NDV is a paramyxovirus that causes Newcastle disease in a wide variety of birds (most notably, in chickens). Reviewed in [1-3] This often fatal disease is characterized by inflammation of respiratory tract and of either the brain or the gastrointestinal tract. Reviewed in [1,2,4,5] NDV can also infect humans, but, in humans, it is generally not very virulent, causing only mild flu-like symptoms or conjunctivitis and/or laryngitis. Reviewed in [1,6-14] The perception that NDV can replicate up to 10,000 times better in human cancer cells than in most normal human cells [12,15-19] Reviewed in [2,6-10,13,20-23] has prompted much interest in this virus as a potential anticancer agent. This phenomenon is apparently caused by defects in intracellular antiviral defenses of some cancer cells.[24-26] NDV was historically considered a CAM approach, but in recent years it has been extensively studied by the conventional medical community. Also, genetically engineered NDV strains are being developed and studied for their anticancer activity.
The genetic material of NDV is RNA rather than DNA. Reviewed in [1,3,13,18,23,28-31] As with other types of viruses, essentially all of NDV’s replication cycle takes place inside infected cells, which are also known as host cells. Reviewed in [13,18,30,32] During a replication cycle, new virus proteins and copies of the NDV genetic material (i.e., genome) are made in the host cell’s cytoplasm. NDV is also an enveloped virus, which means that progeny virus particles are released from infected cells by budding off from them. Reviewed in [18,30,33] In this process, single copies of the NDV genome become wrapped in an outer coat (i.e., an envelope) that is made from a small piece of the host cell’s plasma membrane. Generally, the NDV outer coat contains only virus proteins that have been specifically inserted into the host cell's plasma membrane; Reviewed in [18,28,32,33] however, some host cell proteins may be included as well. Reviewed in [34,35] Two specific virus proteins, hemagglutinin-neuraminidase and the fusion protein, are the main NDV proteins found in the outer coat of isolated virus particles. Reviewed in [3,18,28,30]
There are many different strains of NDV, and they have been classified as either lytic or nonlytic for human cells. Lytic strains and nonlytic strains both appear to replicate much more efficiently in human cancer cells than they do in most normal human cells,[12,15-20] Reviewed in [13,36] and viruses of both strain types have been investigated as potential anticancer agents. One major difference between lytic strains and nonlytic strains is that lytic strains are able to make infectious progeny virus particles in human cells, whereas nonlytic strains are not. Reviewed in [13,18,28-30,37] This difference is due to the ability of lytic strains to produce activated hemagglutinin-neuraminidase and fusion protein molecules in the outer coat of progeny viruses in human cells. The progeny virus particles made by nonlytic strains contain inactive versions of these molecules. Activated hemagglutinin-neuraminidase and fusion protein molecules are required for NDV to enter a cell to replicate. Initial binding of NDV to a host cell takes place through the interaction of hemagglutinin-neuraminidase molecules in the virus coat with sialic-acid –containing molecules (i.e., gangliosides) on the surface of the cell. It is important to note, however, that nonlytic strains of NDV can make infectious progeny viruses in some types of nonhuman cells (e.g., chicken embryo cells), Reviewed in [13,18,28,29,36] thereby allowing these strains to be maintained.
Another major difference between lytic strains and nonlytic strains is that, although they both have the potential to kill infected cells, the mechanisms by which they accomplish this result are different. The production of infectious progeny virus particles by lytic strains gives them the ability to kill host cells fairly quickly. The budding of progeny viruses that contain activated hemagglutinin-neuraminidase and fusion protein molecules in their outer coats causes the plasma membrane of NDV-infected cells to fuse with the plasma membrane of adjacent cells, leading to the production of large, inviable fused cells known as syncytia. Reviewed in [13,18,30] The more efficiently a lytic strain can replicate inside a host cell, the more quickly it can kill that cell. The preferential killing of cancer cells by a lytic virus is known as oncolysis; thus, lytic strains of NDV are also called oncolytic strains. Nonlytic strains of NDV kill infected cells more slowly, with death apparently the result of viral disruption of normal host cell metabolism. Reviewed in 
The specific mechanism by which nonlytic NDV strains cause cell death in cancer cells has not been completely elucidated, but in Vero cells (derived from kidney epithelium) it was determined that NDV caused cell death by decreasing DNA content, increasing the ratio of Bax to Bcl-2, increasing p53 level, and increasing caspase expression, resulting in apoptosis.[39-41]
As indicated previously, both lytic strains and nonlytic strains have been investigated for their anticancer potential. In fact, the major differences between the two strain types have been exploited to develop three different approaches to cancer therapy:
- The infection of cancer patients with a lytic strain of NDV.
- The use of oncolysates, i.e., preparations containing plasma membrane fragments from NDV-infected cancer calls, as anticancer vaccines.
- The use of intact cancer cells infected with a nonlytic strain of NDV as whole cell vaccines.
One proposed advantage of the first approach is that virus replication may allow the spread of cytotoxic viruses to every cancer cell in the body; Reviewed in [8,34] however, the production of virus-neutralizing antibodies by the immune system might limit this possibility. Reviewed in [6,8,13,30,40] The rationale for the second and third approaches is that tumor-specific antigens (i.e., proteins or other molecules that are generally located in the plasma membrane of cancer cells and that are either unique to cancer cells or much more abundant in them) may be better recognized by the immune system if they are associated with virus antigens (i.e., virus proteins that have been inserted into the plasma membrane of host cells). Reviewed in [8,12,13,28,32,34,42-48] If this enhanced recognition takes place, then it may increase the chance that cancer cells, whether they are virus infected or not, will be recognized as foreign by the immune system and be destroyed. Reviewed in [8,12,28,47,48]
The principal developers of the third approach have stated that whole cell vaccines can stimulate the immune system better than oncolysates, Reviewed in [18,28,29,37,38,43,46,49-51] and that cells infected with a nonlytic strain of NDV will remain intact in the body long enough to generate these more effective immune responses. Reviewed in  It should be noted that the cancer cells used in the third approach are treated with enough gamma radiation to prevent further cell division, but not enough to cause cell death, either before or after they are infected with the nonlytic virus.[49,50,52-58] Reviewed in  This precaution ensures that patients are not given a vaccine that contains actively proliferating cancer cells.
Either a patient’s own cancer cells (i.e., autologous cells) or cells from another patient with the same type of cancer (i.e., allogeneic cells) can be used to make oncolysates and whole cell vaccines. It is important to note that immune system responses similar to those obtained with oncolysates and whole cell vaccines may occur in patients infected with a lytic strain of NDV and that these responses would be expected to contribute to any observed anticancer effect.
To conduct human studies with viruses, vaccines, or other biological materials in the United States, researchers must file an Investigational New Drug (IND) application with the U.S. Food and Drug Administration (FDA). Biological materials and drugs have been held to similar safety and effectiveness standards since 1972. In an IND application, researchers must provide safety and toxicity data from laboratory and animal studies to justify the dose, the route, and the schedule of administration to be used in the proposed clinical studies. Among the safety issues to be addressed, researchers must demonstrate an absence of harmful contaminants. Most human studies of NDV as an anticancer agent have taken place outside the United States; therefore, they have not required an IND. At present, at least one group of U.S. investigators has filed an IND application to study NDV as an anticancer treatment. It should be noted that the FDA has not approved the use of NDV to treat any medical condition.
The NDV strains that have been evaluated most widely for the treatment of cancer are 73-T, MTH-68, and Ulster.[1,6,11,42,45,49,50,52-58,60-73] Reviewed in [22,51,74] Strain 73-T is lytic, and Ulster is nonlytic. Strain MTH-68 has not been classified, but it is assumed to be lytic.[1,6,66,75] Reviewed in [22,76,77] All three strains have shown little or no evidence of neurotropism (i.e., an ability to replicate efficiently in normal nerve cells or normal neural tissue).
In animal studies, NDV infection has been accomplished by intratumoral,[9,10,12,23,28] Reviewed in  intraperitoneal,[23,28,78] Reviewed in  intravenous, intramuscular, or subcutaneous  injection. NDV-infected, whole cell vaccines have been given to animals by intraperitoneal, intradermal, Reviewed in  or subcutaneous injection, Reviewed in  or by a combination of subcutaneous and intramuscular injection.[43,79]
In human studies, NDV oncolysates have been administered by subcutaneous [11,42,45,60,63,65,67-70] or intradermal [62,64] injection. NDV-infected, whole cell vaccines have been administered by intradermal injection only.[49,50,52-58,71-73] In cases where patients have been infected with a lytic strain of NDV, intratumoral, intravenous,[1,59,66,80] or intramuscular  injection has been used, as have inhalation [1,6] and direct injection into the colon (i.e., via a colostomy opening). In some instances, cytokine treatment has been combined with NDV therapy.[45,52,53,56,62,64,65,70]Table 1. Strains of NDV Tested in Human/Clinical Cancer Studiesa
|NDV Strain||Strain Type||Formulation||Suggested Mechanism(s) of Action||Reference Citation(s)|
|73-T||Lytic||Infectious virus||Cancer cells killed by virus; stimulation of immune system|||
|73-T||Lytic||Oncolysate vaccineb||Stimulation of immune system||[11,42,45,60,63,65,67-70]|
|Ulster||Nonlytic||Infected tumor-cell vaccine||Stimulation of immune system||[49,50,52-58,71-73]|
|MTH-68||Lytic||Infectious virus||Cancer cells killed by virus; stimulation of immune system||[1,6,61,66]|
|Italien||Lytic||Oncolysate vaccine/infectious virus||Stimulation of immune system; cancer cells killed by virus||[62,64]|
|Hickman||Lytic||Infectious virus||Cancer cells killed by virus; stimulation of immune system|||
|PV701||Lytic||Infectious virus||Cancer cells killed by virus; stimulation of immune system|||
|HUJ||Lytic||Infectious virus||Cancer cells killed by virus; stimulation of immune system|||
|La Sota||Not specified||Infected tumor cell vaccine||Not specified|||
|aRefer to text and the NCI Dictionary of Cancer Terms for additional information and definition of terms.|
|bOncolysates are prepared from virus-infected cancer cells; they consist primarily of cell membrane fragments and contain virus proteins and cancer cell proteins.|
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