The next category of biomarkers, which reflects subsequent events in the multi-step sequence of carcinogenesis, includes markers of early biologic effects resulting from exposure. Like the preceding categories of markers, these effects can be measured directly in target tissues or in a surrogate source of cells, such as peripheral white blood cells. Most of the available biomarkers assess various types of genotoxicity, including chromosomal aberrations, small deletions [loss of heterozygosity LOH ], and point mutations. The powerful PCR method and variations thereof have greatly facilitated the analysis of somatic mutations in molecular epidemiologic studies It is now possible to detect such mutations in tissues of exposed individuals at a very early stage in the carcinogenic process; that is, even before cells carrying mutated genes have undergone clonal expansion.
Characteristic patterns of mutations in tumors have provided valuable, albeit circumstantial, molecular evidence of the importance of specific environmental carcinogens. For example, because mutations of the p53 tumor suppressor gene and the ras oncogene are common events in human cancer, they can be useful reporters of carcinogenic events involved in the development of cancer. In a number of cases, the patterns of p53 and ras mutations in human tumors have been consistent with the types of DNA adducts implicated in their causation and with the types of mutations induced experimentally by the specific environmental carcinogens under investigation 38 , Thus, the mutation profile or spectrum found in certain genes may, in some instances, serve as a fingerprint of the causative agent.
LOH can be considered a biomarker of biologic effect that may be useful in identifying individuals who do not yet have cancer but are at high risk. Other types of biomarkers may be indicative of the dose and effects of agents that enhance the carcinogenic process without forming covalent adducts with cellular DNA or proteins, and without directly inducing gene mutations.
They include certain tumor promoters O -tetradecanoylphorbolacetate and phenobarbitol , xenobiotics such as 2,3,7,8-terachlorodibenzo- p -dioxin, PCBs and various pesticides and natural and synthetic estrogens and androgens. Assays for the biologic effects of these agents are only now being developed, and include occupancy of specific high affinity receptors that mediate the action of these compounds, levels of specific mediators growth factors, growth factor receptors, second messengers like cAMP and diacylglycerol, protein kinases and the phosphorylation of specific proteins , and the expression of genes related to tumor promotion, cell proliferation, apoptosis and differentiation.
Examples of markers related to cell proliferation are proliferating cell nuclear antigen a nuclear antigen associated with cell division and cyclins proteins associated with cell-cycle regulation In the latter category, cyclin D1 may prove to be a very useful biomarker since it is induced by various mitogens and is frequently overexpressed in a wide variety of human cancers Recently, overexpression of cyclin D1 in plasma has been associated with increased risk of breast cancer D.
Tang, A. Rundle, Q. Chen, J. Zhou and P. Brandt-Rauf, manuscript submitted. The fourth category of biomarkers includes those that relate to inherited or acquired variations in host susceptibility. This category is a burgeoning area of research and, among all the categories of biomarkers, generates the greatest concern about ethical issues 8 , 43 — The basic principles of multistage carcinogenesis and of the molecular biology of cancer predict that a number of factors, in addition to exposure to specific causative agents, influence the likelihood that tumors will develop in a given individual.
These individual susceptibility factors can be acquired or inherited. Examples include interindividual differences in the metabolism activation and detoxification of carcinogenic chemicals, DNA repair, and the functions of protooncogenes or tumor suppressor genes, as well as interindividual differences in nutritional, hormonal and immunologic factors.
With respect to genetic factors, rare, highly penetrant dominant mutations in genes, such as p53 in the Li—Fraumeni syndrome and Rb in familial bilateral retinoblastoma confer high individual risk, but account for a small percent of all cancer 12 , 46 — In contrast, relatively common genetic traits that regulate metabolism and detoxification of carcinogens can have a major impact on the population attributable risk of cancer, even though their individual risk is low.
Thus, its level can vary fold in the human liver and fold in the human lung 49 , Inducibility also varies between individuals, and high CYP1A1 inducibility has been correlated in a number of studies with risk of lung cancer 51 , Another common genetic factor related to increased cancer risk is the inheritance of a homozygous recessive mutation in the N -acetyltransferase gene resulting in the inability to efficiently detoxify aromatic amines via N -acetylation. It has been demonstrated that slow acetylators are at increased risk of bladder cancer, especially those occupationally exposed to aromatic amine bladder carcinogens Furthermore, in a study of blond and black tobacco smokers, slow acetylators had higher levels of 4-aminobiphenyl-hemoglobin 4-AB-Hb adducts in their red blood cells than fast acetylators who smoked the same type and quantity of cigarettes 58 , In contrast to its protective effect in bladder cancer, the fast acetylator phenotype is associated with an increased risk of colon cancer 60 , 61 , demonstrating the complexity of gene—environment interactions with respect to cancer susceptibility.
Moreover, combinations of metabolic polymorphisms are increasingly being linked to increased cancer risk 8. Acquired or inherited variations in the efficiency or fidelity of DNA repair can also influence individual susceptibility to cancer. This principle is illustrated by the rare autosomal recessive disease xeroderma pigmentosum, in which defects in the excision of pyrimidine dimers and other bulky DNA lesions lead to a marked increase in susceptibility to skin cancers induced by sunlight In one study, compared with healthy controls, patients with lung cancer were five times more likely to have reduced ability to repair damage induced by the PAH metabolite, benzo[ a ]pyrene diol epoxide Recent studies suggest that polymorphisms in the XPD nucleotide excision repair gene influence the risk of basal cell carcinomas in patients with psoriasis Rapid progress has been made in identifying the numerous genes that play a role in DNA repair pathways in mammalian cells, including direct damage reversal via the enzyme O 6 -methylguanine-DNA methyltransferase , base excision repair, nucleotide excision repair, mismatch repair and double-strand break repair It will be of interest to determine to what extent heritable polymorphic variations in some of these enzymes influence individual susceptibility to specific types of human cancer.
Using combinations of biomarkers, molecular epidemiology has reinforced prior evidence that risk from carcinogenic exposures can vary significantly with ethnicity, age or stage of development, gender, pre-existing health impairment and nutritional factors for review see ref. Biologically based interindividual variation in only a few susceptibility factors can lead to a significant increase in population risk over that expected based on an assumption of uniform susceptibility, possibly by an order of magnitude or more Based on biomarker data, Hattis et al.
There has been dramatic progress in the application of biomarkers to human studies of cancer causation. The populations studied have included: cigarette smokers, workers in specific industries, residents exposed to air pollution, persons with specific dietary patterns and cancer patients given chemotherapy. Progress has been made in the development and validation of biomarkers that are directly relevant to the carcinogenic process and that can be used in large-scale epidemiologic studies.
Study designs have become increasingly complex, with greater attention to the need to incorporate appropriate controls and account for potential confounders. Multiple markers, each reflecting a different stage or mechanism in carcinogenesis, are frequently being assessed in the same biologic samples as well as in surrogate and target tissues, to clarify the relationships between them.
A number of longitudinal or nested case-control studies have been undertaken to establish the predictive value of biomarkers. However, as knowledge of mechanisms in carcinogenesis has evolved, the available armamentarium of biomarkers is no longer sufficient. As discussed above, the majority of the available biomarkers used in molecular epidemiologic studies relate to agents that cause DNA damage and are mutagenic. At the same time, we know that a large number of chemicals hormones, various tumor promoters, pesticides, retinoids, etc.
Therefore, a current challenge is to develop more biomarkers for this category of agents and to incorporate them into molecular epidemiology studies. For example, there is increasing evidence that in addition to mutations due to damage to DNA, the carcinogenic process is often associated with aberrant hypermethylation of CpG islands in the promoter regions of various genes, leading to their transcriptional inactivation.
Since these changes can enhance the process of tumor progression, they might provide informative biomarkers in cell samples obtained from individuals at risk of developing cancer. Additional assays are needed to study oxygen radicals and oxidant stress, the metabolism of nitrogen oxide and nitrites, alterations in DNA methylation, the activities of specific protein kinases, activation of various cytoplasmic and nuclear receptors and transcription factors, cyclins and other cell-cycle control proteins, and aberrant cell proliferation, differentiation, apoptosis and angiogenesis.
Recent advances in genomics, microarray technology and informatics have made it possible to analyze small numbers of cells for their profiles of expression of many different genes. As these techniques become more available they can be applied to exfoliated cells and small biopsies of normal tissues, precursor lesions and tumors. As mentioned earlier, polymorphic variation in several types of genes may influence cancer susceptibility at the population level. In addition to the metabolism of xenobiotics, these polymorphisms can affect the metabolism of various dietary factors, the endogenous synthesis, metabolism and action of hormones, DNA repair, immune and inflammatory processes, oxidant stress, signal transduction and cell-cycle control.
Therefore, recently launched nationwide efforts to assemble and characterize a large panel of such polymorphic genes through the Human Genome and Environmental Genome Project 72 , 73 should provide powerful new biomarkers to the field of molecular epidemiology. Automated DNA-chip technology will greatly facilitate the large scale application of this new technology. An extremely important area for future application of the concepts and methods of molecular epidemiology is the role of nutrition and diet in cancer.
Current issues include: i the identification of specific cancer-preventive chemicals in fruits, vegetables and various phytochemicals, including antioxidants; ii the influence of genetic factors on individual cancer risk from dietary factors; iii the carcinogenic role of heterocyclic amines that are generated by cooking meat at high temperatures; and iv the contribution of specific dietary fats versus caloric excess per se to increased cancer risk.
New types of biomarkers need to be developed to analyze these questions in specific human populations. Bosze, N. Ferrar, H. Gerber, R. Johnson and G. Ma, R. Bai, R. Trieu and L. Frezza, P. Pollard and E. MacKenzie, M. Selak, D. Tennant, L. Payne, S. Crosby, C. Frederiksen, D. Watson and E. Porcelli, A. Ghelli, C. Ceccarelli, M. Lang, G.
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