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Contents lists available at ScienceDirect

Leukemia Research
journal homepage: www.elsevier.com/locate/leukres

Smoking as a contributing factor for development of polycythemia

vera and related neoplasms
Hans Carl Hasselbalch
Department of Hematology, Roskilde Hospital, University of Copenhagen, Koegevej 7-13, 4000 Roskilde, Denmark

a r t i c l e i n f o a b s t r a c t

Article history: Smoking may be associated with accelerated erythropoiesis, leukocytosis and thrombocytosis, which
Received 1 July 2015 are also hallmarks in patients with polycythemia vera, essential thrombocythemia and early stages of
Received in revised form 29 August 2015 myelofibrosis (MPNs). The JAK-STAT and NF-␬B signaling pathways are activated in both smokers and
Accepted 4 September 2015
in patients with MPNs. Additionally, both share elevated levels of several proinflammatory cytokines,
Available online xxx
in vivo activation of leukocytes and platelets, endothelial dysfunction and increased systemic oxidative
stress. Based upon experimental, epidemiological and clinical data it is herein argued and discussed, if
Keywords:
smoking may be involved in MPN pathogenesis, considering most recent studies and reviews which are
Smoking
Chronic myelomonocytic stimulation supportive of the concept that chronic inflammation with NF-␬B activation and oxidative stress may have
Essential thrombocythemia a major role – both as triggers but also as the driving force for clonal expansion in MPNs.
Polycythemia vera © 2015 Elsevier Ltd. All rights reserved.
Primary myelofibrosis
Myeloproliferative neoplasms MPNs
Thrombosis
Atherosclerosis
NF-␬B
JAK-STAT-signaling
IL-8

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2. Link between smoking and risk of thrombosis in MPNs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3. Link between smoking and myeloproliferative cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4. Epidemiological evidence for a link between smoking and myeloproliferative cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
5. NF-␬B and JAK-STAT activation—the molecular links between smoking and development of myeloproliferative cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . 00
6. The transcription factor nuclear factor erythroid-2 (NF-E2) and IL-8. Is IL-8 the master cytokine linking smoking and
myeloproliferative cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7. Experimental evidence that smoking may be associated with myeloproliferative cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
8. Discussion and perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
9. Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

acquired stem cell neoplasms constituting a biological continuum

1. Introduction
from early disease stage (ET and PV) to the advanced “burnt-
out” MF phase and ultimately leukemic transformation [1]. Most
The Philadelphia-negative chronic myeloproliferative neo-
recently, their development from early to advanced disease has
plasms (MPNs) encompass essential thrombocythemia (ET),
been proposed to depict “A Human Inflammation Model for Cancer
polycythemia vera (PV) and primary myelofibrosis (MF), which are
Development” [2], taking into account that chronic inflammation,
which is also generated by the neoplastic cells themselves, may be
an important driver of clonal evolution, premature atherosclero-
E-mail address: hans.hasselbalch@gmail.com sis and development of second cancer as well [2]. In this scenario,

http://dx.doi.org/10.1016/j.leukres.2015.09.002
0145-2126/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: H.C. Hasselbalch, Smoking as a contributing factor for development of polycythemia vera and related
neoplasms, Leuk Res (2015), http://dx.doi.org/10.1016/j.leukres.2015.09.002
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chronic inflammation may also be a promoter of mutations, con-
tributing to the steady increase in mutations that characterizes
MPNs [2]. In 2005, the discovery of the JAK2V617F activating mutation
[4–6] generated increasing research into the role of JAK/STAT dys-
regulation in MPNs [7,8]. Most recently somatic mutations in the
calreticulin (CALR) gene have been identified in a large proportion
of patients with JAK2V617 negative ET and myelofibrosis [9–11].
STAT-mediated transcriptional activation of known target genes
mediates diverse cellular events that affect cell growth, differ-
entiation and apoptosis [12,13]. In general, persistently activated
JAK/STAT signaling is associated with tumorigenesis and cancer
progression [14,15]. Thus, transcriptional targets of STATs are
involved in a number of cancer pathways, including the regulation
of cell survival, proliferation, differentiation, and the angiogenic
cascade [14–16]. In particular, STAT3 has been implicated in induc-
ing cancer-promoting inflammation [16]. By triggering the nuclear
factor-␬B (NF-␬B) and JAK pathways, STAT3 activates the pro-
duction of enzymes such as matrix metalloproteinases, classic
immunomodulatory cytokines including IL-6, IL-10, IL-17, and IL-
23, and growth factors (e.g. VEGF and FGF) [3,17]. Taking into
account that smoking is a highly potent inflammatory stimulus
for NF-␬B and JAK pathways and nicotine is a potent stimulator
of neutrophil-IL-8 production with subsequent NF-␬B activation
and IL-8 production contributing to leukocytosis in tobacco smok-
ers [18], it is intriguing to consider if smoking - by a persistent
chronic myeloid hyperstimulation as evidenced by elevated hema-
tocrit, leukocytosis and thrombocytosis - may actually be one of
several inflammatory triggers of clonal MPN-evolution and the
driving force for further clonal expansion as well. Based on evi-
dence obtained from experimental, clinical and epidemiological
studies, it is argued and discussed, if smoking may be involved in
MPN pathogenesis, considering most recent studies and reviews,
which are supportive of the concept, that chronic inflammation
with NF- ␬B activation and oxidative stress may have a major role,
both as a trigger but also as the driving force for clonal expansion
in MPNs. The perspectives of smoking as one of several inflam-
matory stimuli potentially triggering and driving the MPN-clone
are discussed in the context that both smoking and MPNs give rise
to a continuous release of several proinflammatory cytokines and
chemokines, which may not only predispose to the development of
premature atherosclerosis but also – by a sustained inflammatory
drive – may elicit other inflammation-mediated diseases, immune
deregulation with an impaired tumor immune surveillance, DNA-
damage, genomic instability and ultimately cancer development
[2,3].
2. Link between smoking and risk of thrombosis in MPNs?
Smoking is associated with leukocytosis and elevated C-reactive
protein, reflecting the chronic inflammatory state/oxidative stress
induced by smoking [18,19] and implying an increased risk of
atherothrombosis, cardiovascular diseases, the metabolic syn-
drome and cancer [20–26]. Accordingly, several studies have shown
smoking to be an independent risk factor for cardiovascular events
in the general population. Thus, in the Framingham study smoking
was associated with an elevated hematocrit and multivariate analy-
sis displayed a correlation between the risk of stroke and increased
blood pressure and smoking. However, without the factor of smok-
ing, the association between an elevated hematocrit and stroke was
not significant [27] .
About 20 years ago a significant association between smoking
and the risk of arterial thrombosis was demonstrated in patients
with ET with more than twice as many arterial complications in
those with cardiovascular risk factors, especially smoking [28]. In
particular the association to cigarette smoking was shown to be
Please cite this article in press as: H.C. Hasselbalch, Smoking as a contributing factor for development of polycythemia vera and related
neoplasms, Leuk Res (2015), http://dx.doi.org/10.1016/j.leukres.2015.09.002
strong in younger females with ET, who suffered arterial cerebral
vascular accidents [29]. A few years later – in 2001 – a Finnish study
showed smoking to be an independent cardiovascular risk factor
in ET [30]. Unfortunately, a most recent study on the association
between an increased hematocrit level and vascular complications
in patients with PV did not stratify their patients according to
smoking habits [31]. The impact of smoking on thrombosis risk
was neither addressed in a large epidemiological study of 1.638
patients with PV [32] and in two of the largest randomized studies
in ET and PV [33,34]. However, a later data analysis in the Euro-
pean Collaboration on Low- Dose Aspirin in Polycythemia Vera
(ECLAP) study displayed the risk of arterial thrombosis to be signif-
icantly increased by smoking [35]. For unknown reasons a history
of smoking was less likely to be associated with a history of vascu-
lar complications in one study [36]. Despite the strong association
between smoking and risk of thrombosis in the general population
and therefore – most reasonable – in MPNs as well smoking has
not been addressed as a separate major risk factor for thrombosis
(but included in the cardiovascular risk cluster) in recent reviews
or updates on diagnosis, risk-stratification and management of ET
and PV [37,38].
3. Link between smoking and myeloproliferative cancer?
A possible causal relationship between smoking and the devel-
opment of myeloid cancer has been repeatedly reported in the
literature, focusing largely on an association between smoking and
acute myelogenous leukemia (AML) or myelodysplastic syndrome
(MDS). Most recently, this association has been substantiated in a
large meta-analysis of epidemiological studies, which concluded
that there is a 26% increase in the odds of developing AML in
those, who have ever smoked compared to never smokers and in
current smokers the odds are increased by 42% [39]. Similarily, a
recent meta- analysis has confirmed a positive association between
cigarette smoking and incidence of MDS. This meta-analysis con-
cluded, that this association occurs in a dose-dependent manner
[40]. Whereas the association between smoking and AML/MDS
accordingly is well-established in several studies, information on a
potential association between smoking and the occurrence of the
MPNs has been scanty or not existing until very recently (Fig. 1).
4. Epidemiological evidence for a link between smoking
and myeloproliferative cancer?
A most recent large epidemiological study of about 50,000 Dan-
ish individuals from the general population reported JAK2V 617F to
be more common in smokers than in non-smokers [41] , supporting
the contention that smoking with inflammation-mediated chronic
myeloid hyperproliferation might ultimately elicit mutations in
hematopoietic stem cells, including JAK2V 617F Furthermore, in a
cohort of hospitalized smokers and nonsmokers, JAK2V 617F was
more prevalent and found in higher frequencies among smokers
than nonsmokers [42]. It was suggested that sustained accelerated
erythropoiesis might render the cells susceptible to JAK2V 617F [42].
An association between smoking and an increased risk of MPNs
was also recorded by Kroll et al. among frequent smokers in the UK
Million Women Study [43] . Most lately, a large prospective study
of a cohort of 27,370 women found current cigarette smoking to be
associated with an increased risk of all MPNs. In a subtype analysis,
this association was stronger for PV than for ET and the risk was
only significantly increased for PV patients [44]. Other studies have
found no significant association between smoking and MPNs [45].
Larger epidemiological studies on smoking in MPNs and poten-
tial association to risk of thrombosis are summarized in Table 1.
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Fig. 1. The Smoke-MPN-Cancer Loop.

Smoking is associated with chronic systemic inflammation and oxidative stress. Smoking induces activation of the NF-␬B and JAK-STAT-pathways, which are both involved
in tumorigenesis and cancer progression. By triggering the NF-␬B and JAK pathways, smoking elicits the production of several proinflammatory cytokines, including e.g. IL-6,
IL-8 and TNF- alpha, but also the release of several growth factors, including VEGF, TGF-beta and FGF. Taking into account that both pathways are activated in MPNs as well
these pathways may constitute the common links between smoking, chronic inflammation and the development of MPNs. TGF-beta and VEGF are elevated in patients with
MPNs and are both highly immunosuppressive cytokines, impairing the functionality of several immune cells (dendritic cells, NK cells, and cytotoxic T cells) involved in
tumor immune surveillance and thereby contributing to tumor immune evasion. Clonal evolution in MPNs is thought to be driven by several inflammatory cytokines, growth
factors, and chemokines released from activated platelets, including, e.g. PDGF, TGF, VEGF, HGF,IL-1beta, and IL-8, all having the potential to facilitate metastasis. For instance,
TGFbeta is directly involved in the signaling between platelets and cancer cells, inducing an epithelial–mesenchymal transition of tumor cells, promoting their metastatic
potential. By enhancing inflammation and oxidative stress in MPNs smoking may likely aggravate the detrimental effects of thrombocytosis upon cancer invasiveness and
metastasis [54].

5. NF-␬B and JAK-STAT activation—the molecular links pressing immune cells and accordingly impairing tumor immune
between smoking and development of myeloproliferative surveillance. Regarding the sustained myeloid drive in smokers it
cancer? has been suggested that this might lead to more DNA repair errors
secondary to increased cell division [56,57] and thus to an increased
As previously outlined smoking is a highly potent inflammatory prevalence of the JAK2 mutation [56] . Ultimately, chronic inflam-
stimulus for activation of NF-␬B and JAK pathways [18]. Nicotine mation during MPN-progression may not only drive development
activates neutrophils and triggers neutrophils to produce monocyte of second cancers but also several other inflammation-mediated
chemoattractant protein (MCP)-1 and macrophage inflammatory comorbidities [58].
protein (MIP)-1, both proteins requiring NF-kB for their gene tran-
scription [18]. The NF-kB pathway is considered as the link between
6. The transcription factor nuclear factor erythroid-2
chronic inflammation, atherosclerosis and cancer [46–50]. The NF-
(NF-E2) and IL-8. Is IL-8 the master cytokine linking
kB pathway is constitutively activated in MPNs as well and being
smoking and myeloproliferative cancer?
implicated in the abnormal release of TGF-beta this pathway has
an important role in the development of bone marrow fibrosis
Taking into account that IL-8 is considered of utmost importance
in patients with MPNs [51]. Since smoking (nicotine) deregulates
in MPN-pathogenesis [59–63] and expression of IL-8 is a predic-
microRNAs involved in TGF-␤-dependent epithelial-mesenchymal
tor of inferior outcome in patients with MPNs [61] it is intriguing
transition potentially promoting tumor invasiveness and metasta-
to consider, if IL-8 might be the master cytokine linking smoking
sis [52] it is tempting to speculate, if smoking may have a particular
and myeloproliferative cancer, since smoking (nicotine) potently
detrimental impact in patients with MPNs, when considering that
stimulates neutrophil-IL-8 production with subsequent NF-kB acti-
MPNs are associated with a 40% increased risk of second cancers
vation [18]. In the context of IL-8 being a novel target gene for
[53] and thrombocytosis has a major negative impact on cancer
NF-E2, which has been shown to mediate the expression of IL-8
prognosis in the general population and likely also in patients with
[63] and NF-E2 most recently has been reported to be implicated
MPNs [54]. Thus, smoking and thrombocytosis may have addi-
in the pathophysiology of MPNs [64] it is important to under-
tive deleterious effects in augmenting cancer invasiveness and its
score that NF-E2 upregulation is not specific for MPNs but is seen
metastatic potential. In the context that TGF-␤ is highly immuno-
in polycythemic disorders characterized by increased hypoxia-
suppressive, impairing the functionality of several immune cells
inducible factor (HIF)-signaling [65]. Furthermore, it has recently
(dendritic cells, NK cells, and cytotoxic T cells) involved in tumor
been argued that NF-E2 might actually have a role in sustaining
immune surveillance [55] NF-kB activation by smoking might the-
the chronic inflammatory state and accordingly clonal evolution in
oretically not only enhance TGF-␤ -release in the bone marrow
MPNs [66]. Thus, sustained overexpression of NF-E2 might induce
and thereby promoting bone marrow fibrosis in MPNs but may
myeloid expansion with leukocytosis and thrombocytosis and
also indirectly promote expansion of the malignant clone by sup-
in vivo leukocyte and platelet activation with continuous release of

Please cite this article in press as: H.C. Hasselbalch, Smoking as a contributing factor for development of polycythemia vera and related
neoplasms, Leuk Res (2015), http://dx.doi.org/10.1016/j.leukres.2015.09.002
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Table 1
Studies on smoking in MPNs and potential association to risk of thrombosis.

Article Risk of thrombosis Comments

Watson and Key [28] Increased in smokers In a retrospective analysis of 46 patients, arterial complications occurred in
20/46 patients (43.4%). Cigarette smokers had more than twice as many
arterial complications than patients without risk factors.

Pasqualetti et al. [45] NA A case-control study of a total of 1216 patients with various hematological
malignancies, including 92 MPN patients of whom 52% were smokers.
Smoking was not significantly associated with the development of MPN. An
association between smoking and thrombosis was not addressed.

Randi et al. [29] Increased in smokers A retrospective study of a total of 41 young patients affected by ET. Common
risk factors, such as hypertension, smoke, obesity, dyslipidemia, and diabetes
were registered. Nine out of the 41 patients had CVEs. Four out of the 9
patients were heavy smokers. Amongst the atherosclerotic risk factors
cigarette smoking, in particular, seemed to be related to arterial CVEs in ET.

Jantunen et al. [30]
Increased in smokers A retrospective study of 132 patients with ET. The impact of the cardiovascular
risk factors smoking, hypertension, hypercholesterolemia, and diabetes
mellitus on the risk of thrombotic complications was evaluated. In
multivariate analysis the only independent risk factor was smoking, which had
a strong predictive value for the development of arterial complications in
women but not in men.

Marchioli et al. [32]
NA 1638 Patients were enrolled into a large, prospective multicenter study.
Overall mortality rate resulted from a moderate risk of cardiovascular death
and a high risk of death from noncardiovascular causes (mainly hematologic
transformations). Age older than 65 years and a positive history of thrombosis
were the most important predictors of cardiovascular events. 12.8% were
current smokers. Smoking was not addressed as a contributing risk factor for
cardiovascular events.

Marchioli et al. [31]
NA 365 adults with JAK2-positive polycythemia vera were randomly assigned to
receive either more intensive treatment (target hematocrit, <45%)
(low-hematocrit group) or less intensive treatment (target hematocrit, 45 to
50%) (high-hematocrit group). The patients were treated with phlebotomy,
hydroxyurea, or both. After a median of 31 months patients who were
maintained at hematocrit target of 45 to 50% suffered four times the rate of
death from cardiovascular causes or major thrombosis (primary end point).
Smoking was not included in the subgroup analysis or discussed as a
confounding factor.

Landolfi et al. [35] Increased in smokers Determinants of vascular risks were investigated in this study, which gathered
information from the prospective ECLAP observational study in PV, including
1638 patients and recorded 205 thromboses in 169 patients. A multivariate
analysis on clinical and laboratory parameters showed only leukocytosis to be
significantly associated with the vascular risk. Hypertension was most
prevalent (39.5% of PV patients), followed by smoking (12.8%), diabetes (7.1%),
and high blood cholesterol (3.5%). Smoking was significantly associated with
increased risk of arterial thrombotic events. Smoking as an inflammatory
stimulus contributing to leukocytosis and accordingly also contributing to the
observed link between leukocytosis and vascular risk was not explored or
further discussed.

Harrison et al. [34]
NA A total of 809 patients with essential thrombocythemia who were at high risk
for vascular events received low-dose aspirin plus either anagrelide or
hydroxyurea.Smoking was not included in the high risk criteria which
otherwise included the following: an age of at least 60 years; current or
previous platelet counts of 1 million per cubic millimeter or more; a history of
ischemia, thrombosis, or embolism; hemorrhage caused by essential
thrombocythemia; hypertension requiring therapy; and diabetes requiring the
administration of a hypoglycemic agent. Information on a smoking history was
available in 673 patients. Regular daily cigarette smoking at enrollment was
recorded in 110/673 patients (33%).

Stein et al 2011 [36]
Not increased in smokers
A retrospective study of 270 consecutive JAK2 V617F positive MPN patients
with ET, PV, or MF. A smoking history was recorded in 61 patients (22.6%) (a
significantly higher percentage among men than women). For unknown
reasons, those with a history of tobacco use were less likely to have a history of
vascular complication.

Abbreviations: NA: not addressed; CVE = cerebrovascular events.

inflammatory products from activated leukocytes and platelets [66]
. Importantly, smoking is associated with increased HIF-signaling
and accordingly upregulation of NF-E2 as well [67]. The obser-
vations of identical molecular pathways (e.g. JAK-STAT-signaling,
HIF-signaling) and transcriptions factors (e.g. NF-kB, NF-E2) being
activated in smokers and in patients with MPNs are supportive
of the concept that smoking - as a chronic systemic inflammation
stimulus – might have a role for the development and progression
of MPNs. In this context it is also important to note that several
inflammatory cytokines (e.g. IL-1beta, IL-6, IL-8, TGF- beta) – all
being elevated in both smokers and in MPNs – also induce up-
regulation of HIF1alpha in a STAT3-dependent manner [68]. All
together, IL-8 and NF-E2 may be the major molecular links between

Please cite this article in press as: H.C. Hasselbalch, Smoking as a contributing factor for development of polycythemia vera and related
neoplasms, Leuk Res (2015), http://dx.doi.org/10.1016/j.leukres.2015.09.002
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smoking and MPNs, sharing in addition activation of JAK-STAT, NF-
kB and HIF-signaling pathways.
7. Experimental evidence that smoking may be associated
with myeloproliferative cancer
One of the toxic compounds in cigarette smoke is formaldehyde
(FA), which has been shown to be associated with the develop-
ment of cancer, including leukemia [69] and accordingly has been
classified as a human leukemogen [70,71]. Until recently the bio-
logical plausibility of FA-induced leukemia has been controversial
[72] due to limited information on the ability of FA to disrupt
hematopoietic function [73]. However, a most recent study has con-
vincingly demonstrated that exposure of mice to FA by inhalation
induces bone marrow toxicity with typical MPN-like alterations,
including an increased number of megakaryocytes and myelofibro-
sis [74]. In addition, the mice developed anemia, leukopenia and
thrombocythemia [74]. Highly interestingly, these changes were
accompanied by evidence of oxidative stress and inflammation in
the bone marrows as assessed by significant increases in ROS levels
in concert with significantly increased NF-kB activity at both mRNA
and protein levels and significant increases in the inflammatory
markers – TNF-alpha and IL-1beta – as well [74]. These observations
are in line with studies showing that oxidative stress in hematopoi-
etic stem cells can lead to DNA damage, premature senescence, and
loss of stem cell function [75]. Accordingly, all together these find-
ings are supportive of the concept that smoking by induction of
oxidative stress and an inflammatory bone marrow microenviron-
ment may give rise to DNA damage and likely an impaired stem cell
function with ensuing development of myelofibrosis.
8. Discussion and perspectives
Chronic inflammation is the common link between common
diseases such as atherosclerosis, the metabolic syndrome, type II
diabetes mellitus and cancer, in which the JAK-STAT- signaling
and the NF-kB pathways are activated and have major roles for
disease progression [2,3,20–26,46–50]. These pathways are consti-
tutively activated in patients with MPNs due to mutations [1,4–11].
Consequently, the MPNs constitute a biological continuum from
early cancer stage with elevated cell counts (ET, early prefibrotic
myelofibrosis, PV) to the advanced burnt-out phase with severe
myelofibrosis, anemia and huge splenomegaly. At this metastatic
stage CD34+cells have egressed from the bone marrow to seed
in the spleen and liver and elsewhere. Additional mutations are
common and determinant for leukemic transformation [8,11].
Recent cytokine and transcriptional studies have shown, that
the MPNs are associated with marked deregulation of several
inflammation and immune genes of importance for tumor immune
surveillance [17,59,61,62,76–78]. Thus, it has been proposed that
chronic inflammation may have a role for both disease initiation but
also being the driving force for clonal evolution. In this regard the
MPN clone per se may “fuel the fire “by the continuous release of
inflammatory products, thus creating a vicious self-perpetuating
circle [2,3,17] and a chronic inflammatory state being charac-
terized by a massive cardiovascular disease burden [58] and an
increased risk of second cancers [53,58]. Importantly, MPNs have
most recently been shown to be associated with a marked dereg-
ulation of oxidative and antioxidative defence genes, which might
further add to the development of premature atherosclerosis (early
ageing?), clonal evolution and development of second cancers [79].
In this regard, the MPNs have been described as “A Human Inflam-
mation Model” and “A Human Inflammation Model for Cancer
Development” [2]. To this end, a high JAK2 expression in myeloid
cells – mediated by smoking – might render these cells more prone
Please cite this article in press as: H.C. Hasselbalch, Smoking as a contributing factor for development of polycythemia vera and related
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5
to an increased response to inflammatory cytokines with an inher-
ent risk of errors during DNA replication and ultimately mutations
in JAK2 exons 14 and 12 and other mutations as well [80].
Smoking and MPNs share several clinical, biochemical and
molecular characteristics, which might all be mediated by chronic
inflammation and oxidative stress (summarized in Table 2). These
common features include a high risk of thrombosis, being explained
by leukocytosis, thrombocytosis (in smoking less pronounced than
leukocytosis) and in vivo leukocyte, platelet and endothelial acti-
vation [26,81]. Smoking elicits massive systemic inflammation
with enhanced oxidative stress in virtually all organs, giving rise
to inflammation-mediated premature atherosclerosis with a huge
cardiovascular and pulmonary disease burden [26] and a high risk
of cancer in several organs, primarily lung, esophagus and urinary
tract cancer [25,26] but also an increased risk of hematological can-
cers, including AML and MDS [39,40]. Interestingly, lung cancer
and urinary tract cancer are amongst the most frequent second
non- hematological cancers in patients with MPNs [53], which
might actually reflect an association to smoking. Furthermore,
smoking and MPNs are associated with virtually identical alter-
ations in hemostasis and coagulation parameters [26,81], including
increased blood viscosity associated with an increased hematocrit
(PV) and/or plasma viscosity, the latter being explained by ele-
vated circulating levels of acute phase proteins (e.g. fibrinogen) and
lipoproteins [26,81,82]. Considering markers of endothelial dys-
function endothelial tissue plasminogen activator antigen (t-PA)
has been shown to be elevated in both smokers and patients with
MPNs [26,81]. Endothelial dysfunction in smokers and patients
with MPNs is among others caused by diminished production
or availability of nitric oxide (NO). Ultimately, loss of NO facil-
itates inflammatory cell entry into the arterial wall, oxidatively
modified LDL being taken up by macrophage scavenger recep-
tors, thereby promoting cholesterol ester accumulation and foam
cell formation with ensuing atherothrombosis. Upregulation of
the CD40/CD40L in endothelial cells – likely triggered by oxida-
tively modified LDL-, increased plasma levels of soluble CD40,
soluble adhesion molecule E-selectin (sELAM) and thrombomod-
ulin, and platelet/monocyte aggregation are additional factors,
contributing to atherothrombosis in smokers and patients with
MPNs [81,82]. In both conditions inflammatory cells are activated
and produce a large number of acute-phase proteins and cytokines
[17,50,61,62]. Accordingly, both conditions are characterized by
low-grade inflammation [17,80,81], which per se is associated with
a risk of atherosclerosis [20–26], muscle loss with cachexia and can-
cer [46–50]. These detrimental effects are among others mediated
by activation of the inflammatory pathways – NF-kB and JAK-STAT
[1–3,16,17] – thus being the common molecular links between
chronic inflammation and the development of atherosclerosis and
cancer in smokers and patients with MPNs. Highly interesting,
a most recent epidemiological study on lifestyle risk factors for
myeloproliferative neoplasms in a large cohort of women found
current cigarette smoking to be associated with an increased risk of
all MPNs. This association was stronger for PV than for ET although
not statistically different [44].
The perspectives of smoking as a contributing factor for devel-
opment and progression of MPNs are several. First, smoking
may substantially enhance the chronic inflammatory state in
MPN-patients [2,3,17] , thereby accelerating the development of
atherosclerosis (premature atherosclerosis) and early ageing. Sec-
ond, the increased risk of second cancer in MPN-patients [53,54]
may be further markedly increased by smoking due to enhance-
ment of chronic systemic inflammation [2,3,25,26]. This contention
is supported by the particular risk of lung cancer and urinary tract
cancer in patients with PV [53] and the association between smok-
ing and PV, implying carcinogenic pathways to be involved in
MPN-pathogenesis [44]. Third, smoking is associated with chronic
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Table 2
Similarities between smoking, chronic inflammation and MPNs.

Smoking CI diseases# MPNs# Comments

Clinical
Risk of CVE Increased Increased Increased CI is considered to contribute significantly in all three
entities [2,3,20–26,28,81,89,90,97,98,100]

Risk of CKD Increased Increased Increased CI is considered to contribute significantly in all three
entities [3,20–26,28–32]

Risk of PA Increased Increased ? PA is well described in smokers [20–26,100] and patients

with CI diseases; in MPNs CI has recently been suggested
to elicit and drive the evolution of PA [3,6,17,58]

Risk of VT Increased Increased Increased CI significantly increases the risk of thromboembolic

diseases in all three entities [3,26,58,81]

Risk of MS and DM Increased Increased Increased in ET/? A recent study has found an association between risk of MS
and ET [44]

Risk of AD Increased Increased ? Epidemiological studies are ongoing to investigate

whether MPNs are associated with an increased risk of
dementia, including AD.

Risk of COPD Increased Increased ? Smokers and patients with CI diseases have an increased
risk of developing COPD [26]; studies are ongoing to
elucidate whether MPNs are associated with impaired
pulmonary function (COPD)

Risk of organ fibrosis Increased Increased Increased CI is proposed as the common denominator for organ
fibrosis in smokers, patients with CI diseases and patients
with MPNs.3,99 In this regard the MPNs may depict “ A
Human Inflammation Model for Development of Fibrosis “
the ultimate outcome of CI being the development of
myelofibrosis [3]

Risk of cancer Increased Increased Increased Smokers have an increased risk of cancer, in particular
lung and bladder cancer, which are also associated with
MPNs (a 40 % increased risk of second cancer) [53]

Biochemical

CI markers Increased Increased Increased CI is the common denominator for elevated inflammatory
markers across all there entities

In vivo activation of leukocytes/platelets and endothelial cells Increased Increased Increased CI is the common denominator for in vivo cell activation.
In MPNs the JAK2V617F mutation is a strong contributing
factor which together with CI create a self-perpetuating
inflammatory vicious circle [3]

Markers of ECD Increased Increased Increased CI is considered to play a major role for ECD [26,81,82]

Markers of OS Increased Increased Increased CI with the induction of increased OS is considered of

major importance for development of organ dysfunction
and cancer in smokers, CI diseases and in MPNs as well
[23,26,46–53,79]

Molecular Pathways

JAK-STAT/NF-␬B HIF, NF-E2 Increased Increased Increased The JAK-STAT and NF-␬B signaling pathways are activated
in both smokers, patients with CI diseases and in patients
with MPNs; the common denominator for JAK-STAT,
NF-␬B,HIF and NF-E2 activation is among others CI
[3,20–26]

Abbreviations : # : CI = chronic inflammation : examples of chronic inflammatory: psorias, rheumatoid artritis„ inflammatory bowel diseases (Crohn’s disease,colitis ulcerosa)
; MPNs : essential thrombocythemia, polycythemia vera, primary myelofibrosis; CVE : cardiovascular events = ischemic heart disease, myocardial infarction, apoplexia cerebri,
peripheral arterial arterial diseases ; VT : venous thromboembolism ; CKD: chronic kidney disease ; PA: premature atherosclerosis MS: metabolic syndrome; DM = type
II diabetes mellitus; AD : Alzheimers disease ; COPD : chronic obstructive pulmonary disease; CI markers : leukocytosis, monocytosis, thrombocytosis, C-reactive protein,
fibrinogen; IL-6, IL-8, TNF- alpha, IL-1 beta; ECD : endothelial cell dysfunction; OS : oxidative stress.

lung inflammation and ultimately the development of COPD which
per se has been shown to give rise to systemic inflammation
as well, likely explaining the increased cardiovascular morbidity
and mortality in patients with COPD [26]. Accordingly, smoking-
related chronic lung inflammation may further aggravate the
chronic inflammatory state in patients with MPNs, thereby enhanc-
ing genomic instability, increasing the risk of mutations and
MPN-disease progression from early cancer stage (ET,PV) to the
advanced myelofibrosis stage [2,3,17] . In the context of chronic
lung inflammation it is noteworthy that pulmonary hyperten-
sion is common in patients with MPNs [83]. This complication
may develop consequent to e.g. pulmonary embolism and /or
pulmonary extramedullary hematopoiesis [83]. However, it is
intriguing to consider, if chronic lung inflammation with undiag-
nosed COPD – irrespective of smoking – may actually be much more
prevalent than previously recognized and accordingly integrated in
the MPN- disease complex. In this context it is important to note,
that megakaryocytes and platelets are sequestrated in the lungs
in normal individuals [84]. This sequestration may be markedly
enhanced in patients with MPNs, in whom platelets are usually
elevated and circulating megakaryocytes – prematurely egressing
from the bone marrow – are increased as well [85]. To this end,

Please cite this article in press as: H.C. Hasselbalch, Smoking as a contributing factor for development of polycythemia vera and related
neoplasms, Leuk Res (2015), http://dx.doi.org/10.1016/j.leukres.2015.09.002
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activated leukocytes in MPNs may also be retained and seques-
trated in lung microvessels due to increased l-selectin expression
enhancing their adhesion properties – similar to findings in smok-
ers. Thus, by releasing a vast amount of inflammatory products
in the lungs, including proteolytic enzymes, activated leukocytes
may elicit chronic pulmonary inflammation, damage to alveolar
walls ultimately leading to lung fibrosis and /or emphysema. These
enzymes include among others MPO, elastase, cathepsin G and
proteinase 3, which have all been shown to be elevated or their
genes significantly upregulated in patients with MPNs [76,86].
Indeed, the marked improvement of pulmonary hypertension in
patients with MPNs during treatment with ruxolitinib may indi-
cate, that pulmonary inflammation is a major contributing factor
for the development of pulmonary hypertension in these patients
[87]. Additionally, nuclear factor erythroid-derived 2-related fac-
tor 2 (Nrf2) has most recently been found to be significantly
downregulated in patients with MPNs [79]. Nrf2 is the master reg-
ulator of the antioxidative defence against oxidative stress and
its downregulation in MPNs may contribute to enhancement of
inflammation-driven oxidative stress with all its deleterious effects
[66,79]. Of note, Nrf2 has been found to be downregulated in pul-
monary macrophages of aged smokers and in patients with COPD
[88]. Thus, it is tempting to consider, if smoking may contribute
to downregulation of Nrf2 and thereby enhancing the vicious
inflammation circle in patients with MPNs [2,3,17,66,79]. Fourth, in
medical practice today moderately elevated hematocrits and leuko-
cytosis in smokers are not – in general – further investigated for
underlying MPNs, since it is a priori concluded that the elevated
cell counts are attributed to smoking. Considering that smoking
and thereby sustained activation of NF-kB and JAK-STAT path-
ways might ultimately elicit clonal MPN-evolution with acquisition
of typical mutations (JAK2V617F or CALR-mutations or additional
mutations) [2,3,80] it is timely to reconsider if this practice is appro-
priate in the future. Indeed, the association between smoking and
JAK2V 617F as demonstrated in a large epidemiological study [41]
and – in addition – in a smaller series of hospitalized smokers [42]
are only supportive of the viewpoint that more careful screening for
these diseases should be considered in patient populations with a
clinico-biochemical profile suggestive of MPNs, eg. elevated hema-
tocrits and leukocytosis/thrombocytosis in smokers, patients with
coronary and peripheral arterial diseases [89,90] or chronic inflam-
matory lung diseases (lung fibrosis, emphysema, lung cancer). Fifth,
considering chronic inflammation to be the common driving force
for the development of cancer in smokers and in patients with
MPNs and MPNs having an increased risk of other chronic inflam-
matory diseases, e.g. Crohn’s disease and polymyalgia rheumatica
[91] and an increased risk of second cancer as well [2,3,53,54] it is
intriguing to consider if common genetic polymorphisms in genes
involved in the inflammatory response might exist in patients with
MPNs, in other cancers with a particular high incidence in MPNs
(lung cancer and urinary tract cancers) and in chronic inflammatory
diseases (e.g. Crohn’s disease, polymyalgia rheumatica, psoriasis,
metabolic syndrome, type II DM and COPD) [92]. In this regard, the
particular haplotype JAK2-46/1 is increased in frequency in both
patients with MPNs and in patients with severe chronic inflamma-
tory bowel disease (Crohn’s disease) [80,92,93]. To this end, a single
nucleotide polymorphism in JAK2 (rs10758669) has been identi-
fied in PV patients [94] and in patients with Crohn’s disease as well
[93]. Sixth, in the context of a potential causal association between
smoking, sustained erythrocytosis and the JAK2V617F mutation a
Danish study of blood donors with high hemoglobin concentrations
found that among 46 such donors 39 had a history of smoking and
2 had PV [95]. Seventh, it is timely to consider if smoking might
be an independent risk factor for thrombosis and development of
other inflammation- mediated comorbidities (e.g. second cancers)
in MPN-patients. Thus, it might be foreseen, that smoking – mag-
Please cite this article in press as: H.C. Hasselbalch, Smoking as a contributing factor for development of polycythemia vera and related
neoplasms, Leuk Res (2015), http://dx.doi.org/10.1016/j.leukres.2015.09.002
7
nifying the deleterious effects of chronic inflammation in MPNs
– actually may have a major impact upon the frequency of car-
diovascular complications and the comorbidity burden (e.g. giant
cell arteritis, Crohn’s disease and second cancers) [53,54,91,96,97]
. Lastly, by enhancing systemic inflammation and oxidative stress
MPN-patients who smoke may have an inferior response to treat-
ment with interferon since JAK-STAT-signaling has been shown
to be impaired by oxidative stress [98]. An impaired response to
other agents (eg. hydroxyurea, anagrelide, JAK2-inhibitor) and/or
a higher dose of these agents might also be anticipated to obtain
complete hematological remissions.
In conclusion, evidence is accumulating that a link exists
between smoking and the development of PV and related neo-
plasms, the common denominator being chronic inflammation and
systemic oxidative stress. In this regard smoking may further aggra-
vate the detrimental impact of chronic inflammation and oxidative
stress in MPNs, thereby contributing to accelerated atherosclerosis,
genomic instability, subclone formation with MPN-disease pro-
gression and the increased risk of second cancers [53,54], which are
considered to be facilitated by the MPN-clone per se [2,3]. In this
regard, chronic inflammation is likely the common denominator for
development of (premature) atherosclerosis, organ injury/fibrosis
and failure and the development of cancer in both smokers, patients
with chronic inflammatory diseases and patients with MPNs [3,99].
Clinical comorbidity studies on these important topics are urgently
needed, including both epidemiological studies and molecular
screening studies (JAK2V617F and CALR- mutations) in large cohorts
of “target populations”, including smokers, patients with chronic
inflammatory lung diseases and in patients with inflammatory vas-
cular diseases [89,90,100].
9. Conflict of interest
The author declares no competing financial interests.
Acknowledgement
None.
References
[1] P.J. Campbell, A.R. Green, The myeloproliferative disorders, N. Engl. J. Med.
355 (2006) 2452–2466.
[2] H.C. Hasselbalch, Chronic inflammation as a promotor of mutagenesis in
essential thrombocythemia, polycythemia vera and myelofibrosis. A human
inflammation model for cancer development? Leuk Res. 37 (2) (2013)
214–220.
[3] H.C. Hasselbalch, Perspectives on chronic inflammation in essential
thrombocythemia, polycythemia vera, and myelofibrosis: is chronic
inflammation a trigger and driver of clonal evolution and development of
accelerated atherosclerosis and second cancer? Blood 119 (2012)
3219–3225.
[4] R. Kralovics, F. Passamonti, A.S. Buser, et al., A gain of function mutation of
JAK2 in myeloproliferative disorders, N. Engl. J. Med. 352 (2005) 1779–1790.
[5] E.J. Baxter, L.M. Scott, P.J. Campbell, et al., Acquired mutation of the tyrosine
kinase JAK2 in human myeloproliferative disorders, Lancet 365 (2005)
1054–1061.
[6] R.L. Levine, M. Wadleigh, J. Cools, et al., Activating mutation in the tyrosine
kinase JAK2 in polycythemia vera, essential thrombocythemia, and myeloid
metaplasia with myelofibrosis, Cancer Cell 7 (2005) 387–397.
[7] R.L. Levine, A. Pardanani, A. Tefferi, D.G. Gilliland, Role of JAK2 in the
pathogenesis and therapy of myeloproliferative disorders, Nat. Rev. Cancer 7
(2007) 673–683.
[8] W. Vainchenker, F. Delhommeau, S.N. Constantinescu, O.A. Bernard, New
mutations and pathogenesis of myeloproliferative neoplasms, Blood 188
(2011) 1723–1735.
[9] T. Klampfl, H. Gisslinger, A.S. Harutyunyan, et al., Somatic mutations of
calreticulin in myeloproliferative neoplasms, N. Engl. J. Med. 369 (25) (2013)
2379–2390.
[10] J. Nangalia, C.E. Massie, E.J. Baxter, et al., Somatic CALR mutations in
myeloproliferative neoplasms with nonmutated JAK2, N. Engl. J. Med. 369
(25) (2013) 2391–2405.
G Model
LR-5454; No. of Pages 9 ARTICLE IN PRESS
8 H.C. Hasselbalch / Leukemia Research xxx (2015) xxx–xxx
[11] M. Cazzola, R. Kralovics, From Janus kinase 2 to calreticulin: the clinically
relevant genomic landscape of myeloproliferative neoplasms, Blood 123
(24) (2014) 3714–3719.
[12] A.L. Mui, The role of STATs in proliferation, differentiation, and apoptosis,
Cell. Mol. Life Sci. 55 (1999) 1547–1558.
[13] P.J. Murray, The JAK–STAT signaling pathway: input and output integration,
J. Immunol. 178 (2007) 2623–2629.
[14] M.M. Seavey, P. Dobrzanski, The many faces of Janus kinase, Biochem.
Pharmacol. 83 (2011) 1136–1145.
[15] W. Vainchenker, S.N. Constantinescu, JAK/STAT signaling in hematological
malignancies, Oncogene 32 (21) (2013) 2601–2613.
[16] H. Yu, D. Pardoll, R. Jove, STATs in cancer inflammation and immunity: a
leading role for STAT3, Nat. Rev. Cancer 9 (2009) 798–809.
[17] H.C. Hasselbalch, The role of cytokines in the initiation and progression of
myelofibrosis, Cytokine Growth Factor Rev. 24 (2) (2013) 133–145.
[18] S. Iho, Y. Tanaka, R. Takauji, et al., Nicotine induces human neutrophils to
produce IL-8 through the generation of peroxynitrite and subsequent
activation of NF-kappaB, J. Leukoc. Biol. 74 (2003) 942–951.
[19] G.S. Tell, R.H.J. Grimm, V. r, O.D. ellar, L. Theodorsen, The relationship of
white cell count, platelet count, and hematocrit to cigarette smoking in
adolescents: the Oslo Youth Study, Circulation 72 (5) (1985) 971–974.
[20] J. Danesh, P. Whincup, M. Walker, et al., Low grade inflammation and
coronary heart disease: prospective study and updated meta-analyses, BMJ
321 (2000) 199–204.
[21] P.M. Ridker, M. Cushman, M.J. Stampfer, R.P. Tracy, C.H. Hennekens, Plasma
concentration of C-reactive protein and risk of developing peripheral
vascular disease, Circulation 97 (5) (1998) 425–428.
[22] G. Brevetti, G. Giugliano, L. Brevetti, W.R. Hiatt, Inflammation in peripheral
arterial disease, Circulation 122 (2010) 1862–1875.
[23] L. Lu, D.F. Mackay, J.P. Pell, Meta-analysis of the association between
smoking and peripheral arterial disease, Heart 100 (2014) 414–423.
[24] G. Siasos, V. Tsigkou, E. Kokkou, et al., Smoking and atherosclerosis:
mechanisms of disease and new therapeutic approaches, Curr. Med. Chem.
21 (34) (2014) 3936–3948.
[25] G.P. Pfeifer, M.F. Denissenko, M. Olivier, et al., Tobacco smoke carcinogens,
DNA damage and p53 mutations in smoking-associated cancers, Oncogene
21 (2002) 7435–7451.
[26] D.G. Yanbaeva, M.A. Dentener, E.C. Creutzberg, G. Wesseling, E.F. Wouters,
Systemic effects of smoking, Chest 131 (2007) 1557–1566.
[27] W.B. Kannel, T. Gordon, P.A. Wolf, et al., Hemoglobin and the risk of cerebral
infarction: the Framingham study, Stroke 3 (1972) 409–420.
[28] K.V. Watson, N. Key, Vascular complications of essential thrombocythaemia:
a link to cardiovascular risk factors, Br. J. Haematol. 83 (2) (1993) 198–203.
[29] M.L. Randi, F. Fabris, G. Cella, C. Rossi, A. Girolami, Cerebral vascular
accidents in young patients with essential thrombocythemia: relation with
other known cardiovascular risk factors, Angiology 49 (6) (1998) 477–481.
[30] R. Jantunen, E. Juvonen, E. Ikkala, K. Oksanen, P. Anttila, T. Ruutu, The
predictive value of vascular risk factors and gender for the development of
thrombotic complications in essential thrombocythemia, Ann. Hematol. 80
(2) (2001) 74–78.
[31] R. Marchioli, G. Finazzi, G. Specchia, et al., Cardiovascular events and
intensity of treatment in polycythemia vera, N. Engl. J. Med. 368 (2013)
22–33.
[32] R. Marchioli, G. Finazzi, R. Landolfi, et al., Vascular and neoplastic risk in a
large cohort of patients with polycythemia vera, J. Clin. Oncol. 23 (2005)
2224–2232.
[33] R. Landolfi, R. Marchioli, J. Kutti, et al., Efficacy and safety of low-dose aspirin
in polycythemia vera, N. Engl. J. Med. 350 (2004) 114–124.
[34] C.N. Harrison, P.J. Campbell, G. Buck, et al., United Kingdom medical
research council primary thrombocythemia 1 study. Hydroxyurea compared
with anagrelide in high-risk essential thrombocythemia, N. Engl. J. Med. 353
(1) (2005) 33–45.
[35] R. Landolfi, L. Di Gennaro, T. Barbui, et al., European collaboration on
low-dose aspirin in polycythemia vera (ECLAP). Leukocytosis as a major
thrombotic risk factor in patients with polycythemia vera, Blood 109 (6)
(2007) 2446–2452.
[36] B.L. Stein, A. Rademaker, J.L. Spivak, A.R. Moliterno, Gender and vascular
complications in the JAK2 V617F-positive myeloproliferative neoplasms,
Thrombosis (2011) 874146.
[37] T. Barbui, G. Barosi, G. Birgegard, et al., European LeukemiaNet.
Philadelphia-negative classical myeloproliferative neoplasms: critical
concepts and management recommendations from European LeukemiaNet,
J. Clin. Oncol. 29 (6) (2011) 761–770.
[38] A. Tefferi, T. Barbui, Polycythemia vera and essential thrombocythemia:
2015 update on diagnosis, risk-stratification and management, Am. J.
Hematol. 90 (2) (2015) 162–173.
[39] S. Fircanis, P. Merriam, N. Khan, J.J. Castillo, The relation between cigarette
smoking and risk of acute myeloid leukemia: an updated meta-analysis of
epidemiological studies, Am. J. Hematol. 89 (8) (2014) E125–E132.
[40] H. Tong, C. Hu, X. Yin, M. Yu, J. Yang, J.A. Jin, Meta-analysis of the
relationship between cigarette smoking and incidence of myelodysplastic
syndromes, PLoS One 8 (6) (2013 21) e67537.
[41] C. Nielsen, H.S. Birgens, B.G. Nordestgaard, S.E. Bojesen, Diagnostic value of
JAK2 V617F somatic mutation for myeloproliferative cancer in 49 488
individuals from the general population, Br. J. Haematol. 160 (1) (2013)
70–79.
Please cite this article in press as: H.C. Hasselbalch, Smoking as a contributing factor for development of polycythemia vera and related
neoplasms, Leuk Res (2015), http://dx.doi.org/10.1016/j.leukres.2015.09.002
[42] I. Weinberg, A. Borohovitz, S. Krichevsky, R. Perlman, A. Ben-Yehuda, D.
Ben-Yehuda, Janus kinase V617F mutation in cigarette smokers, Am. J.
Hematol. 87 (1) (2012) 5–8.
[43] M.E. Kroll, F. Murphy, K. Pirie, et al., Alcohol drinking, tobacco smoking and
subtypes of haematological malignancy in the UK Million Women Study, Br.
J. Cancer 107 (2012) 879–887.
[44] A.D. Leal, C.A. Thompson, A.H. Wang, et al., Anthropometric, medical history
and lifestyle risk factors for myeloproliferative neoplasms in the Iowa
women’s health study cohort, Int. J. Cancer 134 (7) (2014) 1741–1750.
[45] P. Pasqualetti, V. Festuccia, P. Acitelli, A. Collacciani, A. Giusti, R. Casale,
Tobacco smoking and risk of haematological malignancies in adults: a
case-control study, Br. J. Haematol. 97 (3) (1997) 659–662.
[46] D. Hanahan, R.A. Weinberg, The hallmarks of cancer, Cell 100 (1) (2000)
57–70.
[47] E. Pikarsky, R.M. Porat, I. Stein, et al., NF-kappaB functions as a tumour
promoter in inflammation associated cancer, Nature 431 (7007) (2004)
461–466.
[48] M. Karin, F.R. Greten, NF-kappaB linking inflammation and immunity to
cancer development and progression, Nat. Rev. Immunol. 5 (10) (2005)
749–759.
[49] A. Mantovani, C. Garlanda, P. Allavena, Molecular pathways and targets in
cancer-related inflammation, Ann. Med. 42 (3) (2010) 161–170.
[50] M.J. Pittet, F.K. Swirski, Monocytes link atherosclerosis and cancer, Eur. J.
Immunol. 41 (9) (2011) 2519–2522.
[51] E. Komura, C. Tonetti, V. Penard-Lacronique, et al., Role for the nuclear factor
kappaB pathway in transforming growth factor-beta1 production in
idiopathic myelofibrosis: possible relationship with FK506 binding protein
51 overexpression, Cancer Res. 65 (8) (2005) 3281–3289.
[52] Y. Zhang, T. Pan, X. Zhong, C. Cheng, Nicotine upregulates microRNA-21 and
promotes TGF-␤-dependent epithelial-mesenchymal transition of
esophageal cancer cells, Tumour Biol. 35 (7) (2014) 7063–7072.
[53] H. Frederiksen, D.K. Farkas, C.F. Christiansen, H.C. Hasselbalch, H.T. Sørensen,
Chronic myeloproliferative neoplasms and subsequent cancer risk: a Danish
population-based cohort study, Blood 118 (25) (2011) 6515–6520.
[54] H.C. Hasselbalch, The platelet-cancer loop in myeloproliferative cancer. Is
thrombocythemia an enhancer of invasiveness and metastasis in essential
thrombocythemia, polycythemia vera and myelofibrosis? Leuk. Res. 38 (10)
(2014) 1230–1236.
[55] L. Yang, Y. Pang, H.L. Moses, TGF-beta and immune cells: an important
regulatory axis in the tumor microenvironment and progression, Trends
Immunol. 31 (6) (2010) 220–227.
[56] G. Tagariello, R. Di Gaetano, R. Sartori, et al., The JAK2(V617F) tyrosine
kinase mutation in blood donors with upper-limit haematocrit levels, Blood
Transfus. 7 (2009) 111–116.
[57] S. Preston-Martin, M.C. Pike, R.K. Ross, P.A. Jones, B.E. Henderson, Increased
cell division as a cause of human cancer, Cancer Res. 50 (1990) 7415–7421.
[58] H.C. Hasselbalch, Perspectives on the impact of JAK-inhibitor therapy upon
inflammation-mediated comorbidities in myelofibrosis and related
neoplasms, Expert. Rev. Hematol. 7 (2) (2014) 203–216.
[59] S. Hermouet, A. Godard, D. Pineau, et al., Abnormal production of interleukin
(IL)-11 and IL-8 in polycythaemia vera, Cytokine 20 (4) (2002) 178–183.
[60] S. Emadi, D. Clay, C. Desterke, et al., IL-8 and its CXCR1 and CXCR2 receptors
participate in the control of megakaryocytic proliferation, differentiation,
and ploidy in myeloid metaplasia with myelofibrosis, Blood 105 (2) (2005)
464–473.
[61] A. Tefferi, R. Vaidya, D. Caramazza, C. Finke, T. Lasho, A. Pardanani,
Circulating interleukin (IL)-8, IL-2R, IL-12, and IL-15 levels are
independently prognostic in primary myelofibrosis: a comprehensive
cytokine profiling study, J. Clin. Oncol. 29 (10) (2011) 1356–1363.
[62] R. Vaidya, N. Gangat, T. Jimma, et al., Plasma cytokines in polycythemia vera:
phenotypic correlates, prognostic relevance, and comparison with
myelofibrosis, Am. J. Hematol. 87 (11) (2012) 1003–1005.
[63] J. Wehrle, T.S. Seeger, S. Schwemmers, D. Pfeifer, A. Bulashevska, H.L. Pahl,
Transcription factor nuclear factor erythroid-2 mediates expression of the
cytokine interleukin 8, a known predictor of inferior outcome in patients
with myeloproliferative neoplasms, Haematologica 98 (7) (2013)
1073–1080.
[64] K. Kaufmann, A. Gründer, T. Hadlich, et al., A novel murine model of
myeloproliferative disorders generated by overexpression of the
transcription factor NF-E2, J. Exp. Med. 209 (1) (2012) 35–50.
[65] K. Kapralova, L. Lanikova, F. Lorenzo, J. Song, M. Horvathova, V. Divoky, J.T.
Prchal, RUNX1 and NF-E2 upregulation is not specific for MPNs, but is seen
in polycythemic disorders with augmented HIF signaling, Blood 123 (3)
(2014) 391–394.
[66] H.C. Hasselbalch, A role of NF-E2 in chronic inflammation and clonal
evolution in essential thrombocythemia, polycythemia vera and
myelofibrosis? Leuk. Res. 38 (2) (2014) 263–266.
[67] Q. Zhang, X. Tang, Z.F. Zhang, R. Velikina, S. Shi, A.D. Le, Nicotine induces
hypoxia-inducible factor-1alpha expression in human lung cancer cells via
nicotinic acetylcholine receptor-mediated signaling pathways, Clin. Cancer
Res. 15;13 (16) (2007) 4686–4694.
[68] S.N. Greer, J.L. Metcalf, Y. Wang, M. Ohh, The updated biology of
hypoxia-inducible factor, EMBO J. 31 (11) (2012) 2448–2460.
[69] L. Zhang, C. Steinmaus, D.A. Eastmond, X.K. Xin, M.T. Smith, Formaldehyde
exposure and leukemia: a new meta-analysis and potential mechanisms,
Mutat. Res. 681 (2009) 150–168.
G Model
LR-5454; No. of Pages 9 ARTICLE IN PRESS
H.C. Hasselbalch / Leukemia Research xxx (2015) xxx–xxx
[70] IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. A
Review of Human Carcinogens: Chemical Agents and Related Occupations.
WHO International Agency for Research on Cancer 2012; 100F:401–435.
[71] NTP. (National Toxicology Program). Report on Carcinogens, Twelfth
Edition. Research Triangle Park. 2012; 195–205.
[72] L.R. Rhomberg, L.A. Bailey, J.E. Goodman, A.K. Hamade, D. Mayfield, Is
exposure to formaldehyde in air causally associated with leukemia? –A
hypothesis-based weight-of-evidence analysis, Crit. Rev. Toxicol. 41 (2011)
555–621.
[73] L. Zhang, X. Tang, N. Rothman, R. Vermeulen, Z. Ji, et al., Occupational
exposure to formaldehyde, hematotoxicity, and leukemia-specific
chromosome changes in cultured myeloid progenitor cells, Cancer
Epidemiol. Biomarkers Prev. 19 (2010) 80–88.
[74] Y. Zhang, X. Liu, C. McHale, R. Li, L. Zhang, Y. Wu, X. Ye, X. Yang, S. Ding, Bone
marrow injury induced via oxidative stress in mice by inhalation exposure
to formaldehyde, PLoS One 11;8 (9) (2013) e74974.
[75] T. Yahata, T. Takanashi, Y. Muguruma, A.A. Ibrahim, H. Matsuzawa, et al.,
Accumulation of oxidative DNA damage restricts the self-renewal capacity
of human hematopoietic stem cells, Blood 118 (2011) 2941–2950.
[76] V. Skov, T.S. Larsen, M. Thomassen, et al., Whole blood transcriptional
profiling of interferon inducible genes identifies highly upregulated IFI27 in
primary myelofibrosis, Eur. J. Haematol. 87 (1) (2011) 54–60.
[77] V. Skov, M. Thomassen, C.H. Riley, et al., Gene expression profiling with
principal component analysis depicts the biological continuum from
essential thrombocythemia over polycythemia vera to myelofibrosis, Exp.
Hematol. 40 (9) (2012) 771–780.
[78] V. Skov, T.S. Larsen, M. Thomassen, et al., Molecular profiling of peripheral
blood cells from patients with polycythemia vera and related neoplasms:
identification of deregulated genes of significance for inflammation and
immune surveillance, Leuk. Res. 36 (11) (2012) 1387–1392.
[79] H.C. Hasselbalch, M. Thomassen, C. Hasselbalch Riley, et al., Whole blood
transcriptional profiling reveals deregulation of oxidative and antioxidative
defence genes in myelofibrosis and related neoplasms. Potential
implications of downregulation of Nrf2 for genomic instability and disease
progression, PLoS One 9 (11) (2014) e112786.
[80] S. Hermouet, M. Vilaine, The JAK2 46/1 haplotype: a marker of inappropriate
myelomonocytic response to cytokine stimulation, leading to increased risk
of inflammation, myeloid neoplasm, and impaired defense against
infection? Haematologica 96 (11) (2011) 1575–1579.
[81] T. Barbui, G. Finazzi, A. Falanga, Myeloproliferative neoplasms and
thrombosis, Blood 122 (13) (2013) 2176–2184.
[82] S.A. Harding, J. Sarma, D.H. Josephs, et al., Upregulation of the CD40/CD40
ligand dyad and platelet-monocyte aggregation in cigarette smokers,
Circulation 109 (2004) 1926–1929.
[83] R. Gupta, S. Perumandla, Y. Patsiornik, S. Niranjan, A. Ohri, Incidence of
pulmonary hypertension in patients with chronic myeloproliferative
disorders, J. Natl. Med. Assoc. 98 (11) (2006) 1779–1782.
[84] D. Zucker-Franklin, C.S. Philipp, Platelet production in the pulmonary
capillary bed: new ultrastructural evidence for an old concept, Am. J. Pathol.
157 (2000) 69–74.
Please cite this article in press as: H.C. Hasselbalch, Smoking as a contributing factor for development of polycythemia vera and related
neoplasms, Leuk Res (2015), http://dx.doi.org/10.1016/j.leukres.2015.09.002
9
[85] N. Tinggaard Pedersen, B. Laursen, Megakaryocytes in cubital venous blood
in patients with chronic myeloproliferative diseases, Scand. J. Haematol. 30
(1) (1983) 50–58.
[86] H.C. Hasselbalch, V. Skov, L. Stauffer, T. arsen, et al., Transcriptional profiling
of whole blood identifies a unique 5-gene signature for myelofibrosis and
imminent myelofibrosis transformation, PLoS One 9 (1) (2014) e85567.
[87] A. Tabarroki, D.J. Lindner, V. Visconte, et al., Ruxolitinib leads to
improvement of pulmonary hypertension in patients with myelofibrosis,
Leukemia 28 (7) (2014) 1486–1493.
[88] M. Suzuki, T. Betsuyaku, Y. Ito, et al., Down-regulated NF-E2-related factor 2
in pulmonary macrophages of aged smokers and patients with chronic
obstructive pulmonary disease, Am. J. Respir. Cell Mol. Biol. 39 (6) (2008)
673–682.
[89] A. Muendlein, K. Gasser, E. Kinz, et al., Evaluation of the prevalence and
prospective clinical impact of the JAK2 V617F mutation in coronary patients,
Am. J. Hematol. 89 (3) (2014) 295–301.
[90] A. Muendlein, E. Kinz, K. Gasser, et al., Occurrence of the JAK2 V617F
mutation in patients with peripheral arterial disease, Am. J. Hematol. 90 (1)
(2015) E17–21.
[91] S.Y. Kristinsson, O. Landgren, J. Samuelsson, M. Bjorkholm, L.R. Goldin,
Autoimmunity and the risk of myeloproliferative neoplasms, Haematologica
95 (7) (2010) 1216–1220.
[92] L.R. Ferguson, D.Y. Han, A.G. Fraser, et al., Genetic factors in chronic
inflammation: single nucleotide polymorphisms in the STAT-JAK pathway,
susceptibility to DNA damage and Crohn’s disease in a New Zealand
population, Mutat. Res. 690 (1–2) (2010) 108–115.
[93] J.C. Barrett, S. Hansoul, D.L. Nicolae, et al., Genome-wide association defines
more than 30 distinct susceptibility loci for Crohn’s disease, Nat. Genet. 40
(8) (2008) 955–962.
[94] A. Pardanani, B.L. Fridley, T.L. Lasho, et al., Host genetic variation contributes
to phenotypic diversity in myeloproliferative disorders, Blood 111 (2008)
2785–2789.
[95] K. Magnussen, H.C. Hasselbalch, H. Ullum, O.W. Bjerrum, Characterization of
blood donors with high haemoglobin concentration, Vox Sang. 104 (2)
(2013) 110–114.
[96] K. Larsson, D. Mellström, E. Nordborg, A. Odén, E. Nordborg, Early
menopause, low body mass index, and smoking are independent risk factors
for developing giant cell arteritis, Ann. Rheum. Dis. 65 (4) (2006) 529–532.
[97] A. Ponder, M.D. Long, A clinical review of recent findings in the epidemiology
of inflammatory bowel disease, Clin. Epidemiol. 5 (2013) 237–247.
[98] D. Di Bona, M. Cippitelli, C. Fionda, et al., Oxidative stress inhibits
IFN-alpha-induced antiviral gene expression by blocking the JAK-STAT
pathway, J. Hepatol. 45 (2) (2006) 271–279.
[99] D.C. Rockey, P.D. Bell, J.A. Hill, Fibrosis–a common pathway to organ injury
and failure, N. Engl. J. Med. 372 (12) (2015) 1138–1149.
[100] R. Ross, Atherosclerosis—an inflammatory disease, N. Engl. J. Med. 340
(1999) 115–126.