 − 𝑥4 )
+ 𝑎6 (𝑥 − 𝑥0 )(𝑥 − 𝑥1 )(𝑥 − 𝑥2 )(𝑥 − 𝑥3 )(𝑥 − 𝑥4 ) + (𝑥 − 𝑥5 )

Untuk x = 40 maka

𝑝6 (40) = 1,792 − 0,04840(40 − 0) + 7,68 𝑥 10−4 (40 − 0)(40 − 10)

− 8,99 𝑥 10−6 (40 − 0)(40 − 10)(4 − 30)
+ 8,50 𝑥 10−8 (40 − 0)(40 − 10)(40 − 30)(40 − 50)
− 6,81 𝑥 10−10 (40 − 0)(40 − 10)(40 − 30)(40 − 50)(40 − 70)
+ 5,07 𝑥 10−12 (40 − 0)(40 − 10)(40 − 30)(40 − 50)(40 − 70)(40
− 90)

𝑝6 (40) = 1,79200 − 1,93600 + 0,92200 − 0,10790 − 0,01020 − 0,00245 − 0,00091

𝑝6 (40) = 0,657

Maka perkirakan harga viskositas air  pada temperatur 40o adalah 0,657 (10-3
Ns/m2)
Bull Math Biol (2018) 80:283–293
https://doi.org/10.1007/s11538-017-0371-5
ORIGINAL ARTICLE

Mathematical Modeling of the Effects of Tumor

Heterogeneity on the Efficiency of Radiation Treatment
Schedule

Farinaz Forouzannia1 · Heiko Enderling2 ·

Mohammad Kohandel1

Received: 17 November 2016 / Accepted: 22 November 2017 / Published online: 7 December 2017
© Society for Mathematical Biology 2017

Abstract Radiotherapy uses high doses of energy to eradicate cancer cells and control
tumors. Various treatment schedules have been developed and tried in clinical trials,
yet significant obstacles remain to improving the radiotherapy fractionation. Genetic
and non-genetic cellular diversity within tumors can lead to different radiosensitivity
among cancer cells that can affect radiation treatment outcome. We propose a minimal
mathematical model to study the effect of tumor heterogeneity and repair in different
radiation treatment schedules. We perform stochastic and deterministic simulations
to estimate model parameters using available experimental data. Our results suggest
that gross tumor volume reduction is insufficient to control the disease if a fraction
of radioresistant cells survives therapy. If cure cannot be achieved, protocols should
balance volume reduction with minimal selection for radioresistant cells. We show that
the most efficient treatment schedule is dependent on biology and model parameter
values and, therefore, emphasize the need for careful tumor-specific model calibration
before clinically actionable conclusions can be drawn.

Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11538-

017-0371-5) contains supplementary material, which is available to authorized users.

B Farinaz Forouzannia
f3forouz@uwaterloo.ca
B Mohammad Kohandel
kohandel@uwaterloo.ca
Heiko Enderling
heiko.enderling@moffitt.org

1 Department of Applied Mathematics, University of Waterloo, Waterloo, ON N2L 3G1, Canada

2 Department of Integrated Mathematical Oncology, Department of Radiation Oncology,
H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33647, USA

123
284 F. Forouzannia et al.

Keywords Cancer stem cell · Fractionation · Tumor control

1 Introduction

Radiation is commonly used in cancer treatment, either as monotherapy or as com-

bination treatment with surgery and chemotherapy. Radiation is a DNA damaging
agent, and radiation as cancer therapy benefits from cancer cells being less efficient in
repairing radiation-induced damage than normal cells. Total radiation dose is divided
into small frequent fractions to provide temporal windows for normal tissue recovery.
Treatment schedules (fractionation) are predominantly based on evolved empirical
knowledge and wisdom, but greatly constrained by logistical considerations. Recent
developments include hypo- and hyperfractionation for various cancer types, that is
delivery of either larger doses temporally further separated or smaller doses more
frequently.
Despite many technical improvements in the efficiency of radiotherapy, many
tumors are refractory to irradiation. Various clinical and biological factors explain
such complications, including DNA damage repair (Hall and Giaccia 2006; Mathews
et al. 2013), prevalence of hypoxia, and tumor heterogeneity and plasticity. Recently,
the presence of cancer stem cells and a tumor hierarchy has been discussed as source of
intratumoral heterogeneity and therapy response (Marjanovic et al. 2013; Shackleton
et al. 2009). The cancer stem cell hypothesis proposes that the small subpopulation of
so-called cancer stem cells (CSCs) is critically important for the initiation and main-
tenance of the tumor. These CSCs are able to self-renew indefinitely and undergo
symmetric and asymmetric divisions to retrospectively increase the CSC population
and produce progenitor cells that will make up the bulk of the tumor (Reya et al. 2001).
Recent evidence suggests plasticity between non-CSC and CSC states (Gupta et al.
2011), due to genetic or microenvironmental perturbations. CSCs have been shown
to utilize superior radiation-induced DNA damage repair mechanisms to prevent cell
death (Bao et al. 2006). After radiation exposure, cells with damaged DNA attempt
different pathways of repair, and the repair time is likely dependent on the delivered
radiation dose (Lagadec et al. 2010; Sarcar et al. 2011).
The conventional radiotherapy protocol for most tumors delivers a total dose of 50–
70 Gy in 2 Gy fractions on each weekday, with no treatment given on weekends. To
reduce toxicity and increase efficiency, alternative treatments have been considered,
including a hyperfractionated protocol with 1 Gy per fraction twice a day; an accel-
erated regimen of 1.2 Gy per fraction twice daily; and hypofractionation with 5 Gy
twice-a-week fractions. Here, we develop a minimal mathematical model to study the
effect of tumor heterogeneity and repair in tumors exposed to theses different radiation
treatment schedules.
Several mathematical models have been developed to simulate the effects of radio-
therapy. Most models utilize the so-called linear quadratic (LQ) model and its various
extensions (Hall and Giaccia 2006). In the original LQ model, cell survival probability
S after acute doses of radiation d can be estimated with

S(d) = exp(−αd − βd 2 ), (1)

123
Mathematical Modeling of the Effects of Tumor Heterogeneity… 285

where α (Gy−1 ) and β (Gy−2 ) are tissue-specific radiosensitivity parameters that are
usually derived from fitting the LQ model to clonogenic survival data (Hall and Giaccia
2006). More recently, mathematical frameworks have been combined with experimen-
tal data to investigate the different responses to clinically available radiation protocols
(Dhawan et al. 2014; Dionysiou et al. 2004; Enderling et al. 2009; Stamatakos et al.
2014). Recently, Leder et al. (2014) proposed an optimized radiation dosing schedule
for PDGF-driven glioblastoma. The model, however, is dependent on a large number
of parameters and, with limited biological data, some parameters are far from bio-
logical realism. In particular, tissue-specific radiosenstivity parameters α and β are
derived such that the derived ratio of α/β = 865, 789 Gy is five orders of magnitude
larger than frequently derived α/β = 3 − 10 Gy (Leder et al. 2014). Nevertheless, the
model-predicted optimal dose fractionation showed prolonged survival in subsequent
mouse experiments, emphasizing that the currently applied standard-of-care radia-
tion fractionation may not yield optimal outcomes. Mathematical models may help
decipher the complex biology underlying cancer cell response to irradiation, with the
ultimate aim to improve clinical application of radiotherapy.
Herein we propose a simple mathematical model of breast cancer cell dynamics
under fractionated radiation exposure. The model includes phenotypic cell hetero-
geneity and plasticity, as well as radiation-induced cell cycle arrest, which may play
a pivotal role in analyzing radiation protocols with multiple doses per day. The effect
of different model parameters and repair mechanisms on heterogeneity are studied for
different clinically feasible radiotherapy treatments.

2 Method

We developed a two-compartment mathematical model to analyze the effect of radi-

ation therapy on the two phenotypically distinct subpopulations of radioresistant and
radiosensitive cancer cells. In breast cancer, these populations have been identified by,
respectively, CD44highCD24low (C D + ; biomarker positive) and CD44lowCD24high
(C D − ; biomarker negative), which are also markers of cancer stemness (Al-Hajj et al.
2003; Fillmore and Kuperwasser 2008). Both subpopulations are capable of self-
renewal, albeit with lower rates for biomarker negative CD− cells that also feature
higher death rates. We discuss the balance of self-renewal and cell death as the net pop-
ulation growth rate, which does not affect the behavior of the system. As a visualization
of phenotypic plasticity, cells can switch from one phenotype to the other (Marjanovic
et al. 2013). After exposure to radiation, cells in each compartment are forced into
cell cycle arrest to attempt repair from radiation-induced DNA damage. Biomarker
positive cells have been shown to have better repair mechanisms (Bao et al. 2006;
Baumann et al. 2008) and, thus, a larger fraction of growth-arrested biomarker posi-
tive CD+ (calculated by the LQ model with phenotype-specific α S and β S parameters)
returns into the viable population after successful repair. Figure 1 shows a schematic
diagram of the proposed model, and model parameters are summarized in Table 1.
We denote by N S , N R S , N P , and N R P the population of resistant cells, resistant
repairing cells, sensitive cells, and sensitive repairing cells, respectively. The model
can be mathematically represented by the following system of equations

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286 F. Forouzannia et al.

Positive biomarker cells

CD44high/CD24low (CD+) Repairing cells (CD+)
ρS δS f
Dead cells (CD+)

g(d)(1− e(−αS d−βS d ) )

2

g(d)e(−αS d−βS d
2
)

ρSP ρ PS
δP f
Dead cells (CD-)
ρP
g(d)(1− e(−αP d−βP d ) )
2

g(d)e(−α P d−βP d
2
)

Negative biomarker cells Repairing cells (CD-)

CD44low/CD24high (CD-)
Fig. 1 (Color figure online) Schematic diagram of the model

Table 1 Description of the model parameters

Parameters Description

ρS Net proliferation rate of C D + cells

ρS P Rate of switching of C D + cells to C D − cells
ρP Net proliferation rate of C D − cells
ρP S Rate of switching of C D − cells to C D + cells
δS f Rate at which C D + cells go for repair
δP f Rate at which C D − cells go for repair
2
g(d)(1 − e(−α S d−β S d ) ) Rate at which C D + cells that are in repair die
2
g(d)(1 − e(−α P d−β P d ) ) Rate at which C D − cells that are in repair die
2
g(d)e(−α S d−β S d ) Rate at which C D + cells that are in repair become active
again
2
g(d)e(−α P d−β P d ) Rate at which C D − cells that are in repair become active
again

dN S
= ρ S N S + ρ P S N P + g(d)e(−α S d−β S d ) NRS − ρSP N S − δ S f N S ,
2

dt
dNRS
= δ S f N S − g(d)NRS ,
dt (2)
dN P (−α P d−β P d 2 )
= ρ P N P + ρSP N S + g(d)e NRP − ρPS N P − δ P f N P ,
dt
dNRP
= δ P f N P − g(d)NRP .
dt

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Mathematical Modeling of the Effects of Tumor Heterogeneity… 287

Table 2 Fractionated irradition effect on CSC population and mammosphere formation capacity (Lagadec
et al. 2010)

C D24low/−/ C D44high

Dose % of CSCs Sphere forming capacity

2 6.54 (± 1.95) 13.49 (± 1.32)

2–2 8.04 (± 1.47) 10.76 (± 0.96)
2–2–2–2 8.56 (± 1.21) 11.85 (± 1.81)
Overall average 7.71 12.03

Cells acquire on average one DNA double strand break after exposure to 1 Gy of
radiation. Therefore, we assume that each cell will enter cell cycle arrest and attempt
repair after each radiation fraction, but no new damage arises in the interval between
radiation treatments. Hence, f = 1 at discrete times when radiation is given, and f = 0
otherwise. Dependent on radiosensitivity parameters αi and βi with i ∈ {S, P}, cells
will either die due to radiation-induced DNA damage with probability 1 − Si (d) or
return to the viable non-repairing population S or P with probability Si (d) at dose-
dependent rate g(d). We assume the function g(d) to be of the order of inverse square
of the dose (Lagadec et al. 2010; Sarcar et al. 2011), such that cells irradiated with a
dose of 1 Gy spend on average 1 h attempting repair, and 4 h after exposure to 2 Gy.

2.1 Parameter estimation

Stochastic and deterministic simulations have been compared to two sets of experi-
mental data to derive suitable values for model parameters. The experimental study on
breast cancer initiating cells (i.e., CSCs) and mammosphere formation assay (MFA)
data calibrates the fraction of biomarker positive CSCs (Lagadec et al. 2010). In this
study, the breast cancer cell line is irradiated with a single dose or daily doses of 2 Gy.
After 48 hours, single cells are seeded to form spheres for 20 days. The fraction of
CSCs and mammosphere formation capacity are reported in Table 2 (Lagadec et al.
2010).
As the MFA experiment was initiated from a single cell (Lagadec et al. 2010),
stochastic effects are important. We apply the Gillespie algorithm to compare model
sphere forming capacity predictions with the experimental data in Table 2. Since
running the Gillespie algorithm is computationally expensive, it is only used to fit
the parameters of the model when δs = δ p = g = 0. We vary model parameters
without repair to obtain the best fit to the experimental data. At the same time, we
use the deterministic Eq. 2 to compare the theoretical results of average CSC fraction
to experimental data. The estimated model parameters are summarized in Table 3,
alongside the fraction of CSCs and sphere forming capacity using those values, which
show good agreement with the experimental results in Table 2. Of note is that the
reported parameter value combinations are not unique and, thus, we will perform a
sensitivity analysis to investigate the impact of each parameter on model outcome.

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288 F. Forouzannia et al.

Table 3 Estimated model parameters when δ S = δ P = g = 0

Parameters ρS ρSP ρP ρPS % of CSCs Sphere forming capacity

Values 0.2 0.7 0.1 0.05 7.6 12.7

The values of fraction of CSCs and sphere forming capacity that are evaluated based on the estimated
parameters values are also reported. The unit of all parameters is 1/day

100
Fitted curve
Experimental data

10−1
Survival fraction

10−2

10−3

10−4
0 1 2 3 4 5 6 7 8 9 10
Radiation dose (Gy)
Fig. 2 (Color figure online) Fitting the modified linear quadratic model to the experimental data of (Phillips
et al. 2006). The black points are the extracted experimental data. The solid curve is the model result using
the estimated radiosensitivity parameters α S = 0.14 Gy−1 , β S = 0.048 Gy−2 , α P = 0.41 Gy−1 and
β P = 0.17 Gy−2

Herein, resistant and sensitive tumor cells are considered to have different radiosen-
sitivities. Thus, the total population of cells at time t is given by N (t) = N S (t)+ N P (t)
(hereafter, N S ≡ N S + NRS and N P ≡ N P + NRP unless stated otherwise); the pop-
ulation of cells after exposure to treatment for the period of time τ can be calculated
as
N (t + τ ) N S (t) (−α S d−β S d 2 ) N P (t) (−α P d−β P d 2 )
= e + e . (3)
N (t) N (t) N (t)

Assuming that the fraction of CSCs is at its steady-state value before the radiation,
(t)
and using the experimental data of (Lagadec et al. 2010), we set NNS(t) = 0.076 (and
N P (t)
N (t) = 0.924). Then, the modified linear quadratic model (Eq. 3) is used to fit model
results to the experimental data of (Phillips et al. 2006), which yields α S = 0.14
Gy−1 , β S = 0.048 Gy−2 (α S /β S =2.9 Gy), α P = 0.41 Gy−1 and β P = 0.17 Gy−2
(α S /β S =2.4 Gy) (Fig. 2). Since at each radiation fraction the majority of damaged cells
undergo repair mechanisms, we assume that 90% of cells will be arrested (Withers
1992). However, sensitivity analysis shows that reducing this fraction as low as to 40%
does not qualitatively change the results (see Figure S1 and Figure S2 in supplementary
materials). The list of all model parameters and their estimated values are reported in
Table 4.

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Mathematical Modeling of the Effects of Tumor Heterogeneity… 289

Table 4 Model parameter values

Parameters Value (unit) Reference

ρS 0.2 (day−1 ) Using experimental data (Lagadec et al. 2010)

ρS P 0.7 (day−1 ) Using experimental data (Lagadec et al. 2010)
ρP 0.1 (day−1 ) Using experimental data (Lagadec et al. 2010)
ρP S 0.05 (day−1 ) Using experimental data (Lagadec et al. 2010)
δS = δ P 310 (day−1 ) Assuming 90% of cancer cells undergo repair
αS 0.14 (Gy−1 ) Using experimental data (Phillips et al. 2006)
αP 0.41 (Gy−1 ) Using experimental data(Phillips et al. 2006)
βS 0.048 (Gy−2 ) Using experimental data (Phillips et al. 2006)
βP 0.17 (Gy−2 ) Using experimental data (Phillips et al. 2006)
f 1 or 0 1: radiation, 0: no radiation

3 Results

We consider different clinical radiotherapy treatment protocols for one week includ-
ing standard of care (SoC; daily doses of 2 Gy), hyperfractionated (HR; two daily
doses of 1 Gy), accelerated hyperfractionation (AC; two daily doses of 1.2 Gy), and
hypofractionated (HO; twice-a-week doses of 5 Gy). Additionally, we simulate the
recently suggested optimal protocol for PDGF-driven glioblastoma by Leder (Leder
et al. 2014) (Optimum-1, OP; see Table 5). All protocols deliver a total dose of D = 10
Gy per week, except accelerated hyperfractionated with a total dose of D = 12 Gy.
However, the accelerated hyperfractionated protocol has the same biologically effec-
tive dose (BED) as SoC (see Table 6). BED is used to describe the biological effect of
dose fractionation and is defined as
 
− ln(S F(d)) d
BED = = D 1+ , (4)
α α/β

where S F(d) is the LQ model derived single dose d-dependent survival fraction with
radiobiological parameters α and β (compare Eq. 1). Due to the linear quadratic rela-
tionship of dose and survival, total dose can be increased when smaller doses are
given in each fraction (Fowler 1989). The model introduced in Sect. 2 considered two
subgroups of cancer cells (resistant cells and sensitive cells) with different radiosensi-
tivities. Thus, following the survival fraction of cancer cells in Eq. 3, the BED is given
by
− ln(m S FS + (1 − m)S FP )
BED = , (5)
mα S + (1 − m)α P

where S FS and S FP are survival fractions for resistant cells and sensitive cells, respec-
tively. The constant m represents the proportion of resistant cells in the tumor prior
to irradiation. Table 6 shows the BED for the standard of care (SoC), hyperfrac-

123
290 F. Forouzannia et al.

Table 5 Radiotherapy schedules for one week of treatment. Different colors are used for corresponding
colors in the figures

Schedule Day 1 Day 2 Day 3 Day 4 Day 5

Standard of care (SoC) 2 2 2 2 2

Hyperfractionated (HR) 2×1 2×1 2×1 2×1 2×1
Optimum-1 (OP) 3×1 1 2×1 1 3×1
Hypofractionated (HO) 5 – – – 5
Accelerated hyperfractionated (AC) 2 × 1.2 2 × 1.2 2 × 1.2 2 × 1.2 2 × 1.2

Table 6 Biological effective dose for hyperfractionation, standard of care, and accelerated hyperfraction-
ated protocols

BED Schedules

HR (d = 1, n = 10) SoC (d = 2, n = 5) AC (d = 1.2 n = 10)

BED S (m = 1) 13.5 17.1 17.1

BED P (m = 0) 14.1 18.3 17.9
BED S P (m = 0.076) 11.1 12.7 12.7

tionated (HR), and accelerated hyperfractionated (AC) protocols with different initial
fractions of resistant cells: tumors containing only resistant cells (m = 1), tumors
containing only sensitive cells (m = 0), and heterogeneous tumors with a small sub-
population of resistant cells (m = 0.076) as estimated. The BED is almost identical
for standard-of-care and accelerated hyperfractionation, but significantly smaller for
hyperfractionation.
Figure 3 shows the number of cancer cells N S + N P and fraction of resistant cells
N S /(N S + N P ) for all considered radiation schedules (compare Table 5). Simula-
tions show that protocols with larger number of fractions leads to more cell kill, with
accelerated hyperfractionation yielding the smallest number of cells after one week
of therapy. However, the fraction of stem cells is largest compared to the other radio-
therapy protocols. Hypofractionation with smallest overall cell kill leads also to least
competitive release of the most resistant stem cell subpopulation (Enderling et al.
2009).
For the chosen parameter combinations (Table 4), accelerated hyperfractionation
and SoC schedules yield the lowest number of cancer cells after one week of treatment
(Fig. 3). Sensitivity analysis showed that the results are robust to changes in the
parameter values (Table 7), with the exception that decreasing α P and β P by 50%
produces hypofractionated and accelerated hyperfractionated as best protocols (Fig.
4).
Heretofore we assumed that 90% of cells undergo arrest to attempt repair, and the
parameter values for δ S and δ P were chosen large enough to satisfy this assumption.
However, decreasing the values for these parameters so that less than 40% of cells
attempt repair suggests accelerated hyperfractionated as the best schedule (see Figure

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Mathematical Modeling of the Effects of Tumor Heterogeneity… 291

Approximately 90% of cells go for repair Approximately 90% of cells go for repair

Fraction of resistant cells

106 0.4
Total number of cells
SoC
HR 0.35
OP
105 0.3
HO
AC
0.25
104
0.2

103 0.15
0.1
102 0.05
0 1 2 3 4 5 6 7 0 1 2 3 4 5
Days Days
Fig. 3 (Color figure online) Number of cancer cells N S + N P and the fraction of resistant cells N S /(N S +
N P ) for radiotherapy protocols reported in Table 5

Table 7 Sensitivity analysis for different parameters of the model

Parameters αS , βS αP , βP ρS ρP ρPS ρSP 1st best 2st best

Default 0.14, 0.05 0.41, 0.17 0.2 0.1 0.044 0.73 AC SoC
α S , β S (+ 50%) 0.21, 0.07 0.41, 0.17 0.2 0.1 0.044 0.73 AC SoC
α S , β S (− 50%) 0.07, 0.04 0.41, 0.17 0.2 0.1 0.044 0.73 AC SoC
α P , β P (+ 50%) 0.14, 0.05 0.61, 0.25 0.2 0.1 0.044 0.73 AC SoC
α P , β P (− 50%) 0.14, 0.05 0.21, 0.08 0.2 0.1 0.044 0.73 HO AC
ρ S (+ 50%) 0.14, 0.05 0.41, 0.17 0.3 0.1 0.044 0.73 AC SoC
ρ S (− 50%) 0.14, 0.05 0.41, 0.17 0.1 0.1 0.044 0.73 AC SoC
ρ P (+ 50%) 0.14, 0.05 0.41, 0.17 0.2 0.15 0.044 0.73 AC SoC
ρ P (− 50%) 0.14, 0.05 0.41, 0.17 0.2 0.05 0.044 0.73 AC SoC
ρ P S (+ 50%) 0.14, 0.05 0.41, 0.17 0.2 0.1 0.066 0.73 AC SoC
ρ P S (− 50%) 0.14, 0.05 0.41, 0.17 0.2 0.1 0.022 0.73 AC SoC
ρ S P (+ 50%) 0.14, 0.05 0.41, 0.17 0.2 0.1 0.044 1.09 AC SoC
ρ S P (− 50%) 0.14, 0.05 0.41, 0.17 0.2 0.1 0.044 0.36 AC SoC

Approximately 90% of cells go for repair Approximately 90% of cells go for repair
Fraction of resistant cells

106 0.11
Total number of cells

SoC
HR
OP
0.1
105 HO
AC 0.09

0.08
104
0.07
3
10 0.06
0 1 2 3 4 5 6 7 0 1 2 3 4 5
Days Days
Fig. 4 (Color figure online) Number of cancer cells N S + N P and the fraction of resistant cells N S /(N S +
N P ) when α P and β P are changed to α P − 0.5α P and β P − 0.5β P for radiotherapy protocols reported in
Table 7

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292 F. Forouzannia et al.

S1 and Figure S2 in supplementary materials). Furthermore, the model considers that

cells leave arrest with rate g(d), which is assumed to be on the order of 1/dose2 . If
g(d) was proportional to 1/dose the number of cancer cells at the end of the course of
radiation therapy decreases significantly; however, the accelerated hyperfractionated
schedule remains the best treatment protocol followed by SoC. Moreover, if g(d) =
1, the order of the best treatment regimens remains (see Figures S3, S4, and S5 in
supplementary materials).

4 Conclusion

In this paper, a two-compartment mathematical model has been developed to assess the
effect of tumor heterogeneity and radiotherapy fractionation on treatment response.
Model simulations suggest that radiotherapy can alter tumor heterogeneity and elevates
the fraction of resistant cells. Future studies may further increase biological complex-
ity by considering increased self-renewal of the resistant population in response to
radiation (Gao et al. 2013). If the total radiation dose is insufficient to eradicate the
tumor, enrichment in cancer stem cells may lead to tumor relapse and recurrence.
Therefore, if total tumor control cannot be achieved optimal therapies should balance
decreases in tumor burden and prevention of outgrowth of the most resistant subpopu-
lation. Interestingly, none of our simulations suggested standard-of-care fractionation
as the best therapeutic approach, further emphasizing the need to prospectively evalu-
ate alternative fractionation protocols in the clinic. Furthermore, our model calibrated
for breast cancer was unable to confirm the optimum treatment schedule for PDGF-
driven glioblastoma (as in Leder et al. 2014). This suggests that treatment optimization
may be highly tumor biology, mathematical model, and model parameter dependent,
and utmost importance must be paid to identifying underlying biological mechanisms.
Hence, a general optimal radiation schedule as suggested in (Conforti et al. 2008; Leder
et al. 2014; Wein et al. 2000) may not be feasible and designing an efficient protocol
may be required for each type of cancer, and even each individual patient.
At the moment, the study is hypothesis generating, and we sincerely hope that the
presented results are exciting and encouraging for experimentalists and clinicians to
test the presented model predictions.

Acknowledgements Financial support by the Natural Sciences and Engineering Research Council of
Canada (NSERC) (MK) is gratefully acknowledged.

References
Al-Hajj Muhammad, Wicha Max S, Benito-Hernandez Adalberto, Morrison Sean J, Clarke Michael F (2003)
Prospective identification of tumorigenic breast cancer cells. Proc Nat Acad Sci 100(7):983–3988
Bao Shideng, Qiulian Wu, McLendon Roger E, Hao Yueling, Shi Qing, Hjelmeland Anita B, Dewhirst Mark
W, Bigner Darell D, Rich Jeremy N (2006) Glioma stem cells promote radioresistance by preferential
activation of the DNA damage response. Nature 444:756–760
Baumann Michael, Krause Mechthild, Hill Richard (2008) Exploring the role of cancer stem cells in
radioresistance. Nat Rev Cancer 8:545–554
Conforti Domenico, Guerriero Francesca, Guido Rosita (2008) Optimization models for radiotherapy patient
scheduling. 4OR 6:263–278

123
Mathematical Modeling of the Effects of Tumor Heterogeneity… 293

Dhawan Andrew, Kohandel Mohammad, Hill Richard, Sivaloganathan Sivabal (2014) Tumour control
probability in cancer stem cells hypothesis. PLoS ONE 9:e96093
Dionysiou Dimitra D, Stamatakos Georgios S, Uzunoglu Nikolaos K, Nikita Konstantina S, Marioli Antigoni
(2004) A four-dimensional simulation model of tumour response to radiotherapy in vivo: parametric
validation considering radiosensitivity, genetic profile and fractionation. J Theor Biol 230:1–20
Enderling Heiko, Park Derek, Hlatky Lynn, Hahnfeldt Philip (2009) The importance of spatial distribution
of stemness and proliferation state in determining tumor radioresponse. Math Model Nat Phenom
4:117–133
Enderling Heiko, Anderson Alexander RA, Chaplain Mark AJ, Beheshti Afshin, Hlatky Lynn, Hahnfeldt
Philip (2009) Paradoxical dependencies of tumor dormancy and progression on basic cell kinetics.
Cancer Res 69(22):8814–8821
Fillmore Christine M, Kuperwasser Charlotte (2008) Human breast cancer cell lines contain stem-like cells
that self-renew, give rise to phenotypically diverse progeny and survive chemotherapy. Breast Cancer
Res 10(2):1
Fowler John F (1989) The linear-quadratic formula and progress in fractionated radiotherapy. Br Jo Radiol
62:679–694
Gao Xuefeng, McDonald John T, Hlatky Lynn, Enderling Heiko (2013) Acute and fractionated irradiation
differentially modulate glioma stem cell division kinetics. Cancer Res 73(5):1481–1490
Gupta Piyush B, Fillmore Christine M, Jiang Guozhi, Shapira Sagi D, Tao Kai, Kuperwasser Charlotte,
Lander Eric S (2011) Stochastic state transitions give rise to phenotypic equilibrium in populations of
cancer cells. Cell 146:633–644
Hall Eric J, Giaccia Amato J (2006) Radiobiology for the radiologist. Lippincott Williams and Wilkins,
Philadelphia
Haviland Joanne S, Owen J Roger, Dewar John A, Agrawal Rajiv K, Barrett Jane, Barrett-Lee Peter J, Dobbs
H Jane et al (2013) The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy
hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised
controlled trials. Lancet Oncol 14:1086–1094
Lagadec Chann, Vlashi Erina, Della Donna Lorenza, Meng YongHong, Dekmezian Carmen, Kim
Kwanghee, Pajonk Frank (2010) Survival and self-renewing capacity of breast cancer initiating cells
during fractionated radiation treatment. Breast Cancer Res 12:R13
Leder Kevin, Pitter Ken, LaPlant Quincey, Hambardzumyan Dolores, Ross Brian D, Chan Timothy A, Hol-
land Eric C, Michor Franziska (2014) Mathematical modeling of PDGF-driven glioblastoma reveals
optimized radiation dosing. Cell 156:603–616
Mathews Lesley A, Cabarcas Stephanie M, Hurt Elaine M (2013) DNA repair of cancer stem cells. Springer,
Berlin
Marjanovic Nemanja D, Weinberg Robert A, Chaffer Christine L (2013) Cell plasticity and heterogeneity
in cancer. Clin Chem 59:168–179
Phillips Tiffany M, McBride William H, Pajonk Frank (2006) The response of CD24-/low/CD44+ breast
cancer initiating cells to radiation. J Natl Cancer Inst 98:1777–1785
Reya Tannishtha, Morrison Sean J, Clarke Michael F, Weissman Irving L (2001) Stem cells, cancer, and
cancer stem cells. Nature 414:105–111
Sarcar Bhaswati et al (2011) Targeting radiation-induced G2 checkpoint activation with the Wee-1 inhibitor
MK-1775 in glioblastoma cell lines. Mol Cancer Ther 10:2405–2414
Stamatakos GS, Antipas VP, Uzunoglu NK, Dale RG (2014) A four-dimensional computer simulation
model of the in vivo response to radiotherapy of glioblastoma multiforme: studies on the effect of
clonogenic cell density. Br J Radiol 79:389
Shackleton Mark, Quintana Elsa, Fearon Eric R, Morrison Sean J (2009) Heterogeneity in cancer: cancer
stem cells versus clonal evolution. Cell 138:822–829
Trialists’ Group (2008) The START, The UK Standardisation of Breast Radiotherapy (START) Trial B
of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet
371:1098–1107
Wein Lawrence M, Cohen Jonathan E, Wu Joseph T (2000) Dynamic optimization of a linear-quadratic
model with incomplete repair and volume-dependent sensitivity and repopulation. Int J Radiat Oncol
Biol Phys 47:1073–1083
Withers HR (1992) Biological basis of radiation therapy for cancer. Lancet 339(8786):156–9

123