Often, resistance to drugs is an obstacle to a successful treatment of cancer. In spite of the importance of the problem, the actual mechanisms that control the evolution of drug resistance are not fully understood. Many attempts to study drug resistance have been made in the mathematical modeling literature. Clearly, in order to understand drug resistance, it is imperative to have a good model of the underlying dynamics of cancer cells. One of the main ingredients that has been recently introduced into the rapidly growing pool of mathematical cancer models is stem cells. Surprisingly, this all-so-important subset of cells has not been fully integrated into existing mathematical models of drug resistance. In this work we incorporate the various possible ways in which a stem cell may divide into the study of drug resistance. We derive a previously undescribed estimate of the probability of developing drug resistance by the time a tumor is detected and calculate the expected number of resistant cancer stem cells at the time of tumor detection. To demonstrate the significance of this approach, we combine our previously undescribed mathematical estimates with clinical data that are taken from a recent six-year follow-up of patients receiving imatinib for the first-line treatment of chronic myelogenous leukemia. Based on our analysis we conclude that leukemia stem cells must tend to renew symmetrically as opposed to their healthy counterparts that predominantly divide asymmetrically.branching processes | symmetric renewal | cancer stem cells D rug resistance is a fundamental problem in the treatment of cancer, strongly limiting the effects of the drugs used in therapy, and therefore considerably reducing the probability of treatment success and survival of the patient. There are multiple mechanisms by which drug resistance may develop. It appears to be both a stochastic phenomenon caused by random genetic mutations, as well as a drug-induced one (in which using the drug increases the chances of developing resistance to it). There is clear experimental evidence that at least in the case of certain drugs, known as "mutagenic drugs," the drug can induce resistance to itself (see refs. 1 and 2).In this work we focus on genetic mutations, mutations that are genetic changes that occur during cell division. The best example is that of "point mutations," i.e., mutations that cause the replacement of a single base nucleotide or pair, with another nucleotide or pair in the DNA or RNA. Such an event may modify the cellular phenotype, making any of its daughter cells resistant to the drug. Other examples of genetic mutations are frameshift and missense mutations.The cause for genetic mutations is not completely clear. Is it a mainly random phenomenon, or rather a drug-induced, directed one, perhaps both? Such a fundamental question has been the focus of the Nobel Prize winning work of Luria and Delbrück (3). Using fluctuation analysis, Luria and Delbrück showed that drug resistance in in vitro bacterial cultures seems to have an...