Chapter 16

Cancer

Cancer: General Background

I. What is cancer?
- uncontrollable cell proliferation forming malignant
tumors that invade surrounding healthy tissues

A. Is cancer a genetic disease or not?

- Cancer is a genetic disease because it can be traced to
alterations within specific genes but, in most cases, it is
not an inherited disease
1. In inherited disease, the genetic defect is present in
the chromosomes of a parent & transmitted to the
zygote
2. In contrast, the genetic alterations (mutations) leading
to most cancers arise mostly in the DNA of somatic cells
during the affected individual's lifetime, and are not
inherited from parents

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B. Tumors destroy normal tissues &
organs
1. If they remain localized, they
can be treated & cured
surgically by removal of tumor
- primary tumors
2. If they metastasize, they are
harder to treat & more deadly;
can invade surrounding healthy Metastasized melanosarcoma
(red) invaded in normal liver
tissues – metastatic tumors

C. Metastasis - establishment of secondary tumors

1. Cells are spawned that break away from the parent mass
2. They enter lymphatic or vascular circulation
3. They spread to distant sites in body where lethal
secondary tumors are established

II. Cancer has been a massive focus of research for

decades, but they have had little impact on either
preventing the occurrence of cancers or increasing the
chances of survival in most cancers

A. Current treatments (chemotherapy & radiation) are

unable to kill cancer cells selectively
1. These treatments lack the specificity needed to kill
cancer cells without simultaneously damaging normal
cells; the serious side effects accompanying these
treatments
2. Patients cannot usually be subjected to high enough
doses of chemicals or radiation to kill all the tumor cells
in their body
B. Cancer immunotherapy - the artificial stimulation of the
immune system to treat cancer, improving on the
immune system's natural ability to fight the disease

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The incidence of cancer cases and deaths in the US

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Basic Properties of a Cancer Cell

I. 2 ways of obtaining cancer cells for culturing

A. Cancer cells can be obtained by removing a malignant
tumor from patients, dissociating the tissue into its
separate cells & culturing them in vitro
1. Many different cell lines originally derived from human
tumors have been collected in cell banks & are available
for study

B. Normal cells can be converted to cancer cells by

treatment with carcinogenic chemicals, radiation or
tumor viruses
1. Cells that have been transformed in vitro by chemicals
or viruses can cause tumors when they are introduced
into a host animal

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II. The most important trait of a cancer cell - loss of
growth control
A. Capacity for growth & division is not much different
between cancer & normal cells
1. When normal cells are grown in tissue culture, they
grow & divide at rates similar to malignant cells
2. If normal cells grow to cover culture dish, their
growth rate decreases markedly & they form a
monolayer of cells covering the dish —> contact
inhibition
3. Normal cells respond to growth-inhibitory
environmental influences (growth factor depletion,
contact with surrounding cells) with a decrease in
their growth rate
4. Malignant cells keep growing, piling on top of one
another to form clumps (foci)

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B. Malignant cells are not responsive to the types of
signals that cause their normal cells to cease growth &
division

1. Cancer cells ignore inhibitory growth signals, continue

to grow in the absence of stimulatory growth signals
2. Normal cells growing in culture depend on growth
factors present in serum
3. Cancer cells can
proliferate in the
absence of growth
factors because their
cell cycle does not
depend on signals
transmitted from
growth-factor receptors
located at their surface Effects of serum deprivation

C. Normal cells growing in culture exhibit a limited

capacity for cell division – after a finite number of
mitotic divisions, they undergo an aging process
1. Cancer cells are immortal because they continue to
divide indefinitely

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The Causes of Cancer

I. Many chemical carcinogens, ionizing radiation, UV light, a

variety of DNA & RNA viruses cause cancer
A. One property in common —> they can alter the genome
B. Carcinogenic chemicals can be directly mutagenic or be
converted to mutagenic compounds by cellular enzymes
C. UV radiation (skin cancer) is also strongly mutagenic

II. Many viruses can invade mammalian cells growing in

culture, transforming them into cancer cells – tumor
viruses
A. The viruses are divided into 2 large groups depending on
type of nucleic acid in mature virus particles
1. DNA tumor viruses - polyoma virus, simian virus 40
(SV40), adenovirus, herpeslike viruses
2. RNA tumor viruses (retroviruses) – Rous sarcoma
virus (RSV), human T cell leukemia virus (HTLV-1)

B. Tumor viruses transform cells - they carry genes whose

products interfere with the cell's normal growth-
regulating activities
1. Tumor viruses were valuable for identifying genes
involved in tumorigenesis, but they are associated with
only a small fraction of human cancers
2. Usually, these viruses greatly increase a person's risk of
developing cancer, rather than being the sole
determinant responsible for the disease

C. Ex.: human papilloma virus (HPV) – transmitted through

sexual intercourse; rising in frequency within
population; found in ~90% of cervical cancers, indicating
its importance in disease development
1. Majority of women infected with the virus will never
develop this malignancy
2. A vaccine against this virus is now available (Cervarix,
Gardasil), high risk HPV 16, 18 (low risk HPV 6, 11)

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 D. Other viruses linked to human cancers - hepatitis B
(liver cancer), Epstein-Barr (Burkitt's lymphoma), a
herpes virus, HHV-8 (Kaposi's sarcoma)

E. Certain gastric lymphomas are associated with chronic

infection with the stomach-dwelling bacterium
Helicobacter pylori, which is also responsible for ulcers
1. Unlike any other known cancer, treatment with
bacteria-killing antibiotic cures the lymphoma

III. Causes of cancer

A. Some obvious causes - smoking —> lung cancer
ultraviolet radiation exposure —> skin cancer
B. Still unsure about causes of most types of human cancers
1. Environmental factors (e.g., diet) - children moved from
Asia to the U. S. no longer exhibit a high rate of gastric
cancer, instead elevated risk of colon & breast cancer
C. Diet can help or hurt -
animal fat & alcohol
increase risk; certain
fruit & vegetable
compounds & tea can
reduce that risk

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IV. Analysis of the types of mutations caused by specific
carcinogens has shed light on the causes of a few
cancers
Ex.: aflatoxin B (produced by mold Aspergillus flavus)
- contributes to high incidence of liver cancer in Asia

A. It causes a characteristic G —> T substitution in

tumor-suppressor gene TP53 (in a codon 249 base pair);

The Genetics of Cancer

I. A. Malignant transformation (tumorigenesis) requires

> 1 genetic alteration

1. Tumorigenesis is a multistep process characterized by

a progression of permanent alterations in a single cell
2. Each change makes the cell increasingly less
responsive to the body's regulatory machinery
3. They become more able to invade normal tissues &
thus more life-threatening

B. In tumor progression, not all of the changes result from

genetic mutation
1. Activation of telomerase expression is considered an
epigenetic change, resulting from the activation of a
gene that is normally repressed

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 2. This type of activation process involves a change in the
structure of chromatin in & around the gene and a
change in the state of gene methylation

3. Once epigenetic change has occurred, it is transmitted

to all progeny of that cell & thus represents a
permanent, inheritable alteration

4. Even after they become malignant, cancer cells continue

to accumulate mutations & epigenetic changes; making
them increasingly abnormal with new properties; get
even more dangerous

5. This genetic instability makes the disease difficult to

treat by conventional chemotherapy since cells often
arise within tumor mass that are resistant to the drug

II. Steps in the development of some malignant tumors

A. First step in formation of malignant tumors is often
formation of a benign tumor
1. Benign tumors are made of cells no longer responsive to
normal growth controls; cannot metastasize to distant
sites & lack ability to invade normal tissues
2. Some benign tumors pose little threat of becoming
malignant, others do (polyps in colon wall)

B. Premalignant cells can be identified by their morphology

1. Pap smear detects precancerous cervical epithelium
cells (cells less well differentiated than normal cells,
larger nuclei)

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III. Genes involved in carcinogenesis are a gene subset;
products are involved in growth-related functions

A. Types of functions these genes affect:

1. Progression of cell through cell cycle
2. Adhesion of cell to its neighbors
3. Repair of DNA damage
4. Apoptosis

B. Different types of cancers typically have different

mutated gene combinations; however, even within a
specific type of cancer, there is great variability
among the particular genes typically mutated
1. In genetic terms, the best-defined cancer is colon
cancer, where different genes tend to be mutated at
different stages of tumorigenesis

IV. Detailed model of colon cancer genetic progression

A. APC gene mutations seen in > 60% of smallest benign

adenomas of colon (first step in the formation of colon
cancers)
B. TP53 gene mutations tend to occur only at later stages
C. Cells from metastatic colon cancers, the last stage of
cancer progression, exhibit high expression levels of the
PRL3 gene, which encodes a tyrosine phosphatase

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V. Technology for analyzing gene expression – DNA
microarrays and proteomics
A. Ex.– Study of 50 genes transcribed in 2 different
leukemias: acute lymphoblastic leukemia (ALL) & acute
myeloid leukemia (AML)

1. Different tumors have

characteristic gene-
expression profiles
2. This suggest genes to look
at as targets for drug
therapy

B. The earlier a cancer is discovered, the more likely is a

cure

1. Some early-stage breast cancers release cells capable

of forming secondary tumors (metastases), while others
do not à these differences determine prognosis
2. Recently, prognosis of a given breast cancer is revealed
in expression level of ~70 genes out of 1000s studied in
DNA microarrays – important treatment guide

3. Patients with early-stage tumors displaying "poor

prognosis" profile of gene expression can be treated
aggressively with chemotherapy to maximize the chance
of preventing secondary tumors
4. Patients with "good prognosis" profile might be spared
debilitating chemotherapy, even if their tumors appear
to be more advanced

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5. In 2003, Netherland Cancer Institute became first
major institute to use gene-expression profiling to
determine treatment using 70 gene treatment guide for
breast cancer

C. Proteomics – identify proteins differentially expressed in

a given conditions

Tumor-Suppressor Genes and Oncogenes - Genes

implicated in tumorigenesis

I. Tumor-suppressor genes - encode proteins that restrain

cell growth & prevent malignancy
A. Specific regions of particular
chromosomes were consistently
deleted in certain cancers
1. Absence of such genes correlates
with tumor development à their
presence normally suppresses
tumor formation
2. The missing chromosomal regions
contain genes that suppress cancer
growth & development
3. Tumor suppressor genes act recessively - both copies
must be deleted or mutated before protective function
is lost

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II. Oncogenes - encode proteins that promote growth
control loss & conversion of cell to malignant state; act as
accelerators of cell proliferation & tumorigenesis
A. Oncogenes
1. lead to the generation of genetic instability
2. prevent a cell from becoming a victim of apoptosis
3. promote metastasis
B. Cells have proto-oncogenes that
subvert their own activities & push
them toward malignant state; they
encode proteins that have various
functions in cell's normal activities
C. Oncogenes act dominantly - one copy
of gene makes cell express altered
phenotype, regardless of whether or
not there is a normal, unactivated
copy of the gene on the homologous
chromosome

III. Mechanisms that proto-oncogenes are converted into

oncogenes
A. Mutation- mutate gene in way that alters gene product
properties so it can no longer carry out normal activities
B. Amplification- Gene can be duplicated one or more times,
resulting in gene amplification & excess production of
encoded protein
C. Chromosome
rearrangement -
DNA sequence from
a distant site in
genome into close
proximity to gene,
altering gene
expression or the
nature of the gene
product

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Tumor Suppressor Genes: Retinoblastoma - The RB Gene

I. Normal cell to cancer cell transformation is accompanied

by loss of function in ≥ 1 tumor suppressor genes
A. Tumor suppressor genes implicated in human cancers
1. Transcription factors (TP53 & WT1)
2. Cell-cycle regulators (RB & p16)
3. Components that regulate signaling pathways (NF1)
4. Phosphoinositide phosphatase (PTEN)
5. RNA polymerase II elongation regulator (VHL)

II. Retinoblastoma - rare childhood cancer of the retina of

eye à gene responsible for this disorder is RB

A. Incidence of retinoblastoma
1. It occurs at high frequency & young age in members of
certain families, so it could be inherited, and
2. It occurs sporadically at an older age among members
of the population at large

B. Genetic basis -
retinoblastoma development
requires that both RB gene
copies in retinal cell be
eliminated or mutated first

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 1. Since chance that both alleles of the same gene will be
target of mutations in the same cell is very unlikely
(sporadic is rare), incidence of the cancer in general
population is very low
2. Those who inherit a chromosome with an RB deletion
are halfway there

III. Role of pRb in regulating the cell cycle à pRb

regulates G1 - S transition & cell division

A. G1-S transition is accompanied by activation of proteins

from DNA polymerases to cyclins & histones

B. E2F transcription factor family members are required

for S-phase activities & are key pRb targets
1. During G1, unphosphorylated pRb binds to E2F,
preventing them from activating genes encoding
proteins required for S phase activities (cyclin E and
DNA polymerases)
2. E2F-pRb complex is associated with DNA, but acts as
gene repressor
3. As the end of G1 approaches, the pRB subunit of the
complex is phosphorylated by cdks that control G1 - S
transition at numerous ser & thr residues

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 4. After pRb phosphorylation, pRb releases E2F, allowing
E2F to activate gene expression —> cell's irreversible
commitment to enter S phase
C. If a cell loses pRb activity due to
RB mutation —> it cannot
inactivate E2F —> removes
certain restraints on the entry
into S phase
D. pRb binds to many proteins other
than E2F, so it has numerous
other functions
E. pRb contains at least 16 different
ser & thr residues that can be
phosphorylated by cyclin-
dependent kinases

Tumor Suppressor Genes: TP53 - the Role of p53

I. p53 is a polypeptide with 53 kDa MW; its gene (TP53)

is a tumor-suppressor gene; it has more to do with the
development of human cancer than any other
component of genome

A. When it is absent, it causes a rare, inherited disorder,

Li-Fraumeni syndrome - very high incidence of some
cancers (breast, brain, leukemia, etc)
1. Like people with inherited form of retinoblastoma,
these patients inherit one copy of p53 gene (other is
mutated or deleted) —> get cancer if random mutation
knocks out other copy of gene
2. These people are very susceptible to cancers resulting
from random mutations in normal allele

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B. p53 is important : >50% of human cancers have deletions
/point mutations of both TP53 genes in their cells
1. Tumors with mutations in TP53 are more virulent,
metastasize better, more invasive, poorer survival rate
than in those that have a wild-type TP53 gene
2. Loss of TP53 function is a big step in progression of
many cancer cells to fully malignant state
3. > 1000 mutations seen in human tumors; proper p53
functioning is very sensitive to slight changes in amino
acid sequence

Frequently mutated aa
residues

II. How does p53 suppress cancers & why is it so

important in suppressing malignancy?

A. p53 is a TF that activates expression of many other

genes involved in cell cycle regulation & apoptosis,
including the gene encoding p21
1. p21 inhibits cdk that drives cell through G1
checkpoint
2. As p53 levels rise in damaged G1 cell —> p21 gene is
activated & cell cycle progression is arrested
3. Allows the cell time to repair genetic damage before
DNA replication is initiated
4. If both TP53 copies are mutated, so their product is
nonfunctional —> cell makes no p21 inhibitor
5. There is no feedback control keeping cell out of S
phase before it is ready (repairs unfinished) —> failure
to repair DNA damage —> get abnormal cells with
potential to be malignant

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B. p53 also leads genetically damaged cells along pathway
that leads to death by apoptosis —> rids body of cells
with malignant potential

1. p53 activates the expression of the Bax gene —>

initiates apoptosis
2. If both TP53 alleles are inactivated —> a cell with
damaged DNA is not destroyed even though it lacks the
genetic integrity required for controlled growth
3. Reintroduce normal TP53 gene into cancer cell lacking it
—> genetically engineered cell undergoes apoptosis

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III. Control of p53 production – the level of p53 in a
healthy G1 cell is very low

A. If G1 cell sustains genetic damage (UV light, chemical

carcinogens) —> p53 concentration rises fast

B. The increase in p53 levels is not due to increased

expression of the gene, but to decrease in proteasomal
degradation; p53 degradation is facilitated by protein
called MDM2
1. MDM2 binds to p53 & escorts it from the nucleus into
the cytosol
2. In the cytosol, MDM2 adds ubiquitin molecules to p53
(E3 ubiquitin ligase), leading to its destruction by
proteasome
3. MDM2 is also expressed by p53

C. How does DNA damage lead to stabilization of p53? –

1. ATM is normally activated after DNA damage & p53 is

one protein it phosphorylates
2. Phosphorylated p53 is no longer able to interact with
MDM2 —> stabilizes existing p53 molecules in nucleus —>
allows p53 to activate expression of p21 & Bax genes

D. Some tumor cells contain wild-type TP53 gene, but

contain extra copies of MDM2 gene
1. Such cells make excessive amounts of MDM2 —>
prevents p53 levels from building to required levels to
stop cell cycle or induce apoptosis after DNA damage
2. Overexpression of MDM2 can have the same effect as
the absence of p53

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 Experimental demonstration of the role of p53 in the
survival of cells under chemotherapy

Tumor-Suppressor Genes: Other Examples

I. Colon cancer - results from mutation accumulation in a

number of different genes
A. Familial adenomatous polyposis coli (FAP) - inherited;
individuals develop many premalignant polyps (adenomas)
from epithelial cells lining the colon wall

1. If they are not removed,

cells within some of these
polyps often progress to
fully malignant stage
2. Patients have a small
chromosome 5 deletion;
later found to be site of
APC tumor-suppressor gene

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 B. If a person inherits mutant APC gene & the other one is
knocked out (or mutated) in a given cell —> the protective
function of the APC gene is lost in that cell
1. The cell proliferates to form a polyp rather than
differentiating into a normal intestinal epithelial cell
2. Conversion of cells in the polyp to the more malignant
state is gained by accumulation of additional mutations,
includingTP53

C. Mutated APC genes are found in up to 80% of sporadic

colon tumors in addition to inherited forms of colon
cancer; suggests that the APC gene plays a major role in
the development of this disease

II. Breast cancer - strikes 1 in 8 women living in U. S.,

Canada & Europe; 5 - 10% of these cases are traced to
inheritance of a gene that predisposes the individual to
development of breast cancer

A. 2 genes (BRCA1 & BRCA2) identified as being responsible

for inherited breast cancers
1. BRCA mutations also predispose women to ovarian cancer
development (an especially high mortality rate)

B. Precise functions of BRCA1 & BRCA2 remain unclear, but

BRCA proteins are part of a large protein complex that
responds to DNA damage & activates DNA repair
1. BRCA proteins are part of checkpoint mechanism that halts
cell cycle progression after DNA damage
2. Cells with mutant BRCA proteins contain unrepaired DNA
& other abnormalities like an excess number of
centrosomes lead to abnormal chromosome segregation

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 3. In cells with a functional TP53 gene, failure to repair
DNA damage leads to the activation of p53, which
causes the cell to either arrest the cell cycle or
undergo apoptosis

Oncogenes and the Function of Oncogene Proteins

I. Oncogenes encode proteins that promote loss of growth

control & conversion of cell to
malignant state

A. They are derived from proto-

oncogenes that encode proteins
having a function in normal cell
1. Most known proto-oncogenes play
a role in control of cell growth
(growth stimulation by external
ligands, signal transduction within
the cell or progression through
the cell cycle)
2. ~100 different oncogenes
identified

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B. Most of the known oncogenes encode proteins with the
following types of functions:
1. Oncogenes that encode growth factors and receptors
2. Oncogenes that encode cytoplasmic protein kinases
3. Oncogenes that encode nuclear transcription factors
4. Oncogenes that encode products that affect apoptosis
5. Genes that encode proteins involved in DNA repair

II. Oncogenes that encode growth factors or their

receptors - cancer-causing simian sarcoma virus has an
oncogene (sis)

A. The sis oncogene was derived from the cellular gene for
PDGF present in human blood

1. Cultured cells infected with the virus —> secrete large

amounts of PDGF into medium —> uncontrolled
proliferation of cells & become cancerous

2. PDGF overexpression is implicated in the development

of brain tumors (gliomas)

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 B. Avian erythroblastosis virus (AEV) is another tumor virus -
it carries the oncogene (erbB) that encodes altered EGF
receptor
1. Altered receptor constitutively stimulates the cell in
the presence & absence of growth factors
2. As a result of the constant receptor stimulation, the
cells proliferate in an uncontrolled manner
3. Malignant cells usually have a much larger number of
receptors in membrane than normal cells

III. Oncogenes that encode cytoplasmic protein kinases –

include both ser/thr & tyr kinases

A. Raf – ser/thr protein kinase at head of the MAP kinase

cascade, the primary growth-controlling signaling pathway
1. If RAF gene is mutated, Raf is "on" constitutively à loss
of growth control

B. The oncogene most often mutated in human tumors is

RAS, encoding the GTP-binding Ras protein; it serves as
on-off switch for a key cell signaling pathway that
controls cell proliferation

1. Oncogenic RAS mutants typically encode a protein whose

GTPase activity cannot be stimulated
2. This leaves the protein in an active GTP-bound form,
sending continuous proliferation signals
3. The human genome contains 3 different RAS genes (K-
Ras, N-Ras, and H-Ras) & 3 different RAF genes (Raf-1,
B-Raf, and C-Raf) that are active in different tissues; of
these, K-RAS & B-RAF are most often implicated in
tumor formation

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IV. Oncogenes that encode nuclear transcription factors -
MYC is the best studied

A. Cells not actively growing & dividing tend to withdraw from

the cell cycle & enter into G0
1. MYC gene is activated if cells are stimulated by growth
factors to re-enter the cell cycle, leave G0 & divide
2. Myc protein is one of first to appear after stimulation by
growth factors to re-enter the cell cycle

B. Burkitt's lymphoma (one of Africa's most common types

of cancer) - MYC gene is translocated to a position
adjacent to an antibody gene —> MYC gene is activated,
initiating malignancy
1. Occurs mostly in people who have been infected with the
herpeslike Epstein-Barr virus

V. Oncogenes that encode products that affect apoptosis

A. Alteration of the apoptotic process damages cell's ability

to self-destruct —> increases chance of that cell giving
rise to a tumor

B. BCL-2 oncogene is the oncogene most closely linked to

apoptosis; it encodes a membrane-bound protein that
normally acts to inhibit apoptosis

C. Follicular B-cell lymphomas – correlated with BCL-2 gene

translocation next to a gene coding for the heavy chain of
antibody molecules
1. Overexpression of BCL-2 may lead to apoptosis
suppression in lymphoid tissues
2. Abnormal cells can thus proliferate to form lymphoid
tumors

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VI. The mutator phenotype: mutant genes involved in DNA
repair

A. Nucleotides that are chemically altered or incorporated

incorrectly during replication are selectively removed
from the DNA strand by DNA repair (mismatch repair)

B. If proteins involved in mismatch repair are damaged, the

mutation rate & cancer risk rise (mutator phenotype)
1. Cells with the mutator phenotype are to incur mutations
in both tumor-suppressor genes & oncogenes, greatly
increasing their risk of becoming malignant

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New Strategies for Combating Cancer

I. Immunotherapy – an approach that attempts to treat

cancer patients by administering antibodies as therapeutic
agents; they recognize & bind specific proteins that play
key role in activities of targeted tumor

II. Gene therapy - treatment in which patient's genotype is

changed by addition, deletion or alteration of specific
gene, now applied to cancer

III. Inhibiting the activity of cancer-promoting proteins

IV. Inhibiting new blood vessel formation (angiogenesis) - as

tumors grow in size, they stimulate angiogenesis supplying
nutrients & O2, removing wastes from fast-growing
tumors & provides channel for cancer spread

V. Presently, the best anticancer strategy is early detection

A. Screening procedures are in place – mammography

(breast cancer); Pap smears (cervical cancer); PSA
determinations (prostate cancer); colonoscopy (colorectal
cancer)

B. The earlier cancer is discovered, the greater is the

chance for survival, so screening procedures could have
significant impact in lowering the death rates from
cancer

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