“The Biology of Cancer”

Gracieux Y. Fernando, MD, MHPEd

Associate Professor 4
Division of Medical Oncology
[Link]
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The Hallmarks of Cancer

Douglas Hanahan and Robert Weinberg. The Hallmarks of Cancer – The Next Generation. Cell (144), March 4, 2011, pp. 646-674.
The Hallmarks of Cancer

Douglas Hanahan and Robert Weinberg. The Hallmarks of Cancer – The Next Generation. Cell (144), March 4, 2011, pp. 646-674.
Hallmarks Associated with
Cellular Growth
 Hallmarks 1 and 2: Sustained Proliferative
Signaling and Evasion of Growth Suppressors
 Oncogene Family

+ oncogenes

Oncogenes
 promote cell proliferation

 dominant & highly conserved

 types: viral oncogenes [v-oncs]
cellular oncogenes [c-oncs]

Proto-oncogene  “Mutation”  Oncogene

 Tumor Suppressor Genes
TS Genes
 inhibit growth and multiplication of mutated cells
 prevent neoplastic transformation
 recessive & highly conserved

Prototype Growth Suppressors

Regulators of the Cell Cycle
➢ RB1

➢ Tp53
 Tumor Suppressor Genes
KNUDSON’S Two-Hit Hypothesis

1st Hit: TS mutation or Inherited mutation

2nd Hit: gross chromosomal loss
 DNA Repair Genes

DNA Repair Genes

 involved in ensuring the fidelity of replication
 function: checks for & corrects mismatched pairs
 mutation  inefficient repair & replication leading
increased propensity of oncogenes and tumor
suppressor genes to undergo mutation
 leads to the formation of Microsatellite Instability
[MIN+]
 Gene Mutations: Mechanisms
• Point mutations
‒ Frame shift mutations
• Splice site mutations
• Consequences of aging and
chromosome damage
‒ Gene amplifications
‒ Translocations
• Viral etiologies
De Vita VT, Lawrence TS, Rosenberg SA, editors. Cancer: Principles and Practice of Oncology, Primer of the Molecular Biology of Cancer.
Philidelphia, PA: Lippincott, Willliams and Wilkins, 2011
Oncogene Tumor suppressor genes
Tumor suppressor genes
Oncogene
Normal genes (regulate
Normal genes cell growth)
(regulate cell
growth)

Active oncogene
1st mutation Tumor suppressor genes
1st mutation (susceptible
(leads to carrier)
accelerated cell
division)

No brakes!
2nd mutation or loss
(leads to cancer)

No brakes!

Active oncogene
 Recap of Molecular Oncogenesis

Proto-oncogene Gain-of-function
TS gene Loss-of-function PROLIFERATION
DNA Repair gene Loss-of-function
Hallmark 3: Evading Apoptosis
 Cyclin Regulators
• p 21: inhibits cell cycle progression and permits DNA
repair to take place
• p53: “the guardian of the genome”
‒ In the presence of DNA damage:
▪ Halts cell cycle progression to facilitate DNA repair, or
▪ Activates apoptosis in cases of severe DNA damage
‒ The most common genetic alterations found in human cancer
[Link]
Embracing Death: A Paradox for Survival
AUTOPHAGY NECROSIS
‒ Induced by nutrient • Cells become bloated and
deficiency explode, releasing contents
‒ Removes pathologic proteins into environment
and damaged organelles
• Creates a pro-inflammatory
‒ Cellular organelles are broken reaction
down and recycled
‒ Cross-signaling with apoptotic • Recruitment of inflammatory
pathway cells
‒ Paradox • Bioactive regulators:
▪ Protective for cancer stimulate neighbors to
cells participate in neoplastic
▪ Stressed cells may process
shrink to state of
dormancy

Douglas Hanahan and Robert Weinberg. The Hallmarks of Cancer – The Next Generation. Cell (144), March 4, 2011, pp. 646-674.
Hallmark 4: Replicative Immortality

Cellular Senescence
Hayflick Limit
 Telomeres and Telomerase
• Telomeres
▪ Prevent recombination and shortening of the lagging
strand
▪ Repeats of 6 – nucleotide sequences (Humans :
TTAGGG)

De Vita VT, Lawrence TS, Rosenberg SA, editors. Cancer: Principles and Practice of Oncology, Primer of the Molecular Biology of Cancer.
Philidelphia, PA: Lippincott, Willliams and Wilkins, 2011
 Telomeres and Telomerase

• Telomerase
▪ Add 6 nucleotide repeats to 3’ – OH end of
DNA
• RNA serves as template
• Reverse transcriptase
• Premalignant lesions: low levels of
telomerase expression
− Promotes mutations

• Overt carcinomas: telomerase

expression and telomere elongation
− Stabilizes mutant genome and confers
unlimited replication
 Hallmarks That Contribute to
Sustaining the Growth Potential
Hallmark 5: Inducing Angiogenesis
De Vita VT, Lawrence TS, Rosenberg SA, editors. Cancer: Principles and Practice of Oncology, Primer of the Molecular Biology of Cancer.
Philidelphia, PA: Lippincott, Willliams and Wilkins, 2011
 Angiogenesis
• Clinical importance:
‒ Trigger: Hypoxia detected by HIF proteins
‒ Tumor vessel number correlates with risk and degree of
dissemination
‒ Cytokines that stimulate endothelial cell proliferation also
stimulate proliferation of malignant cells
‒ Consequences:
▪ Vessels are dilated, tortuous and have multiple branches
▪ Basement membranes are of varied thickness causing leakiness
▪ Blood flow is chaotic
‒ Redundant pathways exist
Other Modes of Tumor Vascularization
• Vascular co-option
‒ Blood supply is obtained by hijacking existing
vasculature
• Intussusceptive vascular growth
‒ “Splitting angiogenesis”
‒ Existing capillaries split into daughter networks
thus expanding vascular network
• Vasculogenic mimicry
‒ Utilizes plasticity of aggressive tumor cells
‒ Forms stem-cell like phenotypes that create
new vascular networks
Hallmark 6: Dysregulated Cellular Energetics
Reprograming Energy Metabolism
• Adjustments to fuel cell growth
• Aerobic glycolysis
‒ Lactic acid even in presence of O2
‒ Counter-intuitive
‒ Increased glucose transporters like
GLUT1
‒ Accentuated under hypoxic conditions
 Reprograming Energy Metabolism

• Prioritizes pathways used for making new cells

• Two subpopulation of energy-generating cells:
‒ Warburg cells
‒ Lactate-dependent cells employing citric acid cycle
‒ Coopts the physiology of muscle metabolism
‒ Defense against the chaotic blood supply
Dysregulated Cellular Energetics: Application

[Link]

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Hallmarks That Contribute to
Tumor Cell Propagation
Hallmark 7: Invasion and Metastases
Invasion and Metastases
• Events in formation of metastases
‒ Invade through the extracellular matrix
‒ Intravasate into tumor vasculature
‒ Survive transport in circulation
‒ Extravasate in parenchyma of distant
organs
‒ Survive and manipulate a new foreign
environment
‒ Grow
Fouad YA and Aanei C. American Journal of Cancer Research, 7(5):1016-1036, 2017.
Epithelial-Mesenchymal Transition
• Transformed cells can invade, resist apoptosis and
disseminate
• Co-opts processes involved in embryonic
morphogenesis and wound healing
‒ Activated by transcriptional factors (Snail, Slug, Twist, Zeb
1/2)
‒ Consequences: loss of adherans junctions, conversion to a
spindly/fibroblastic morphology, expression of matrix-
degrading enzymes, increased motility, resistance to
apoptosis
• Transformation occurs at the margins of invasion
• Reversible plasticity
 Types of Cellular Invasiveness
• Mesenchymal
‒ Mediated by the EMT program
• Collective invasion
‒ Nodules of cancer cells advancing en masse
‒ Rarely metastatic
• Amoeboid
‒ Morphologic plasticity
‒ Allows cells to slither through interstices in
extracellular matrix
 Cancer Cell Dormancy
• Dormancy - adaptive response of cancer cells that have
arrived in a new environment
• 3 types
‒ “Reversible senescence”
‒ Angiogenic dormancy
‒ Immune-mediated dormancy
• How cancer cells reverse this process remains poorly
understood
 Hallmarks That Contribute to
Survival in a Hostile Environment
Hallmark 8: Evasion of Immune Surveillance
 Immune System Function and Immune
Response
Identify and destroy foreign or abnormal cells in the body

Innate Immunity Adaptive Immunity

▪ Nonspecific ▪ Specific target
recognition
▪ First line of
defense ▪ Slower to develop
▪ WBCs (natural ▪ Ab or cell mediated
killer cells,
neutrophils) ▪ Memory

▪ Activation of – Faster, stronger

adaptive immunity subsequent responses

Janeway CA Jr, et al. Immunobiology: the immune system in

health and disease. 2001. Slide credit: [Link]
Cancer – Immunity Cycle

Chen D and Mellman I. Immunoity, 39, July 25, 2013

 Evading Immune Destruction
• 1st strategy: avoid immune detection
‒ Immunoediting: highly immunogenic clones are routinely
eliminated leaving weakly immunogenic variants behind
‒ Immunogenic tumors may evade immune system by:
▪ Secreting immunosuppressive factors like TGF-β
▪ Recruitment of immunosuppressive inflammatory cells (regulatory T cells,
myeloid-derived suppressor cells)
 Cancer
Immuno
-editing

Meliana A, Nurruni MD, Wijaya A. Indones

Biomed J, 2016; 8(1): 1-20. doi:
10.18585/inabj.vi1.189
 T-Cell Response: Second Signal to
Accelerate or Brake

Activating Signals Inhibitory Signals

CD28
OX40 CTLA-4
T cell
GITR PD-1
CD137 TIM-3

CD27 BTLA

HVEM VISTA

LAG-3

T-Cell Stimulation T-Cell Inhibition

Mellman I, et al. Nature. 2011;480:480-489. Slide credit: [Link]
 Evading Immune Destruction
• 2nd strategy: disable immune response
‒ Minimized detection by immune system due to deficiencies in the
following:
▪ CD8+ Cytotoxic T lymphocytes
▪ CD4+ Th1 helper T cells
▪ Natural killer cells
‒ Utilize the “off switch” in controlling functions of immune effector
cells
From the Presentation: Immunotherapy Shaping the Future of Cancer Management Landscape: Opportunities and Challenges by Emad Shash, MBBCh, MSc, MD, Medical Oncology Department, National Cancer Institute, Cairo University
T-cell Activation Against Cancer
Supportive Hallmarks
Enabling Hallmark: Tumor-Associated Inflammation
 Enabling Characteristics
• Tumor-promoting inflammation
‒ Tumors infiltrated by cells of the immune system
‒ Paradoxical effect: enhance tumor development and progression
‒ Supplies bioactive molecules that may sustain proliferation, improve survival,
induce angiogenesis, promote invasiveness, activate EMT
‒ Evident at earliest stages of tumor formation
‒ Release chemicals like reactive oxygen species that are actively mutagenic
Enabling Hallmark: Genomic Instability
 Enabling Characteristics
• Genome instability and mutation
‒ May confer advantages to cells and their clones
‒ Acquiring mutations needed for tumor formation may increase
mutation rates
▪ Increased sensitivity to mutagens
▪ Breakdowns in genomic maintenance machinery
▪ Compromise surveillance systems that monitor genomic integrity
The New Hallmarks
Hanahan D. Cancer Discovery, January 2022, p.32
 Emerging Hallmark: Phenotypic Plasticity

• Cellular changes in
physiology and morphology
in response to a unique
environment
• Intrinsic vs. Extrinsic
Plasticity

Hanahan D. Cancer Discovery, January 2022, p.33

 Emerging Hallmark: Senescent Cells
• Senescence represents an irreversible form of proliferation
arrest
• Factors that contribute to development of senescence
‒ Microenvironmental stress (nutrient depravation, DNA damage)
‒ Damage to cellular organelles and structures
‒ Imbalances in cellular signaling network
• Types of senescence
‒ Oncogene-induced
‒ Therapy-induced
 Emerging Hallmark: Senescent Cells
• Senescent cells may be • SASP cells greatly impact the
tumor promoting tumor microenvironment
‒ Activation of EMT and • Pro-tumorigenic SASPs:
promotion of local invasion
‒ Immune cell modulating
‒ Development of cellular cytokines
dormancy in the face of anti-
‒ Pro-angiogenic factors
cancer therapies
‒ Extracellular matrix
‒ Production senescence
modulating factors
associated secretory
phenotype (SASP) • SASP cell action dependent
on cell type
Soon Sang Park, et al. Experimental and Molecular Medicine (2021) 53:1834-1841
 Enabling Characteristic: Epigenetic
Reprograming
• Epigenetics
‒ study of changes in the organism as a result of modifications in
gene expression rather than alterations in the genetic code itself
‒ Include the interactions between tumor cells and the
microenvironment
• Epigenetic mechanisms
‒ DNA methylation
‒ Histone modification
‒ Non-coding RNAs
 Mechanisms of Epigenetic Reprograming
MECHANISMS ACTION LOCATION MEDIATORS ACTIONS
DNA Methylation lead to inhibition of promoter
DNA CpG Islands Methyltransferases regions and gene silencing
Methylation (Promoter Regions) Removal of methyl groups allows recovery of
DNA demethylation
silenced genes
Histone Tightens histone packaging of DNA causing
Histone Chromatin Acetyltransferases gene silencing
Modification (Histones) Histone Removal of acetyl group loosens chromatin
deacetylases structure allowing access to transcription
Non-coding Small non-coding
mRNA
RNA RNA (microRNA) Downregulate gene expression; tumorigenic
Long non-coding effects depends on affected genes
RNA
Yuanjun Lu, et al. Molecular Cancer (2020) 19:79
 Enabling Characteristic: Polymorphic
Microbiomes
• The ecosystem of the human microbiome has profound
effects on health and disease
• Dysbiosis: distortions in the microbial population
• Some microorganisms may have protective or deleterious
effects on cancer development, progression and response to
therapy
• Carcinogenic effects of microbiomes:
‒ Release of genotoxins that can damage host DNA
‒ Induction of a chronic inflammatory state through toxin
production
‒ Dysregulation of the immune response Hanahan D. Cancer Discovery, January 2022
Rajagopala S, et al. Cancer Prev Res; 10(4) April 2017
 Enabling Characteristic: Polymorphic Microbiomes
• Most studied microbiome involves the flora of the gut
• Microbiomes are also present in other tissues and organs that
are exposed, directly or indirectly, to the outside environment
• Recent findings have demonstrated the existence of microbes,
particularly bacteria, and can be located within tumor cells and
immune cells

Hanahan D. Cancer Discovery, January 2022, p.38-41

 Microbes Designated as Class I Carcinogens

MICROBE CANCER SITE

Helicobacter pylori Stomach
Hepatitis B virus
Hepatitis C virus
Liver
Opisthorchis viverrine
Clonorchis sinensis
Human Papillomavirus Cervix, Vagina, Vulva, Anus, Penis, Oropharynx
Epstein-Barr Virus Nasopharynx, non-Hodgkin’s lymphoma, Hodgkin’s lymphoma
Herpesvirus (KSHV or HHV8) Kaposi’s sarcoma, Primary effusion lymphoma
Human T-cell Lymphotropic Virus Type I Adult T-cell lymphoma
Schistosoma haematobium Bladder
Bhatt A et al. CA Cancer J Clin. 2017 July 8; 67(4): p. 30
Rajagopala S, et al. Cancer Prev Res; 10(4) April 2017
Nowell’s Hypothesis

[Link]
 Somatic vs. Germline Mutations
Somatic mutations Germline mutations

Occur in nongermline tissues Present in egg or sperm

Are nonheritable Are heritable

Cause cancer family syndrome

Nonheritable

Somatic mutation Mutation in egg All cells affected in

(e.g., breast) or sperm offspring
Clinical Features of Hereditary Cancer Syndromes
• Two or more relatives in a family have been diagnosed with
cancer.
• More than one generation is affected.
• Cancer has been diagnosed in a family member under 50
years of age.
• The same type of cancer has occurred in several members
of the family.
• More than one type of cancer has occurred in one person
or a clustering of specific tumor types is present.
• A rare cancer has occurred in one or more members of the
family.
• Certain ethnic groups (e.g. Ashkenazi Jews)

Sifri R, et al. Identifying and Testing for Hereditary Susceptibility to Common Cancers. CA : Cancer Journal for Clinicians; 54: 309-26; 2004.
McKelvey K and Evans J. Cancer Genetic in Primary Care. Journal of Nutrition; 133: 3767S-3772S: 2003.
 Cell Regeneration Cycle
DEATH
G0
DIFFERENTIATION

G2/M checkpoint

Mitosis
M
DNA content = 2n

DNA content = 4n G2 G1

S G1/S checkpoint
DNA synthesis
 G1/S Checkpoint

• Area most often disrupted in cancer.

• Mechanism of regulation is complex and involves the
phosphorylation of the Rb gene. This results in:
‒ Activation of several genes needed for S phase progression.
‒ Promotes differentiation through association with transcription
factors.
 Tumor Growth
number of
cancer cells PLATEAU

10 12

LOG
10 9 diagnostic
threshold
(1cm)

LAG
time

undetectable detectable
cancer cancer

limit of host
clinical death
detection
Microscopic Appearance of Cancer Cells
Multistage Carcinogenesis
 Carcinogenesis
Initiation
 rapid, genotoxic, irreversible
 results in the formation of mutant DNA
 requires at least one round of cell division
 normal cells are exposed to a carcinogen
1. Direct-acting carcinogens
2. Indirect-acting carcinogens
or procarcinogens

procarcinogen Cytochrome Ultimate

p450 carcinogen
 Carcinogenesis
Promotion
 chronic, epigenetic, potentially reversible
 initiated cells are exposed to promoters
 promoters are not carcinogens !
 properties of promoters  reversible
 dose-dependent
 time-dependent
 Lag Time
20-Year Lag Time Between
Smoking and Lung Cancer
Cigarette
consumption (men)

4000
150
Lung
Cigarettes 3000 cancer
Smoked (men) Lung Cancer
per Person 100 Deaths (per
per Year 2000 100,000 people)
50
1000

1900 1920 1940 1960 1980

Year
 Carcinogens

• Occupation related causes

• Lifestyle related causes
‒ Tobacco
‒ Diet
‒ Sexual practices
• Multi-factorial causes
• Viral carcinogens
• Chemical carcinogens
• Ionizing radiation
Phenotypic Characteristics of Malignant
Cells
• Failure to differentiate
• Deregulated cell proliferation
• Loss of normal apoptotic pathways
• Loss of replicative senescence
• Increased angiogenesis
• Invasion and metastasis
• Evasion of the immune system
• Genetic instability
 Etiology Of Cancer

ENVIRONMENT GENES

CELL

CANCER
Douglas Hanahan and Robert Weinberg. The Hallmarks of Cancer – The Next Generation. Cell (144), March 4, 2011, pp. 646-674.
 References
• “Cancer Genetics” and “Cancer Cell Biology
and Angiogenesis” in Harrison’s Principles of
Internal Medicine, 20th ed.
• Dennis Cassiato. Manual of Clinical
Oncology, 6th ed.
• Roland Skeel and Samir Khleif. Handbook of
Cancer Chemotherapy, 8th ed.
 References
• Douglas Hanahan and Robert Weinberg. “The
Hallmarks of Cancer.” Cell, 100: 57-70, 2000.
• Douglas Hanahan and Robert Weinberg.
“Hallmarks of Cancer: The Next Generation.” Cell,
144: 646-74, March 4, 2011.
• Yousef Ahmed Fouad and Carmen Aanei.
“Revisiting the Hallmarks of Cancer.” American
Journal of Cancer Research, 7(5): 1016-1036, 2017.
• Douglas Hanahan. The Hallmarks of Cancer: The
Next Generation. Discovery, 2022, p. 33-41.
 References
• Siddhartha Mukherjee. The Emperor of All
Maladies: A Biography of Cancer. Scribner:
Ney York, New York, 2010.
• Robert Weinberg. One Renegade Cell. Basic
Books: USA, 1998.