Cancer Immunotherapy:
The Fundamentals And Its Emerging Role

FORWARD

Immunotherapy has been under evaluation for more than a century, but only recently has it entered a renaissance phase with approval of multiple agents for the treatment of cancer. Now, immunotherapy stands high above traditional modalities, including surgery, chemotherapy, radiation, and hormone therapy, as the most significant pillar of cancer treatment. Importantly, immunotherapy is not a single entity but represents several types of treatments, including checkpoint inhibitors, monoclonal antibodies, growth factors, and most significantly therapeutic antigen presentation immunomodulation, to boost or restore the ability of the immune system to fight cancer.

This monograph provides an overview of the role of the immune system in cancer and describes how the various immunotherapies are designed to target cancer cells. This information is highly relevant to understanding immunotherapy and may improve outcomes of patients with cancer.

Key Objectives
After reading this monograph, people will understand:

  • The evidence supporting the immune system’s role in cancer and the characteristics of an immune response
  •  Several mechanisms of immunotherapy
  • Treatment considerations of cancer immunotherapy

THE IMMUNE SYSTEM’S ROLE IN CANCER

Hallmarks of Cancer Pathogenesis
Six traits common to most, if not all, cancers were identified in a landmark paper by Hanahan and Weinberg published in 2000.1 These hallmark traits reflect changes that normal cells must acquire to become malignant tumor cells. A recent update to this paper acknowledged that the immune system has a critical role in cancer pathogenesis.2 In particular, tumors have the ability to specifically evade the immune system, allowing cancers to grow and spread. The traits common to cancers are listed in Table 1.2

 

Hallmarks_of_cancer_1000x1082

Table 1. Hallmarks of Cancer Cells [2]

1. Grow in the absence of growth signals
2. Evade the normal signals that stop growth
3. Evade the normal death signals that prevent proliferation of damaged cells
4. Escape from an intrinsic signal that limits cell replication to a finite number
5. Induce the formation of new blood vessels to feed themselves
6. Acquire the ability to invade other tissues and spread throughout the body
7. Change cellular metabolism to support proliferation of cancer cells
8. Evade the immune system to avoid destruction
9. Tumor-promoting inflammation
10. Genomic instability and mutation

The Immune System in Cancer: Clinical Evidence
A significant and growing body of scientific evidence substantiates the role of the immune system in battling cancer. Evidence has demonstrated that patients with compromised or suppressed immune function have an increased risk of cancer compared to individuals with intact immune systems. [3-10] In particular, it has been shown that patients who have undergone organ transplantation and are chronically immunosuppressed to prevent transplant rejection have an increased incidence of several cancers (Figure 1).

Figure 1. Increased Incidence of Cancer in Immunocompromised Individuals [3-5]

Tumor/Cancer Risk in Transplant Patients Compared to General Population

fig-1

In patients who have undergone kidney transplantation, this increased cancer risk ranges from 2-fold for common tumors, like colon, lung, prostate, and breast, to greater than 20-fold for non-melanoma skin cancer, non-Hodgkin’s lymphoma, and Kaposi’s sarcoma compared to the general population with intact immune systems. [3,4] A similar trend toward an increased cancer risk has been seen with patients who have undergone liver or heart transplants. [5,6] In addition, cancer rates are increased in human immunodeficiency virus (HIV)-infected individuals, and an estimated 40% of all patients with acquired immune deficiency syndrome (AIDS) develop cancer during their lifetime. [8] In several observational studies, the risk of malignancies in patients with AIDS increased as certain immune cell counts declined. [9,10]

Furthermore, although somewhat controversial, the use of immunosuppressive agents, including biologics that block tumor necrosis factor, has been associated with an increased risk or incidence of certain cancers. In a large US observational study, the use of immunosuppressive biologic agents for the treatment of rheumatoid arthritis was associated with a significant 1.5-fold increase in the risk of non-melanoma skin cancer and a trend for increased risk of melanoma. [11]

Additionally, intratumoral T cells, which are key mediators of cellular immunity, have been associated with increases in overall survival (OS) in different cancers.[12-14] In a study in which tumor-infiltrating T cells were measured in tumor specimens obtained from patients with advanced ovarian carcinomas,12 patients with intratumoral T cells had significantly longer median overall survival (OS) (50.3 vs. 18.0 months) and higher 5-year overall survival (OS) (38.0% vs. 4.5%) compared with those having no intratumoral
T cells (P<0.001) (Figure 2). [12]

Figure 2. Immune Cells Within Tumors Predicts overall survival (OS) [12]

Kaplan-Meier Curve for overall survival (OS) in Advanced Ovarian Cancer

fig-2

Adapted from Zhang L, et al. [12]
Cancer and the Immune System: A Dynamic Relationship
The regulation of tumor growth represents a dynamic state, in which the immune system can either block tumor growth, development, and survival (ie, immune protection) or may promote development of tumors (ie, immune evasion). [15] This process can be conceptualized by a seesaw that balances immune protection on one side with immune evasion on the other (Figure 3). There are 3 stages of this process known as the 3 E’s: elimination, equilibrium, and escape. [15]

fig-3

A dynamic balance exists between the immune system and tumor cells. Most of the time, the immune system is able to effectively remove abnormal cells; however, sometimes tumor cells are able to evade detection by the immune system, which allows the tumor to develop.

Elimination refers to the stage in which cancer cells are identified and effectively eliminated by the immune system. In this stage, the balance is shifted in favor of immune protection (Figure 3A).[15]

The equilibrium phase is entered in the event that the immune system is not able to completely eliminate all cancer cells but can control or prevent further outgrowth.[15] As a result, the tumor cells persist but are ultimately prevented from spreading by the actions of the immune system. In the equilibrium stage, the conceptual seesaw is balanced (Figure 3B). This stage is thought to be the longest of the 3 stages and may persist for many years.

The escape phase is characterized by the inability of the immune system to eliminate and control the outgrowth of cancer cells.[15] This stage may occur as a result of immune system exhaustion or when cancer cells acquire phenotypic alterations, thereby allowing them to evade or avoid the immune system.[15] In the escape stage, the conceptual seesaw tips in favor of immune evasion, leading to progressive disease (Figure 3C).

Key Learnings
• There is a dynamic relationship between the immune system and tumor cells. Normally, the immune system is capable of eliminating tumor cells. However, tumor cells use multiple evasion techniques to avoid the immune system.

Native Immune Response
Antigen presenting cells, or APCs, are specialized cells that recognize foreign antigens and present antigen fragments to T cells. Antigens are the molecules produced by microbes or foreign agents that bind to T cells and antibodies. The interaction between APCs and T cells activates the T cells (Figure 4). These activated T cells replicate and specialize to mount an attack on cells expressing the specific antigen. This specialization includes proliferation of target cells to kill cancer, the activation of additional immune cells and mediators to enhance the immune response, and the development of memory T cells that can rapidly respond upon re-exposure to the same antigen. [7]

APCs interact with T cells to elicit a specific and enduring immune response. This immune response is thought to be critical to controlling cancer.

Characteristics of an Effective Immune Response
There are several key characteristics or features of an effective immune response that result in the ability of the body to protect against foreign antigens. These key characteristics or features include target specificity, trafficking, adaptability, and durability (memory). [7,16,17] The most important characteristic of an effective immune response may be target specificity, which ensures that the immune response is targeted toward specific antigens. An example of immune response target specificity is demonstrated in the autoimmune disease, type 1 diabetes mellitus. In this disease, specific T cells recognize and destroy insulin-producing beta cells in the pancreatic islets of Langerhans, while sparing other islet sub-types. Target specificity prevents off-target effects to other cell types. [18]

Key characteristics or features of an effective immune response include target specificity, trafficking, adaptability, and durability (memory).

Figure 4. Initiation of Immune Response: Key Components [7]
fig-4

The second characteristic of an effective immune response is trafficking, which refers to the ability of activated immune cells to migrate to particular antigens throughout the entire body. [7,17,19] As an example, upon infusion into a rodent model, naive T cells were detected exclusively in secondary lymphoid tissues, such as the spleen and lymph nodes, where they normally circulate scanning for antigen presentation by APCs. [7,19] Following exposure to the target antigen (ovalbumin), T cells proliferated and the activated T cells migrated to the organs where the target antigen was localized, including the lungs, liver, intestines, and salivary glands. [19]

The third characteristic of an effective immune response is target adaptability. Adaptability allows for an expanded immune response beyond the initially targeted antigen through processes called epitope and antigen spreading. Epitope spreading occurs when immune cells are able to generate an immune response to other epitopes or regions of the target antigen, whereas antigen spreading occurs when immune cells are able to generate an immune response to related antigens originating from the same cell. [7,20] As shown below, injection with a single peptide (corresponding to amino acids 611-626 of target antigen) elicits T-cell responses not only against the original peptide but also against 6 peptides in different regions of the same target antigen, reflecting the adaptability of the immune response. [21]

fig-5

The fourth characteristic of an effective immune response is durability or memory, the ability of T cells to recognize antigens over time.[7] Immunologic memory allows for an expedited and durable immune response upon re-exposure to antigens. [7]

As shown in the picture below, a smallpox-specific T-cell response remained detectable for many years after a single vaccination. [22] Detectable immune responses were seen in 89% of patients who had been vaccinated 31 to 50 years earlier and in 52% of those vaccinated 51 to 75 years earlier. These native immune functions are thought to apply to protection of the body against cancer. [7]

fig-6

Key Learnings
• APCs are the initiators of T-cell driven immune responses. An effective immune response includes the key characteristics or features of target specificity, trafficking, adaptability, and durability (memory).

The Rise of Immunotherapy
For more than a century, advancements in cancer immunotherapy have spread across several phases.[23-27] In 1890, Coley developed the first cancer vaccine (based on bacterial toxins), which was shown to have benefit in patients with inoperable cancer. Driven by findings from Coley and others, numerous researchers including 2 time Nobel Laureate Linus Pauling demonstrated significant survival benefits using immune system boosting supplementation. Interests soared in cancer immunotherapy following his discoveries. Subsequently, in 2000 there was a further increase of interest in cancer immunotherapy as a viable treatment option due to the successes and sensation of the Boston-C treatment protocols. This initiated a number of clinical studies and significant researches that have demonstrated at least 16 components that have been identified that enhance, based on their immune modulator activity, the Natural Killer Cell. [28]

Immunotherapy Approach
The National Cancer Institute defines immunotherapy as “treatment to boost or restore the ability of the immune system to fight cancer, infections, and other diseases.” [29]

Dynamics of Immunotherapy
Immunotherapy may have the potential to continuously refine its effect on mutating cancer cells through the dynamic interplay between cancer and the immune system.[36] As the immune system targets and lyses ever-mutating cancer cells, additional tumor antigens are able to be taken up by APCs, potentially activating a broader immune response.[36] In the hypothetical example shown in Figure 8, activated T cells that target a prostatic tumor attack and lyse tumor cells. This releases other tumor-associated antigens (such as prostate-specific membrane antigen [PSMA] or mucin-1 [MUC-1]), which may be taken up by APCs to subsequently activate additional T cells specific for those antigens. [36] This dynamic process between the immune system and cancer contributes to the different kinetics of response that immunotherapy has compared with traditional cancer therapy (ie, chemotherapy). [36]

Kinetics of Response to Immunotherapy
Immunotherapy is associated with a durable response that differs from the transient response of traditional cytotoxic chemotherapy.[32,34,35,36,37] As an example, in metastatic castrate-resistant prostate cancer (mCRPC), cytotoxic chemotherapy can dramatically affect tumor growth rates just during the active course of treatment. However, the tumor growth rate returns to its pretreatment value once chemotherapy is discontinued, reflecting the underlying tumor characteristics and the transient effect of traditional chemotherapy.[37] Often following cytotoxic chemotherapy, the tumor growth rates are greatly accelerated. In contrast, immunotherapy can induce immunologic memory as well as change and even boost the immune status of the patient, even after the course of immunotherapy has been completed. Because it can take several weeks to elicit a significant immune response, immunotherapy may not necessarily cause a dramatic or immediate reduction in tumor burden or tumor-specific markers right away. However, it has been shown to ultimately prolong overall survival (OS). [32,34,35] There are also numerous instances where extremely rapid disappearances of tumors have been seen.

The differing immunotherapy response kinetics infer that biomarkers used to monitor the effects of traditional therapies may not always be appropriate. For example, prostate-specific antigen (PSA) is routinely used to monitor the effects of hormonal therapy in patients with prostate cancer. However, agents that slow tumor growth may not necessarily cause PSA reductions, and consequently changes in PSA levels may be difficult to interpret with immunotherapy. [38] The Prostate Cancer Clinical Trials Working Group recommends expanding the focus from rising PSA levels to evaluating additional measures of disease progression (eg, bone lesions, substantive pain, soft tissue lesions) to make decisions about when to stop a given therapy in advanced prostate cancer. [38]

Immunotherapy Treatment Considerations
Based on the noted duration of response compared to traditional cytotoxic chemotherapy, it has been suggested that the relative efficacy of immunotherapy may be greater with a smaller tumor burden,[17] This also suggests that improved treatment responses and outcomes may be expected at earlier stages of disease.[17,23] We suggest that Immunotherapy is superior in virtually every regard to chemotherapy, and anyone whose opinion differs in this regard, must surely have a financial interest in the administration of chemotherapeutic agents, or is grossly misinformed with current science.

Key Learnings
• Immunotherapy demonstrates a proven ability to prolong overall survival (OS) versus chemotherapy. Because immunotherapy has a different mechanistic approach than traditional agents, immunotherapy offers superior, durable results compared to other therapies.

SUMMARY
The immune system has a critical role in controlling cancer. 15 Key features of an effective immune response include specificity (which ensures an antigen-targeted response), trafficking (which enables antigen targeting throughout the body), adaptability (which allows for a response against related antigens), and durability (which allows for an expedited and long-lasting response upon re-exposure to the antigen).[7,18,19,22,36] Over time, cancer cells develop mechanisms to escape control by the immune system, leading to progression of disease.[2] Immunotherapy is designed to boost and restore the ability of the immune system to fight cancer.[29] It has led to increased overall survival (OS) in certain cancers.[32,34,35] Future use and clinical trials should take into consideration that immunotherapies may elicit a better immune system response if used while the patient is still immunocompetent.[39,40] In addition, immunotherapy can offer the potential for durable clinical effects and synergy with subsequent therapies. [30,31,33,41]

REFERENCES

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2. Hanahan D, Weinberg RA. Cell. 2011;144(5):646-674.
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4. Le Mire L, Hollowood K, Gray D, Bordea C, Wojnarowska F. Br J Dermatol. 2006;154(3):472-477.
5. Herrero JI. Liver Transpl. 2009;15(suppl 2):S90-S94.
6. Krynitz B, Edgren G, Lindelöf B, et al. Int J Cancer. 2013;132(6):1429-1438.
7. Abbas AK, Lichtman AH. Basic Immunology: Functions and Disorders of the Immune System. 3rd ed. Philadelphia, PA: Saunders Elsevier; 2011.
8. Burgi A, Brodine S, Wegner S, et al. Cancer. 2005;104(7):1505-1511.
9. Guiguet M, Boué F, Cadranel J, Lang JM, Rosenthal E, Costagliola D; Clinical Epidemiology Group of the FHDH-ANRS CO4 cohort. Lancet Oncol. 2009;10(12):1152-1159.
10. Petoumenos K, van Leuwen M, Vajdic C, et al; The Australian HIV Observational Database. HIV Med. 2013;14(2):77-84.
11. Wolfe F, Michaud K. Arthritis Rheum. 2007;56(9):2886-2895.
12. Zhang L, Conejo-Garcia JR, Katsaros D, et al. N Engl J Med. 2003;348(3):203-213.
13. Galon G, Costes A, Sanchez-Cabo F, et al. Science. 2006;313(5795):1960-1964.
14. Jochems C, Schlom J. Exp Biol Med (Maywood). 2011;236(5):567-579.
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16. Pardoll DM. Nat Rev Cancer. 2012;12(4):252-264.
17. Drake CG. Nat Rev Immunol. 2010;10(8):580-593.
18. Murphy K. Janeway’s Immunobiology. 8th ed. New York, NY: Garland Science, Taylor & Francis Group, LLC; 2012.
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20. Nesslinger NJ, Ng A, Tsang KY, et al. Clin Cancer Res. 2010;16(15):4046-4056.
21. Inderberg-Suso EM, Trachsel S, Lislerud K, Rasmussen AM, Gaudernack G. Oncoimmunology. 2012;1(5):670-686.
22. Hammarlund E, Lewis MW, Hansen SG, et al. Nat Med. 2003;9(9):1131-1137.
23. Kirkwood JM, Butterfield LH, Tarhini AA, et al. CA Cancer J Clin. 2012;62(5):309-335.
24. Lesterhuis WJ, Haanen JB, Punt CJ. Nat Rev Drug Disc. 2011;10(8):591-600.
25. Krummel MF, Allison JP. J Exp Med. 1995;182(2):459-465.
26. DeVita VT Jr, Lawrence TS, Rosenberg SA, et al, eds. Cancer: Principles & Practice of Oncology. 9th ed. Philadelphia, PA: LWW; 2011.
27. Leget GA, Czuczman MS. Curr Opin Oncol. 1998;10(6):548-551.
28. J.T. Thornthwaite et al. Journal of Immune Based Therapies, Vaccines and Antimicrobials, 2012, 1, 21-52
29. National Cancer Institute. NCI dictionary of cancer terms: immunotherapy. http://www.cancer.gov/ dictionary?print=1&cdrid=45729. Accessed March 14, 2013.
30. Slamon DJ, Leyland-Jones B, Shak S, et al. N Engl J Med. 2001;344(11):783-792.
31. Vermorken JB, Mesia R, Rivera F, et al. N Engl J Med. 2008;359(11):1116-1127.
32. Hodi FS, O’Day SJ, McDermott DF, et al. N Engl J Med. 2010;363(8):711-723.
33. Robert C, Thomas L, Bondarenko I, et al. N Engl J Med. 2011;364(26):2517-2526.
34. Kantoff PW, Higano CS, Shore ND, et al. N Engl J Med. 2010;363(5):411-422.
35. Kantoff PW, Schuetz TJ, Blumenstein BA, et al. J Clin Oncol. 2010;28(7):1099-1105.
36. Gulley JL. Hum Vaccin Immunother. 2013;9(1):219-221.
37. Stein WD, Gulley JL, Schlom J, et al. Clin Cancer Res. 2011;17(4):907-917.
38. Scher HI, Halabi S, Tannock I, et al; Prostate Cancer Clinical Trials Working Group. J Clin Oncol. 2008;26(7):1148-1159.
39. Gulley JL, Drake CG. Clin Cancer Res. 2011;17(12):3884-3891.
40. Schlom J, Arlen PM, Gulley JL. Clin Cancer Res. 2007;13(13):3776-3782.
41. Mercader M, Bodner BK, Moser MT, et al. Proc Natl Acad Sci U S A. 2001;98(25):14565-14570.

CURRENT UNDERSTANDING AND APPROACHES TO CANCER IMMUNOTHERAPY

Immunotherapy – The basics (2:32)

Immunotherapy Cancer a guide for patients (3:26)

Immunotherapy is Tumor-Specific (2:03)

Immunotherapy is Designed to Support Immune System Adaptability (2:42)

Immunotherapy Empowers a Durable Immune Response (2:19)


immunotherapy_fights_cancer_720pImmunotherapy – The basics (2:32)

patient-immunotherapyImmunotherapy Cancer a guide for patients (3:26)

immunotherapy_empowers_a_durable_immune_response_720pImmunotherapy Empowers a Durable Immune Response (2:19)

immunotherapy_is_tumor-specific_720pImmunotherapy is Tumor-Specific (2:03)

immunotherapy_is_designed_to_support_immune_system_720pImmunotherapy is Adaptable (2:42)

immunotherapy-creates-cancer-killing-ninjasImmunotherapy Creates Cancer Killing Ninjas (1:28)

immunotherapy-is-now-promoted-by-uclaImmunotherapy is now promoted by UCLA (3:12)

immunotherapy-now-promoted-by-johns-hopkinsImmunotherapy Now Promoted By Johns Hopkins (3:59)

immunotherapy-is-now-promoted-by-mskccImmunotherapy is now promoted by MSKCC (1:19)

university-of-kansas-now-promotes-immunotherapyUniversity of Kansas now promotes Immunotherapy

immunotherapy-awareness-monthImmunotherapy Awareness Month (0:46)

immunotherapy-fox-newsImmunotherapy Fox News

the-today-show-is-promoting-immunotherapyThe TODAY show is promoting Immunotherapy

immunotherapy-on-nbc-newsImmunotherapy on NBC News

the-importance-of-immunomodulationThe importance of Immunomodulation

real-video-natural-killer-t-cellNatural killer T cell (0:54)

real-video-killer-t-cell_the-cancer-assassinKiller T Cell The Cancer Assassin (1:58)

immunotherapy-our-immune-system-immune-response-high-qualityOur Immune System Inflammatory Response (4:45)

real-video-natural-killer-cell-01Natural Killer Cell 01 (0:25)

real-video-natural-killer-cell-attacking-a-tumor-cellNatural Killer Cell Attacking a Tumor Cell (0:47)

real-video-nk-cells-killing-cancer-cellsNK cells killing cancer cells (0:20)

real-video-killer-t-cell-destroying-cancerKiller T-cell Destroying Cancer (1:10)

immunotherapy-animated-explanationImmunotherapy Animated Explanation (3:02)

real-video-cytotoxic-t-cells-killing-cervical-cancer-cellsCytotoxic cells killing cervical cancer cells (0:32)

immunotherapy-how-the-immune-system-sees-and-destroys-tumorsImmune system see’s and destroy tumors (28:35)

immunology-in-the-gut-mucosaImmunology Gut Mucosa (5:56)

immunotherapy_commercialImmunotherapy Commercial (0:57)

terminatorTerminator NK Cells (0:51)

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This site may contain certain historical information. Historical information, necessarily, is not current and is provided for your reference only. We reserve the right to modify the contents of this site at any time, but we have no obligation to update any information on our site. You agree that it is your responsibility to monitor changes to our site.

 

SECTION 4 – MODIFICATIONS TO THE SERVICE

We reserve the right at any time to modify or discontinue the Service (or any part or content thereof) without notice at any time.

We shall not be liable to you or to any third-party for any modification, change, suspension or discontinuance of the Service.

 

SECTION 5 – OPTIONAL TOOLS

Any use by you of optional tools offered through the site is entirely at your own risk and discretion and you should ensure that you are familiar with and approve of the terms on which tools are provided by the relevant third-party provider(s).

We may also, in the future, offer new services and/or features through the website (including, the release of new tools and resources). Such new features and/or services shall also be subject to these Terms of Use.

 

SECTION 6 – THIRD-PARTY LINKS

Certain content, products and services available via our Service may include materials from third-parties.

Third-party links on this site may direct you to third-party websites that are not affiliated with us. We are not responsible for examining or evaluating the content or accuracy and we do not warrant and will not have any liability or responsibility for any third-party materials or websites, or for any other materials, products, or services of third-parties.

We are not liable for any harm or damages related to the purchase or use of goods, services, resources, content, or any other transactions made in connection with any third-party websites. Please review carefully the third-party’s policies and practices and make sure you understand them before you engage in any transaction. Complaints, claims, concerns, or questions regarding third-party products should be directed to the third-party.

 

SECTION 7 – USER COMMENTS, FEEDBACK AND OTHER SUBMISSIONS

If, at our request, you send certain specific submissions (for example contest entries) or without a request from us you send creative ideas, suggestions, proposals, plans, or other materials, whether online, by email, by postal mail, or otherwise (collectively, ‘comments’), you agree that we may, at any time, without restriction, edit, copy, publish, distribute, translate and otherwise use in any medium any comments that you forward to us. We are and shall be under no obligation (1) to maintain any comments in confidence; (2) to pay compensation for any comments; or (3) to respond to any comments.

We may, but have no obligation to, monitor, edit or remove content that we determine in our sole discretion are unlawful, offensive, threatening, libelous, defamatory, pornographic, obscene or otherwise objectionable or violates any party’s intellectual property or these Terms of Use.

You agree that your comments will not violate any right of any third-party, including copyright, trademark, privacy, personality or other personal or proprietary right. You further agree that your comments will not contain libelous or otherwise unlawful, abusive or obscene material, or contain any computer virus or other malware that could in any way affect the operation of the Service or any related website. You may not use a false e-mail address, pretend to be someone other than yourself, or otherwise mislead us or third-parties as to the origin of any comments. You are solely responsible for any comments you make and their accuracy. We take no responsibility and assume no liability for any comments posted by you or any third-party.

 

SECTION 8 – ERRORS, INACCURACIES AND OMISSIONS

Occasionally there may be information on our site or in the Service that contains typographical errors, inaccuracies or omissions that may relate to product descriptions, pricing, promotions, offers, product shipping charges, transit times and availability. We reserve the right to correct any errors, inaccuracies or omissions, and to change or update information or cancel orders if any information in the Service or on any related website is inaccurate at any time without prior notice (including after you have submitted your order).

We undertake no obligation to update, amend or clarify information in the Service or on any related website, including without limitation, pricing information, except as required by law. No specified update or refresh date applied in the Service or on any related website, should be taken to indicate that all information in the Service or on any related website has been modified or updated.

 

SECTION 9 – PROHIBITED USES

In addition to other prohibitions as set forth in the Terms of Use, you are prohibited from using the site or its content: (a) for any unlawful purpose; (b) to solicit others to perform or participate in any unlawful acts; (c) to violate any international, federal, provincial or state regulations, rules, laws, or local ordinances; (d) to infringe upon or violate our intellectual property rights or the intellectual property rights of others; (e) to harass, abuse, insult, harm, defame, slander, disparage, intimidate, or discriminate based on gender, sexual orientation, religion, ethnicity, race, age, national origin, or disability; (f) to submit false or misleading information; (g) to upload or transmit viruses or any other type of malicious code that will or may be used in any way that will affect the functionality or operation of the Service or of any related website, other websites, or the Internet; (h) to collect or track the personal information of others; (i) to spam, phish, pharm, pretext, spider, crawl, or scrape; (j) for any obscene or immoral purpose; or (k) to interfere with or circumvent the security features of the Service or any related website, other websites, or the Internet. We reserve the right to terminate your use of the Service or any related website for violating any of the prohibited uses.

 

SECTION 10 – DISCLAIMER OF WARRANTIES; LIMITATION OF LIABILITY

We do not guarantee, represent or warrant that your use of our service will be uninterrupted, timely, secure or error-free.

We do not warrant that the results that may be obtained from the use of the service will be accurate or reliable.

You agree that from time to time we may remove the service for indefinite periods of time or cancel the service at any time, without notice to you.

You expressly agree that your use of, or inability to use, the service is at your sole risk. The service and all products and services delivered to you through the service are (except as expressly stated by us) provided ‘as is’ and ‘as available’ for your use, without any representation, warranties or conditions of any kind, either express or implied, including all implied warranties or conditions of merchantability, merchantable quality, fitness for a particular purpose, durability, title, and non-infringement.

In no case shall anyone affiliated with drfarrahcancercenter.com including our directors, officers, employees, affiliates, agents, contractors, interns, suppliers, service providers or licensors be liable for any injury, loss, claim, or any direct, indirect, incidental, punitive, special, or consequential damages of any kind, including, without limitation lost profits, lost revenue, lost savings, loss of data, replacement costs, or any similar damages, whether based in contract, tort (including negligence), strict liability or otherwise, arising from your use of any of the service or any products procured using the service, or for any other claim related in any way to your use of the service or any product, including, but not limited to, any errors or omissions in any content, or any loss or damage of any kind incurred as a result of the use of the service or any content (or product) posted, transmitted, or otherwise made available via the service, even if advised of their possibility. Because some states or jurisdictions do not allow the exclusion or the limitation of liability for consequential or incidental damages, in such states or jurisdictions, our liability shall be limited to the maximum extent permitted by law.

You understand and agree that no singular individual, group of individuals or entity in any form whatsoever is responsible or liable in any manner for any content generated on, for, or as a result of the existence of this site, since this is a community generated site. You understand and agree that as this is a community generated site, and as a result of this, there is no good way to control what users and contributors post on or through the sites and drfarrahcancercenter.com cannot be responsible for any offensive, inappropriate, obscene, unlawful, infringing or otherwise objectionable or even illegal user generated content you may encounter on the sites or, in connection with your use of the sites.

You understand and agree with the following statement made on behalf of drfarrahcancercenter.com, “We, on behalf of our directors, officers, employees, agents, suppliers, licensors, contributors and service providers, exclude and disclaim liability for any losses and expenses of whatever nature and howsoever arising including, without limitation, any direct, indirect, general, special, punitive, incidental or consequential damages; loss of use: loss of data; loss caused by a virus: loss of income or profit: loss of or damage to property: loss of life: claims of third parties: or other losses of any kind or character, or the inability to use, the site or the content even if we have been advised of the possibility of such damages or losses, arising out of or in connection with the use of this site or any web site with which it is linked.”

 

SECTION 11 – INDEMNIFICATION

You agree to indemnify, defend and hold harmless drfarrahcancercenter.com and our parent, subsidiaries, affiliates, partners, officers, directors, agents, contractors, licensors, service providers, subcontractors, suppliers, interns and employees, harmless from any claim or demand, including reasonable attorneys’ fees, made by any third-party due to or arising out of your breach of these Terms of Use or the documents they incorporate by reference, or your violation of any law or the rights of a third-party.

 

SECTION 12 – SEVERABILITY

In the event that any provision of these Terms of Use is determined to be unlawful, void or unenforceable, such provision shall nonetheless be enforceable to the fullest extent permitted by applicable law, and the unenforceable portion shall be deemed to be severed from these Terms of Use, such determination shall not affect the validity and enforceability of any other remaining provisions.

 

SECTION 13 – TERMINATION

The obligations and liabilities of the parties incurred prior to the termination date shall survive the termination of this agreement for all purposes.

These Terms of Use are effective unless and until terminated by us. You may terminate use of the drfarrahcancercenter.com site, but this Terms of Use shall survive in perpetuity.

If in our sole judgment you fail, or we suspect that you have failed, to comply with any term or provision of these Terms of Use, we also may terminate this agreement at any time without notice and you will remain liable for all amounts due up to and including the date of termination; and/or accordingly may deny you access to our Services (or any part thereof).

 

SECTION 14 – ENTIRE AGREEMENT

The failure of us to exercise or enforce any right or provision of these Terms of Use shall not constitute a waiver of such right or provision.

These Terms of Use and any policies or operating rules posted by us on this site or in respect to The Service constitutes the entire agreement and understanding between you and us and govern your use of the Service, superseding any prior or contemporaneous agreements, communications and proposals, whether oral or written, between you and us (including, but not limited to, any prior versions of the Terms of Use).

Any ambiguities in the interpretation of these Terms of Use shall not be construed against the drafting party.

 

SECTION 15 – GOVERNING LAW

These Terms of Use and any separate agreements whereby we provide you Services shall be governed by and construed in accordance with the laws of the Republic of Panama.

 

SECTION 16 – CHANGES TO TERMS OF USE

You can review the most current version of the Terms of Use at any time at this page.

We reserve the right, at our sole discretion, to update, change or replace any part of these Terms of Use by posting updates and changes to our website. It is your responsibility to check our website periodically for changes. Your continued use of or access to our website or the Service following the posting of any changes to these Terms of Use constitutes acceptance of those changes.

 

SECTION 17 – CONTACT INFORMATION

Questions about the Terms of Use should be sent to us at staff@drfarrahcancercenter.com

Upon agreeing to these terms and conditions, you gain access to the drfarrahcancercenter.com website and assume total responsibility for any and all actions undertaken by you as a result of your access to the drfarrahcancercenter.com website. You agree and understand that the terms of this agreement shall be binding upon you, your respective heirs, successors, assigns and legal representatives. You understand and agree that all provisions of this Terms of Use agreement that by their nature should survive termination shall survive termination, including, without limitation, ownership provisions, warranty disclaimers, indemnity, licensing in perpetuity and limitations of liability.