BASIC SCIENCE
The molecular biology of
cancer: the basics
Stewart Fleming
Cancer is the second most common cause of death in the ‘devel-
oped’ world; only cardiovascular disease mortality exceeds that of
malignancy. The last two decades have seen enormous advances
in our understanding of the cellular and molecular basis of malig-
nancy, its initiation, promotion and progression. There is no single
molecular cause of cancer, and for each different cancer type,
many genes are involved.
Important definititions
Carcinogenesis is a sequence of events comprising non-lethal
genetic injury to the cell which alters the genetic code, leading to
an altered gene function. The sub-lethal nature of these insults
means that the cells survive. The cells pass the genetic alteration
to daughter cells during cell division. When the genetic alteration
gives the affected cells selective advantage in growth, there is clonal
expansion and progression towards malignancy.
Tumour progression involves interactions between tumour cells
and surrounding parenchymal or vascular components. The fol-
lowing are important in the progression of neoplasia:
• development of a supporting stroma
• sustained neoangiogenesis
• the capacity to invade, metastasize and survive in distant
sites.
Carcinogenesis and tumour progression will be addressed in a
forthcoming contribution. This review concentrates on the molecu-
lar biology of the fundamental genetic changes of the tumour cells
which lead to enhanced growth and survival (Figure 1). Readers
are strongly advised to read this contribution in conjunction with
‘Cancer biology: clinical applications’ (see CROSS REFERENCE).
Self-sufficiency for growth
Growth factors
Normal cell and tissue growth are under strict regulation which,
at the cellular level, involves a cascade of events linking cell divi-
sion to external regulatory stimuli. One important aspect of this
regulation is the cellular response to growth factors.
Growth factors are a large and heterogeneous group of sub-
stances which can act at autocrine, paracrine or endocrine levels.
In acquiring self-sufficiency of growth, many cancer cells develop
the ability to synthesize growth factors and respond to those in
an autocrine manner. Cell stimulation is termed ‘autocrine’ (or an
‘autocrine loop’) when a cell responds to a growth factor produced
by itself. The growth factor genes in cancer cells and the growth
Stewart Fleming is Professor of Cellular and Molecular Pathology,
Department of Molecular and Cellular Pathology, Ninewells Hospital and
Medical School, Dundee, UK.
SURGERY
Mechanisms for the enhanced growth of tumour cells
Self-sufficiency for growth
Insensitivity to growth inhibition
Evasion of apoptosis
Limitless growth potential
factors produced are usually normal. However, as part of the car-
cinogenesis event, some tumours produce increased amounts of
growth factors, thereby stimulating tumour cell division.
An example of this is the production of large amounts of
platelet derived growth factor by glioblastomas. The subsequent
platelet derived growth factor-dependent activation of an autocrine
growth loop is a key event in the initiation and progression of these
glioblastomas.
Receptors
Most growth factors act by binding to cell surface receptors. Cell
surface receptors are activated by ligand binding, but activated in
a transient and closely regulated way. Mutation or overexpression
of growth factor receptors is found in a large number of common
malignancies such as breast, lung and ovary (see ‘Principles of
cancer treatment by hormone therapy, page 280).
Growth factor receptor mutation: many of the mutational events
affecting growth factor receptors lead to autonomous stimulation
of the receptor independently of ligand binding.
In the papillary type of renal cell carcinoma, the C-met proto-
oncogene, which is the receptor for hepatocyte growth factor, is
truncated by mutation. This truncated form cannot bind external
hepatocyte growth factor, but exhibits spontaneous and non-regu-
lated tyrosine kinase activity. The result is renal tubular epithelial
cell growth and tumour formation, even in the absence of the
hepatocyte growth factor.
Overexpression: possibly even more frequent than growth factor
receptor mutation is the phenomenon of overexpression. The level
of expression of the growth factor receptor is increased either by
genetic amplification or a translocation event, resulting in altered
gene regulation.
Up to 30% of breast cancers show marked amplification of an
epidermal growth factor-related receptor called HER-2. Amplifi-
cation of this growth factor receptor renders the cell extremely
sensitive to physiological/subphysiological amounts of the relevant
growth factor. A high level of the HER-2 protein in breast cancer
cells has previously been an indicator of a poor prognosis. However,
the significance of its presence in breast cancer cells is focused by
the development of humanized monoclonal antibodies (e.g. trastu-
zumab). Trastuzumab can recognize the HER-2 receptor, block its
function and reduce tumour cell growth. This is an example of
the progress (through basic molecular biology) of applied cancer
research to modern clinical practice.
Signal transduction
An important step in the transfer of information from the growth
factor receptor to the nucleus is the cascade of intracellular events
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BASIC SCIENCE
known as signal transduction. Signal transduction involves several
stages, each of which amplifies the growth factor signal. There are
also regulatory elements which may dampen this signal. It is hardly
surprising that abnormalities in such key pathways regulating cell
growth have been found to be involved in a number of cancers.
Retrovirus-associated DNA sequences (RAS) are the most promi-
nent genes altered during tumourigenesis. This family of proteins
bind guanosine nucleotides and the RAS proteins ‘shuttle’ between
an activated signal transmitting state and a quiescent non-trans-
mitting state. In the quiescent state, RAS proteins bind guanosine
diphosphate. When a cell is stimulated and growth factor recep-
tor activated, the quiescent form becomes activated, exchanging
guanosine diphosphate for guanosine triphosphate. This event
activates further downstream regulators of cell proliferation.
The RAS gene may be spontaneously activated by the acquisi-
tion of point mutations. Point mutations are changes in a single
base pair in a gene usually resulting in a single amino acid change
in the encoded protein. Detailed mutational analysis of Ki-RAS
gene mutations in cancer has revealed three important mutation
‘hot spots’ at codons 12, 13 and 61, which encode amino acids in
the important guanosine triphosphate-binding region. The effect
of these mutations is to ‘hold’ the RAS protein in a permanently
activated form, resistant to quiescence. This leads to spontaneous
activation of the downstream signalling cascade, including activa-
tion of the mitogen-activated protein (MAP) kinase pathways and
enhanced cell growth.
Abelson tyrosine kinase (ABL) genes: in addition to RAS genes,
other signalling cascade genes are involved in the development of
malignancy. The ABL oncogenes, encoding a signalling tyrosine
kinase, may be activated in certain leukaemias and in some con-
nective tissue tumours. The activation of these oncogenes during
tumour formation may be dependent on mutation, or due to altered
regulation during chromosomal translocation. The importance of
the ABL kinase in malignancy has been demonstrated by the effec-
tiveness of an inhibitor of the kinase (imatinib mesylate) in chronic
myeloid leukaemia and gastrointestinal stromal tumours.
Nuclear transcription
The signalling cascade driven by growth factor receptors ultimately
leads to changes within the nucleus and of gene expression pat-
terns. These changes are mediated by families of proteins which
regulate the transcriptional activity of important cell growth genes.
Important oncoproteins include:
• MYC
• JUN
• FOS
• REL.
The MYC proto-oncogene is important in a variety of tumours,
including:
• non-Hodgkin’s lymphoma
• neuroblastoma
• small-cell cancer of the lung.
In B-cell lymphomas, the position of the MYC gene is moved by a
chromosomal translocation to the region of the immunoglobulin
heavy-chain genes. These are genes highly expressed in B-cells
and the MYC gene becomes upregulated by this close association.
SURGERY
Overexpression of MYC leads to activation of a number of cell
cycle-dependent kinases and increased cell proliferation, resulting
in B-cell lymphoma (see below).
Cell cycle-dependent genes
The consequence of activation of any of the above stages of the
growth promoting pathway is the entry of cells into the active
phase of the cell cycle (see the cell cycle in ‘Principles of cancer
treatment by radiotherapy’, page 269). The progression of cells
through the cell cycle is regulated by a number of kinases and
proteins called cyclins.
Cyclins and cyclin-dependent kinases may exist in either active
or inactive forms. In their active form, they are important in ‘driv-
ing’ the cell past key cell cycle ‘checkpoints’. In particular, the
transition from G1 to S is an extremely important checkpoint in
the cell cycle (see below). During growth stimulation, the cyclin
D family is upregulated and the cyclin-dependent kinases 4 and
6 activated.
Insensitivity to growth inhibitory signals
Growth inhibitory signals are equally important as growth stimu-
latory signals in regulating cell cycle progression. Insensitivity to
these signals (acquired by genetic alteration) is important in the
genesis of many malignancies. The genes affected are collectively
known as ‘oncosuppressor’ genes or ‘tumour suppressor’ genes,
and usually act in either a recessive manner or occasionally by a
dominant negative mechanism.
Knudson’s ‘two-hit hypothesis’
The concept of tumour suppressor genes was first elucidated
by Knudson in 1974. He showed that both copies of the onco-
suppressor genes have to be altered for tumour development to
occur (two-hit hypothesis), which he described following research
on retinoblastoma. The identity of the retinoblastoma gene was
subsequently confirmed, and its mode of action extensively
studied. Knudson also proposed a ‘two-hit event’ in Wilms’
tumour (nephroblastoma), a hypothesis which was subsequently
confirmed.
Retinoblastoma
Knudson’s two-hit hypothesis stated that the functional loss of
both copies of the retinoblastoma gene are required for tumour
formation. In familial cases of retinoblastoma, children inherited
one defective copy from a parent and the other copy was normal.
Subsequently a mutation was acquired in the previously normal
copy. Research in experimental animals has suggested that ultra-
violet light landing on the retina may be one of the causes of this
second mutation in retinoblastoma. In sporadic cases of retino-
blastoma, both retinoblastoma alleles are normal at birth, but are
then lost by later somatic events.
Although the retinoblastoma gene was identified in the retino-
blastoma tumour, it is also known to be involved in many other
forms of cancer, especially breast cancer and small-cell carcinoma
of the lung.
The retinoblastoma gene acts as a ‘gatekeeper’ in the cell cycle
checkpoint between G1 and S (Figure 2). In its active non-phos-
phorylated state, it prevents the transition of the cell from G1 to S.
iv © 2003 The Medicine Publishing Company Ltd
BASIC SCIENCE
However, when it is phosphorylated and inactivated, the cell can
progress through to the S, G2 and M phases. During this progression
round the cell cycle, the phosphate groups are removed from the
retinoblastoma gene by cell cycle-dependent phosphatases regen-
erating the active (suppressor) gatekeeper form of the protein.
The main mode of action of retinoblastoma involves the
transcription regulatory proteins of the E2F family. The active
(suppressor) form of retinoblastoma protein binds E2F, whereas
phosphorylation to the inactive form allows the release of E2F.
The released E2F binds to promoter regions of S phase genes,
allowing their transcriptional activation and the progression of
the S phase. Mutant retinoblastoma protein is unable to perform
this task of binding E2F proteins. Therefore, cells lacking func-
tional retinoblastoma protein are maintained in a state where the
transition from G1 to S and progression through the cell cycle can
be readily achieved because of the absence of the retinoblastoma
gatekeeper function.
Adenomatous polyposis coli (APC) genes
Another growth regulatory pathway which has been shown to be de-
fective in malignancy is that involving the APC and β-catenin genes.
The APC gene, which is commonly impaired in colon cancer,
has a strong, but unusual, antiproliferative action. The product
of the APC gene is a cytoplasmic protein, the main function of
which is to regulate the levels of β-catenin. It does so by binding
free β-catenin within the cytoplasm and targeting the catenin for
intracellular destruction. β-catenin has two main roles, functioning
as part of the cell adhesion complex and, when translocated to the
nucleus, activating the transcription of cell proliferation genes.
When the APC gene is mutated and functional APC protein
absent, cytoplasmic levels of β-catenin rise, leading to increased
translocation to the nucleus and activation of proliferation path-
ways. APC mutation, like retinoblastoma mutation, can arise by
either inherited or sporadic pathways. Loss of APC appears to be
The relationship between activated cell cycle-dependent kinase and phosphorylation of
retinoblastoma protein in overcoming the G1–S transition in the mammalian cell cycle
ACTIVE KINASE
Rb
G1 G1–S checkpoint
KINASE ACTIVATION
M
G0
INACTIVE KINASE
Rb: Retinoblastoma protein
pRb: Phosphorylated retinoblastoma protein
2
SURGERY
an early event in the pathway to colorectal cancer, leading to the
increased cell proliferation of adenomas and early carcinoma.
Evasion of apoptosis
In any cell population, an increase in cell number may arise by
either increased proliferation or by reduced cell death. Although
there are two forms of cell death, apoptosis and necrosis, the one
which is used as a regulatory mechanism is apoptosis. Tumours
may therefore occur in circumstances where apoptosis pathways
are blocked. One of the first examples of this mechanism to be
identified was the role of Bcl-2 in B-cell lymphomas.
B-cell lymphomas
Many B-cell lymphomas (particularly follicular) involve chromo-
somal translocations of t(14,18) (q32, q21). The Bcl-2 gene is car-
ried in the 18q21 region and this translocation results in it being
regulated by the immunoglobulin heavy gene promoter region
on chromosome 14. In B-cells, this leads to active transcription
of high levels of Bcl-2. Bcl-2 inhibits apoptosis by preventing the
release of cytochrome C from mitochondria. Hence, B-cells with
this translocation, and high levels of Bcl-2 are resistant to the regu-
latory effects of apoptosis. These lymphomas arise from reduced
cell death rather than increased proliferation; they therefore tend
to be rather indolent, but are particularly resistant to any therapies
which involve activating the apoptosis pathway.
Tumour protein 53 (p53) suppressor gene
One of the most frequent mutations in human malignancy involves
the p53 tumour suppressor gene. The normal function of this gene
is to exert anti-proliferative and pro-apoptotic effects in response,
amongst other things, to genotoxic damage. Normal p53 has a
short half-life because of its rapid destruction in association with
the protein called Mdm-2. Following genotoxic damage, abnormal
pRb
S
INACTIVE KINASE
G2
v © 2003 The Medicine Publishing Company Ltd
BASIC SCIENCE
p53 is released from Mdm-2, increasing its half-life and leading
to accumulation within cells. Normal p53 activates a number of
growth inhibitory proteins and pro-apoptotic genes, allowing cells
to be paused during proliferation and for DNA repair to occur. If
repair cannot be achieved satisfactorily, there is elimination of the
damaged cells by apoptosis.
p53 functions as a tumour suppressor gene, so complete func-
tional loss is required for carcinogenesis. This is often achieved,
even in the heterozygous state, by a dominant negatively acting
mutation. A proposed mechanism suggests that the mutant protein
interferes with the protective action of the normal p53 protein.
This functional loss allows survival and continued proliferation of
cells which have acquired genotoxic damage and mutations. There
is, therefore, a mechanism within tumours for the acquisition of
further mutations in other key pro-neoplastic genes. Since many
chemotherapeutic and radiotherapeutic regimens act on tumour
cells by triggering p53-dependent apoptosis, tumours with these
mutations tend to be more resistant to therapy. It has been esti-
mated that up to 70% of human epithelial malignancies exhibit
functional loss of p53.
Limitless growth potential
The capacity for cells to continue dividing is limited by a phenom-
enon known as cellular senescence. This phenomenon is thought
SURGERY
to depend on progressive shortening of the chromosome ends (telo-
meres). The enzyme telomerase acts to restrict telomeric shortening.
Although it is important that telomerase is active in self-replicating
stem cells (which allow the re-population of labile cell types such
as intestinal and epidermal cells), most normal cells lack telom-
erase. Tumour cells may increase their potential for replication by
activating telomerase and resisting cellular senescence.
Summary
A number of different cell processes are involved in the increased
growth potential seen in tumours. I have focused on tumour cell
growth achieved by several different cellular processes in this
review. Each of these mechanisms involves well-recognized gene
families, either activated (in the case of oncogenes) or lost (in the
case of oncosuppressor genes).
However, further stages of tumour progression, invasion and
metastasis are equally important in the biology of cancer. These
later cellular events will be discussed in a subsequent contribution
in this series. u
CROSS REFERENCE
Johnston S R D, Gore M E. Cancer biology: clinical applications.
Surgery 2003; 21(6): 160a–e.
vi © 2003 The Medicine Publishing Company Ltd