BBADIS-63368; No.

of pages: 11; 4C: 4, 5

Biochimica et Biophysica Acta xxx (2011) xxx–xxx

Contents lists available at SciVerse ScienceDirect

Biochimica et Biophysica Acta

journal homepage: www.elsevier.com/locate/bbadis

Review

Antioxidants in cervical cancer: Chemopreventive and chemotherapeutic effects

of polyphenols☆
F. Di Domenico a, C. Foppoli b, R. Coccia a, M. Perluigi a,⁎
a
Department of Biochemical Sciences, Sapienza University of Rome, P.le A. Moro, 5-00185 Rome, Italy
b
CNR Institute of Molecular Biology and Pathology, Sapienza University of Rome, Rome, Italy

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

Article history: Cervical cancer lesions are a major threat to the health of women, representing the second most common
Received 27 August 2011 cancer worldwide. The unanimously recognized etiological factor in the causation of cervical cancer is the in-
Received in revised form 5 October 2011 fection with human papilloma virus (HPV). HPV infection, although necessary, is not per se sufficient to in-
Accepted 6 October 2011
duce cancer. Other factors have to be involved in the progression of infected cells to the full neoplastic
Available online xxxx
phenotype. Oxidative stress represents an interesting and under-explored candidate as a promoting factor
Keywords:
in HPV-initiated carcinogenesis. Oxidative stress is known to perturb the cellular redox status thus leading
Cervical cancer to alteration of gene expression responses through the activation of several redox-sensitive transcription fac-
HPV tors. This signaling cascade affects both cell growth and cell death. The ability of naturally occurring antiox-
Polyphenol idants to modulate cellular signal transduction pathways, through the activation/repression of multiple
Apoptosis redox-sensitive transcription factors, has been claimed for their potential therapeutic use as chemopreven-
Oxidative stress tive agents. Among these compounds, polyphenols have been found to be promising agents toward cervical can-
cer. In addition to acting as antioxidants, polyphenols display a wide variety of biological function including
induction of apoptosis, growth arrest, inhibition of DNA synthesis and modulation of signal transduction path-
ways. They can interfere with each stage of carcinogenesis initiation, promotion and progression to prevent can-
cer development. The present review discusses current knowledge of the major molecular pathways, which are
involved in HPV-driven cancerogenesis, and the ability of polyphenols to modulate these pathways. By acting at
specific steps of viral transformation cascade, polyphenols have been demonstrated to selectively inhibit tumor
cell growth and may be a promising therapeutic tool for treatment of cervical cancer. In addition, recent results
obtained in clinical trials using polyphenols are also discussed. This article is part of a Special Issue entitled: An-
tioxidants and Antioxidant Treatment in Disease.
© 2011 Elsevier B.V. All rights reserved.

1. Introduction: cervical cancer
Cervical cancer lesions are a major threat to the health of the
women, representing the second most common cancer worldwide.
Human papillomaviruses (HPVs) have been identified as the major
etiological factor in cervical carcinogenesis. The hypothesis of a corre-
lation between HPV infection and cervical neoplasia was formulated
first time at the beginning of the 70's by Harold zur Hausen [1].
HPVs can be clinically classified as “low-risk” (LR-HPV) and “high-
risk” (HR-HPV) depending on the relative propensity of the HPV-
associated lesions to undergo malignant progression. HPV 16 is the
most prevalent HR-HPV type, followed by HPV 18 and others. LR-
HPVs generate moderate dysplasia and genital warts, while high-risk
HPVs are associated with cervical dysplasia or cervical intraepithelial
neoplasia (CIN), currently indicated as squamous intraepithelial lesions
☆ This article is part of a Special Issue entitled: Antioxidants and Antioxidant Treatment
in Disease.
⁎ Corresponding author. Tel.: + 39 0649910900.
E-mail address: marzia.perluigi@uniroma1.it (M. Perluigi).
(SIL), graded as low (LSIL) or high (HSIL). Cervical cancers are thought
to arise from these lesions after long persistent infection. The majority
of HPV infections are subclinical and transitory (80% disappears) and
in most of the cases they are resolved spontaneously by an effective im-
mune response that eliminates virus or suppresses it down to unde-
tected levels [2]. In few subjects, when the virus is not suppressed, the
infection progress to CIN 1 and evolve to CIN 2/3 but the development
of cervical carcinoma is a multi-step carcinogenesis, however the
steps in the progression from LSIL to tumor remain unknown. It has
been estimated that approximately 10% of LSIL and about 20–30% of
HSIL actually progress to cancer [3, 4].
2. HPV: structure, infection and transformation activity
HPVs are small, non-enveloped DNA viruses with a circular genome
of around 8 kb. The viral genome can be divided into three regions. The
up-stream regulatory region is largely responsible in determining the
host range and tissue tropism of each HPV type and regulates viral
gene expression after infection. This region contains the viral origin of

0925-4439/$ – see front matter © 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.bbadis.2011.10.005

Please cite this article as: F. Di Domenico, et al., Antioxidants in cervical cancer: Chemopreventive and chemotherapeutic effects of polyphe-
nols, Biochim. Biophys. Acta (2011), doi:10.1016/j.bbadis.2011.10.005
2 F. Di Domenico et al. / Biochimica et Biophysica Acta xxx (2011) xxx–xxx
replication and numerous binding sites for cellular transcription factors.
The rest of the genome comprises eight open reading frames divided
between the early region, that encodes the E1, E2, E4, E5, E6 and E7 pro-
teins and the late region, that encodes the L1 and L2 proteins [5]. E6, E7
and in minor grade E5 are well-recognized oncoproteins responsible for
cell transformation events.
HPVs have a unique life cycle, which is tightly linked to the differ-
entiation program of the infected host epithelium. HPV infection
starts in the basal epithelium (basal cells or stem cells) in prolifera-
tion, where HPVs are in the phase of latent infection and the viral ge-
nome is maintained at a low copy number without production of
virions. In the upper layer, as the daughter cells move towards the
surface and undergo differentiation, vegetative replication of the
viral genome coordinates with expression of capsid proteins to form
viral particles. Finally, the progeny virions are released from the up-
permost layer within terminally differentiated epithelial squamae,
to search for new host cells. HPV infection thus results in enhanced
proliferation of the infected cells and their lateral expansion [2, 6, 7].
The failure of the immune system, in persistent HPV infection clear-
ance, can lead, after about 10–20 years, to the development of cervical
cancer. In LSIL, most HPV genomes are in episomal state whereas, in
many HSIL, genomes are integrated into the host cell. Over one-half of
HPV 16-positive cancers and most HPV 18-positive malignancies con-
tain integrated HPV genomes, suggesting that integration may, in
some cases, contribute to malignant progression. In lesions containing
episomal HPV, the viral E2 protein directly represses early gene expres-
sion regulating copy numbers. Integration of viral DNA usually disrupts
E2 expression, leading to the deregulated expression of early viral
genes, including E6 and E7, as well as increased proliferative capacity,
a crucial step in progression to cancer [6].
In cervical carcinoma cells, the E6 and E7 proteins are continuous-
ly expressed and this is required for transformation. Prior to viral in-
tegration these proteins are believed to cooperate in order to
overcome normal cell cycle controls. Expression of the E6 and E7 pro-
teins from HR- but not from LR-HPV types lead to cell immortaliza-
tion necessary for malignant progression.
The most characterized role of HR-HPV E6 is its ability to bind to
the p53 tumor suppressor protein in conjunction with the cellular
ubiquitin ligase E6AP and target p53 for degradation through the ubi-
quitin–proteasome pathway [8, 9]. This impairs the normal cellular
response to cell stress and DNA damage and allows infected cells to
proliferate. Moreover since p53 plays a key role in preserving genome
integrity, HPV infected cells accumulate chromosomal abnormalities
thus increasing their intrinsic susceptibility towards malignancy. E6
can also interfere with the apoptotic pathway via its association
with proteins belonging to the bcl-2 family, including Bax and Bak
[10, 11]. Another way by which E6 confers resistance to apoptosis is
the up-regulation of inhibitors of apoptosis proteins, as c-IAP2 and
survivin, through a mechanism involving NF-κB [12, 13].
E7 is a small nuclear phosphoprotein known to bind to the retino-
blastoma tumor suppressor gene product, pRb, and its family members,
p107 and p130. HR-HPV E7 protein, by binding to pRb leads to the re-
lease of E2F proteins and prematurely induces cells to enter the S
phase prevailing the normal cell cycle control. E7 from HR-HPV can
also induce the degradation of pRb via a proteasome-dependent path-
way [14]. p16INK4a, a cyclin-dependent kinase (CDK) inhibitor, is over-
expressed when pRb is inactivated by E7 [15] in additional E7 interact
with other CDK inhibitors such as p27 and p21 confirming its involve-
ment in the abrogation of cell-cycle inhibition [2]. Finally, in targeting
pRb, E7 causes deregulated E2F activity and E2F-1 can induce apoptosis
in the presence of p53 [5]. E2F-1 activates expression of p19ARF, which
inhibits Mdm2 and thereby stabilizes p53 [5]. A number of studies dem-
onstrated that HR-HPV oncogenes activate MAPKs and the AP-1 family
of transcription factors [16]. Moreover, increased COX-2 levels were
shown in cervical cancer cells, via the EGFR→Ras→MAPK→AP-1 path-
way and in correlation to E6-mediated p53 degradation [16–19].
Please cite this article as: F. Di Domenico, et al., Antioxidants in cervical cancer: Chemopreventive and chemotherapeutic effects of polyphe-
nols, Biochim. Biophys. Acta (2011), doi:10.1016/j.bbadis.2011.10.005
3. Oxidative stress and cervical cancer
Persistent infection of the cervix with a HR-HPV is necessary to
develop cervical cancer, other associated co-factors are required for
the malignancy progression. Oxidative stress, among others, is receiv-
ing great interest for its role during the progression of neoplasias.
Several risk factors of cervical cancer development, such as exposure
to cigarette smoke and chronic inflammation, are well documented to
increase oxidative stress, which could account for higher risk of cervical
cancer in these two conditions [20, 21].
Oxidative stress is a condition arising from an increased production
of reactive oxygen species (ROS) associated with a decreased antioxi-
dant capability of the cell. ROS are constantly generated in aerobic
cells by the incomplete reduction of molecular O2 to H2O during mito-
chondrial oxidative phosphorylation, as well as during a number of pro-
cesses such as inflammation, infections, mechanical and chemical
stresses, exposure to UV and to ionizing irradiation [22–24]. The effect
of ROS on cell depends on the level at which they are present. Low levels
provide a beneficial effect, support cell proliferation and survival path-
ways. However, at high levels, ROS can oxidatively damage biological
macromolecules and cause detrimental oxidative stress that can lead
to cell death. ROS can induce genotoxic damage, including single- and
double-strand breaks, DNA–protein cross-links, basic sites and modified
bases [25–27].
Cells withstand and counteract oxidative stress by the use of several
and different defense mechanisms, ranging from free radical scavengers
and antioxidant molecules/enzymes to sophisticated and elaborate
DNA repair mechanisms to reduce excessive levels of ROS and prevent
irreversible cellular damage [28, 29].
An increased rate of ROS production occurs in highly proliferative
cancer cells, owing to the presence of oncogenic mutations that pro-
mote aberrant metabolism. Increased oxidative stress is well documen-
ted in transformed cells [30–33] and growing evidence suggests that
ROS act as second messengers in intracellular signaling cascades
which induce and maintain the oncogenic phenotype of cancer cells
[34]. During cervical carcinogenesis an increase of oxidative DNA dam-
age, as shown by progressive increase in the levels of 8-OHdG from nor-
mal to SIL to invasive carcinomas, has been reported [35]. In our recent
work we demonstrated that UVB-induced oxidative stress provoked an
increased and selective protein oxidation in keratinocyte cells trans-
fected with the whole HPV-16 genome [36]. Such oxidative modifica-
tions, combined with UVB-induced modulation of protein expression,
likely lead to protein dysfunctions that might contribute to the malig-
nant progression of transformed cells.
However, ROS regulation is crucial for transformed cells that coun-
teract ROS accumulation by up regulating antioxidant systems, seem-
ingly creating a paradox of high ROS production in the presence of
high antioxidant levels [37]. We further demonstrated that UVB irra-
diation caused, in HPV-transformed cells, a general suppression of
viral transcription, accompanied by a moderate growth arrest, an ap-
propriated response of cellular antioxidant enzymes, the activation of
cell repair mechanisms and a mild induction of apoptosis [38]. This
response was absent in transformed cells devoid of HPV sequences
(HaCaT) that appeared extremely susceptible to apoptosis. We postu-
lated that the suppression of viral oncogenes, restoring the cell con-
trol on growth and repair mechanisms, allows the damage repair,
ultimately resulting in a surviving response. The fine mechanisms ac-
tivated by cancer cells to counteract oxidative attack, allowing them
to avoid ROS-induced cytotoxicity, also make them more exposed to
additional ROS-mediated mutagenic events and accumulation of
DNA damage.
Studies on serum of patients with CIN and carcinoma of the cervix evi-
denced changes in lipid peroxidation and impairment of antioxidant sys-
tems, either enzymatic [21, 39] or not [40]. Other blood-related studies
showed that LSIL, HSIL or cervical cancer can be associated with changes
in three indicators of oxidative stress: increase in erythrocyte TBARS,
 F. Di Domenico et al. / Biochimica et Biophysica Acta xxx (2011) xxx–xxx
ALA-D reactivation index and a decrease in vitamin C content [41]. Nitro-
sative stress was also evidenced in patients with cervical squamous cell
carcinoma, as shown by increased plasmatic NO levels [21].
These data support the hypothesis about the involvement of both
oxidative and nitrosative stress in the pathogenesis of cervical cancer.
4. Antioxidants, chemoprevention and chemotherapy
In recent years, many studies have been carried out to investigate
the potential cancer chemopreventive activities of natural antioxi-
dants, in particular dietary polyphenols [42]. Representative exam-
ples of polyphenols include epigallocatechin-3-gallate (EGCG) from
green tea, curcumin from turmeric, and resveratrol from grapes
(Fig. 2). These compounds have been proved to block carcinogenesis
and to inhibit tumor growth both in vitro and in vivo models (animal
or in cell culture). These effects can be attributed to non-scavenging
role of antioxidants including induction of apoptosis, growth arrest,
inhibition of DNA synthesis and modulation of signal transduction
pathways [43]. Intracellular signaling cascade involve several molec-
ular events, which are initiated by the specific interaction of an extra-
cellular ligand with its receptor at the cell membrane [44]. After this
first event, second messengers participate to amplify signal transduc-
tion pathways, which ultimately lead to modulation of several cellu-
lar functions. Within this frame, ROS/RNS have been proposed as
second messengers in the activation of several signaling pathways
leading to mitogenesis or apoptosis. The effective transmission of sig-
nals occurs through the recruitment of highly specific intermediates,
and how ROS signaling may be activated with specificity and without
oxidative damage is still poorly understood [45]. In addition, gene ex-
pression is significantly regulated in response to oxidative stress and
is necessary to ensure cell survival involving specific redox-sensitive
transcription factors such as Nrf2, NF-κB, AP-1, and MAPKs [46]. Mod-
ulation of their activity leads to changes in the cellular redox status
and alteration of gene expression responses to oxidative stresses, pre-
sumably via sulfhydryl modification of critical cysteine residues found
on these proteins and/or other upstream redox-sensitive molecular
targets [47]. For example, AP-1 is activated by low levels of oxidants
resulting in AP-1/DNA binding and an increase in gene expression.
In turn, AP-1 activation leads to the induction of JNK activity resulting
in the phosphorylation of the c-Jun transactivation domain [48]. On
the contrary, high concentrations of ROS inhibited AP-1 and AP-1 in-
duced gene expression. The inhibition of AP-1/DNA interactions is
caused by the oxidation of specific cysteine residues in c-Jun's DNA
binding region.
Similarly, NF-κB contains a redox-sensitive critical cysteine resi-
due that is involved in DNA binding [47, 49]. NF-κB is normally se-
questered in the cytoplasm by IκB, but under oxidative conditions,
IκB is phosphorylated by IκB kinase (IKK), ubiquitinated, and subse-
quently degraded. ROS production appears to be necessary to initiate
the events leading to the dissociation of the NF-κB/IκB complex [50],
but excessive ROS production results in the oxidation of cysteine res-
idue which does not affect its translocation to the nucleus, but rather,
interferes with DNA binding and decreases gene expression [45].
The ability of naturally occurring antioxidants to modulate cellular
signal transduction pathways, through the activation/repression of
multiple redox-sensitive transcription factors has been claimed for
their potential therapeutic use as chemopreventive agents. They can
interfere with each stage of carcinogenesis—initiation, promotion
and progression—to prevent cancer development [51].
Decreased mutagenic risk could result from the induction of several
phase 2 detoxifying and antioxidant enzymes, such as glutathione-S-
transferase, NAD(P)H quinone reductase and heme oxygenase among
others [46]. This process is known to involve the antioxidant response
element (ARE), which is present in the promoter region of all the afore-
mentioned genes [52–56]. Nuclear factor-E2-related factor-2 (Nrf2) is a
basic leucine zipper, redox-sensitive transcription factor that has been
Please cite this article as: F. Di Domenico, et al., Antioxidants in cervical cancer: Chemopreventive and chemotherapeutic effects of polyphe-
nols, Biochim. Biophys. Acta (2011), doi:10.1016/j.bbadis.2011.10.005
3
widely studied to gain an insight into its role in chemoprevention. It is
known to be involved in the regulation of ARE-mediated gene transcrip-
tion. Polyphenols, such as curcumin and resveratrol, are known to in-
duce ARE-mediated gene expression by increasing the levels of Nrf2
protein or suppressing its turnover by ubiquitination [53]. They activate
Nrf2-mediated gene expression either by directly modifying the cysteine
residues on Keap1 to disrupt the Nrf2–Keap1 complex or by activating
kinase signaling pathways such as MAPKs, protein kinase C (PKC), and
PI3K to phosphorylate Nrf2/Keap1 complex and/or facilitate the release
of Nrf2 or to increase the nuclear translocation of Nrf2 and regulate the
transcriptional activity of Nrf2 nuclear co-activators.
One of the major research focus is to solve the “redox paradigm”,
that is to understand how these compounds can differentiate be-
tween “normal” versus “abnormal tumor” cells in terms of signaling,
gene expression, and pharmacological effects. Oxidative stress and
perturbation of intracellular redox status can have a profound influ-
ence on the direction of signaling between cell survival and cell
death. The comprehension of the mechanisms which lead to cell
death of cancerous cells and cell survival of normal cells will need
to be better investigated.
5. Polyphenols and cervical cancer
Polyphenols, from natural and herbal extract are raising great in-
terest as powerful and safe anticancer strategy for their broad range
targeting capability and low side effects. Many herbal extract are
both able to target against viral oncogenes and to inhibit the cooper-
ative signaling and deregulated gene expression of the host cells [3].
Recently an inverse association between antioxidant nutrients and
HPV persistence, SIL, and cervical cancer was shown, suggesting pro-
tective effect of natural extract against HPV persistence and cervical
dysplasia [57, 58]. A new approach in the use of natural extract con-
cern the sensitization of cancer cells to radio- and chemo-therapy
by a pretreatment before the prolonged cure [59, 60].
In the following sections are described the most recent research
about the anti-cancerogenic activities of curcumin, resveratrol and
epigallocatechin-3-gallate (EGCG), three of the most commonly studied
compounds from herbal extract, for the treatment of cervical cancer
(Figs. 1 and 2). Moreover few preliminary data on the therapeutic use
of these antioxidant compounds are reported.
5.1. Curcumin and ferulic acid
Curcumin (1,7-bis (4-hydroxy 3-methoxy phenyl)-1,6-heptadiene-
3,5-dione) is a natural polyphenolic compound extracted from the rhi-
zome of the medicinal plant Curcuma longa Linn (also known as turmeric)
found in South and Southeast tropical Asia. Curcumin has been used for
centuries throughout Asia as a food additive, cosmetic, and as a tradition-
al herbal medicine for its various biological activities.
Over the past decade, several studies have indicated the potential
therapeutic value of curcumin and have clearly demonstrated that curcu-
min possesses anti-inflammatory, antioxidant, anticarcinogenic, throm-
bosuppressive, cardioprotective, antiarthritic, and anti-infectious
properties [61–68]. Several studies reported that curcumin suppresses
all 3 stages of carcinogenesis: initiation, promotion, and progression. In-
hibition of nuclear factor kappa B (NF-κB) and subsequent downregula-
tion of various NF-κB-related proinflammatory pathways is very likely
the primary target accounting for its efficacy [59]. Moreover curcumin
suppresses a number of key elements in cellular signal transduction
pathways, including c-Jun/AP-1 activation [69, 70] and phosphorylation
reactions catalyzed by protein kinases [71]. Further, curcumin suppresses
angiogenesis in vivo, abrogates FGF-2-induced angiogenic response, ma-
trix metalloprotease expression and cyclooxygenase-2 [72–75] (Table 1).
The varied biologic properties of curcumin and lack of toxicity, even
when administered at doses as high as 8 mg/d [76], make curcumin an
ideal and very attractive compound in the attempt of therapeutic agents
4 F. Di Domenico et al. / Biochimica et Biophysica Acta xxx (2011) xxx–xxx

against various tumors. Curcumin has been shown to prevent cancer in
the colon, skin, stomach, duodenum, soft palate, and breasts of rodents
after oral administration [77, 78]. Recent data indicate that in addition
to its chemopreventive role, curcumin has great potential as a chemo-
and radio-sensitizer [59]. Considering the toxic side effects of radio
and chemotherapy, achieving radio and chemosensitization with mini-
mal toxicity represents a goal for the treatment of cancer patients. In the
other hand, one concern regarding curcumin therapeutic use is its low
bioavailability and poor pharmacokinetics [76].
In regard of curcumin antitumoral properties, several studies were
conducted on cervical cancer. Cervical cancer cell lines were often used
as a preferred carcinogenic model to understand molecular targets and
mechanism of curcumin action. Here are reported all the in vitro and in
vivo advances for the use of curcumin in the treatment of cervical cancer.
Initial studies about the effect of curcumin on NF-κB activity in cervi-
cal cancer cells were conducted by Venkatraman et al. in 2005 [79]. They
demonstrated in SiHa cell line, normally resistant to cisplatin, that inhi-
bition of NF-κB activity induced by curcumin determined increased sen-
sitization to cisplatin treatment evaluated as increased cell-death.
According with this study Bava et al. [80] showed that curcumin sensi-
tizes cervical cancer cells to the therapeutic effect of taxol, acting in the
down-regulation of both NF-κB and serine/threonine kinase AKT path-
way, a survival signal related to NF-κB.
A further step in the investigation of curcumin molecular target
was made by the study of Prusty et al. [81], which showed that curcu-
min can downregulate HPV-18 transcription, selectively inhibit AP-1
binding activity and reverse the expression dynamics of c-fos and
fra-1 in HeLa cells. Subsequently, Divya et al. [82] indicated that cur-
cumin is cytotoxic to cervical cancer cells in a concentration-
dependent and time-dependent manner and the cytotoxicity was
higher in HPV infected cells. The authors confirmed the inhibitory ac-
tion of curcumin on NF-κB activation, through the degradation of IκB,
and on AP-1 binding that results in the downregulation of COX-2 and
increased tumor cell apoptosis. Moreover, it was shown that curcu-
min downregulates the expression of HPV-16 and -18 E6 and E7
resulting in loss of the transforming phenotype and the cessation of
cellular growth. Current studies by Singh and Singh [83, 84] explored
other molecular mechanisms exerted by curcumin in cervical cancer
cells, showing that it inhibits telomerase activity, Ras and ERK signal-
ing pathway, cyclin D1, COX-2 and iNOS activity. Moreover, curcumin
decreases c-Myc transcriptional factor and Hsp 70 chaperone protein,
activates AIF, releases cytochrome c and enhances apoptosis via the
mitochondrial pathway with the upregulation of BAX and the down-
regulation of Bcl-2 and Bcl-XL. The authors further demonstrated that
the activity of curcumin on these multiple targets was able to revert
the proliferative action due to a pretreatment with estradiol on cervi-
cal cancer cell. A different approach was used by Madden et al. [85]
that with a proteomics approach analyzed the effect of curcumin on
HeLa cells, reporting significant changes in tumor-related proteins
linked to cell metabolism, cell cycle, and carcinogenic process.
Other recent mechanistic studies confirmed the suppression of
cancer cell growth by curcumin also in a three-dimensional raft

Fig. 1. Molecular mechanisms of human papillomavirus-induced carcinogenesis. Oncogenic action of high-risk HPV E6 and E7 oncoproteins is exerted through the inactivation of
tumor suppressors p53 and pRb, respectively. Abrogation of p53 by E6 ensures cell survival by preventing apoptosis inactivation while pRb inactivation by E7 forces infected cells to
remain in a proliferative state. The dark red box represent the target of action of the polyphenols considered: C = curcumin; E = EGCG; R = resveratrol.

Please cite this article as: F. Di Domenico, et al., Antioxidants in cervical cancer: Chemopreventive and chemotherapeutic effects of polyphe-
nols, Biochim. Biophys. Acta (2011), doi:10.1016/j.bbadis.2011.10.005
 F. Di Domenico et al. / Biochimica et Biophysica Acta xxx (2011) xxx–xxx
Fig. 2. Polyphenolic antioxidants. Chemical structure, properties and sources of curcumin (1,7-bis (4-hydroxy 3-methoxy phenyl)-1,6-heptadiene-3,5-dione), ferulic acid (3-methoxy-4-
hydroxycinnamic acid), EGCG (epigallocatechin-3-gallate) and resveratrol (trans-3,5,4′-trihydroxy-trans-stilbene).
culture system [86]. This effect was exerted through the induction of
apoptosis, the inhibition of cell motility, the decrease in expression
of HPV oncoproteins, and the restoration of expression of tumor sup-
pressor proteins. Interestingly they also showed that curcumin was
able to inhibit benzo[a]-pyrene (BaP) induced increase in HPV
oncoproteins.
Several studies proposed curcumin as a powerful radio- and
chemo-sensitizer. Javvadi et al. [87] showed that curcumin, with ion-
izing radiation (IR), produced a significant increase of ROS, which fur-
ther led to sustained ERK 1/2 activation, favoring the radiotherapic
effect on cervical cancer cells. Moreover Javvadi et al. showed later
the involvement thioredoxin reductase enzyme in the radiosensitiz-
ing action of curcumin in cervical cancer cells [88]. Very recently the
group of Anto R.J. showed that curcumin given during paclitaxel
treatment act as a down-regulator of paclitaxel pro-survival path-
ways linked to NF-κB and Akt activation in cervical cancer cells and
mouse models of cervical cancer [89, 90]. These studies, both in
vitro and in vivo, indicate that NF-κB is one of the central players in
the synergism of paclitaxel and curcumin and act as a regulator of
Cox-2, Cyclin D1, XIAP and cIAP1. AKT instead is the regulator of
NF-κB, which through the phosphorylation of MAPKs regulates a set
of survival signals.
The degradation of curcumin brings the formation of two products:
vanillic acid and ferulic acid (FA) and FA represent the major compo-
nent of curcumin.
FA (3-methoxy-4-hydroxycinnamic acid) is a dietary phytochemical
that occurs primarily in the seeds and leaves of most plants such as rice,
wheat, barley, oat, roasted coffee, tomatoes, and citrus fruits. FA ethyl
ester, FAEE, has been largely investigated in the protection against OS
during neurodegeneration, driven by Alzheimer disease, for its ability
to cross the brain blood barrier and exert its activity directly on OS chal-
lenged brain cells [91–94]. Moreover FA and FAEE are well-known anti-
oxidant agents used to prevent damage to cells caused by ultraviolet
light [95]. For this property FA is used in a wide range of cosmetics,
such as skin lighteners, sunscreens, anti-aging creams and moisturizers.
However several studies show that FA exhibits chemotherapic proper-
ty. It was described as a specific inhibitor of the anti-apoptotic proteins
Bcl-XL and Bcl-2, thereby inducing apoptosis [96]. However, a
Please cite this article as: F. Di Domenico, et al., Antioxidants in cervical cancer: Chemopreventive and chemotherapeutic effects of polyphe-
nols, Biochim. Biophys. Acta (2011), doi:10.1016/j.bbadis.2011.10.005
5
prooxidant activity of FA was observed in different experimental
models that might help to enhance radiation effects in cancer cells, as
was previously proven for other phenolic compounds [97].
A recent study from Karthikeyan et al. [98] investigated the radio-
sensitizing effect of FA on two human cervical carcinoma cell lines.
The authors showed that FA enhances radiation effects by decreasing
cancer cell viability through the influence on mitochondrial activity,
cell survival, and antioxidant status. Further was showed that FA
and IR increase lipid peroxidative markers, ROS levels, oxidative
DNA damage and apoptotic morphological changes, corroborating
that treatment of cancer cells with FA may help in augmenting the an-
ticancer effect of radiation.
From the studies aforementioned in this review, it is clear that
curcumin and its product FA holds great potential in the prevention
and therapy of cervical cancer. Researchers suggest that curcumin
represents an ideal compound for cancer patient treatment, consider-
ing the encouraging data as a safe and effective antitumoral and
chemo- and radio-sensitizer agent, and considering also its ability to
prevent depression, fatigue, lack of appetite and most of the symp-
toms induced by cancer.
5.2. Epigallocatechin-3-gallate
Green tea is one of the most widely consumed beverages. It has
been proven that it possesses beneficial anticarcinogenic and antipro-
liferative properties attributed to the biological properties of green
tea polyphenolic compounds. Consumption of green tea has been
reported to lower the risk of developing gastric, pancreatic, and colo-
rectal cancers in human populations [99, 100]. The polyphenols ac-
count for up to 30% of the dry weight of green tea and include
flavanols, flavandiols, flavonoids, and phenolic acids [101]. In particu-
lar, flavanols, known as catechins, are a major component of most
green tea. Generally, a typical cup of green tea contains 100 to
150 mg catechins, including 50% of epigallocatechin-3-gallate, 15%
of epigallocatechin, 15% of epicatechin-3-gallate, and 8% of epicate-
chin [102]. Epigallocatechin-3-gallate (EGCG) is the major bioactive
polyphenol present in green tea and displays antiproliferative, anti-
angiogenic, antimetastatic, proapoptotic, and cell cycle perturbation
6 F. Di Domenico et al. / Biochimica et Biophysica Acta xxx (2011) xxx–xxx

Table 1
Biochemical effects and molecular targets of chemopreventive action of polyphenols (curcumin, ferulic acid, EGCG, and resveratrol) in cervical cancer models.

Effects in cervical Compound Molecular targets References

cancer models

Cell growth Curcumin WAF-1/p21; Cdc2; p16; Venkatraman et al. (2005); Prusty et al. (2005); Bava et al. (2005); Divya et al. (2006); Javvadi et al. (2008);
inhibition F.A. PCNA; cyclin D1 Singh et al. (2009); Maher et al. (2011); Singh et al. (2011); Sreekanth et al. (2011); Bava et al. (2011);
Karthikeyan et al. (2011)
EGCG G1 phase arrest; WAF-1/ Ahn et al. (2003); Sah et al. (2003); Yokoyama et al. (2004); Noguchi et al. (2006); Yokoyama et al. (2008);
p21; KIP-1/p27; cyclin; Qiao et al. (2009); Zou et al. (2010)
CDK
Resveratrol S phase arrest Zoberi et al. (2002); Roy et al. (2002); Kramer et al. (2009)
Apoptosis induction Curcumin Caspases 3, 8, 9; DNA Venkatraman et al. (2005); Prusty et al. (2005); Bava et al. (2005); Divya et al. (2006); Singh et al. (2009);
F.A. damage; p53; PARP; Bava et al. (2011); Maher et al. (2011); Karthikeyan et al. (2011)
cytocrome c; Bax, AIF;
Bcl-2; Bcl-XL; annexin V
EGCG p53; BAD; caspase 3 Ahn et al. (2003); Sah et al. (2003); Yokoyama et al. (2004); Yokoyama et al. (2008);
Qiao et al. (2009); Siddiqui et al. (2010); Zou et al. (2010)
Resveratrol DNA damage; caspase 3; Roy et al. (2002); Hsu et al. (2009)
cathepsin L
Angiogenesis Curcumin VEGF Sreekanth et al. (2011)
inhibition F.A.
EGCG VEGF; HIF-1α Zhang et al. (2007)
Resveratrol VEGF; HIF-1α Tang et al. (2007)
Transcriptional Curcumin AKT; NF-κB; AP-1; Venkatraman et al. (2005); Bava et al. (2005); Prusty et al. (2005); Divya et al. (2006); Javvadi et al. (2008);
activity inhibition F.A. telomerase; c-fos; fra-1 Singh et al. (2009); Singh et al. (2011); Sreekanth et al. (2011);
Bava et al. (2011); Maher et al. (2011)
EGCG AKT; RNA pol. III; Sah et al. (2003); Yokoyama et al. (2004); Noguchi et al. (2006); Li et al. (2007);
telomerase Zhang et al. (2007); Jacob et al. (2007); Yokoyama et al. (2008)
Resveratrol AKT Sexton et al. (2006)
Signal transduction Curcumin ERK 1/2; JNK; p38; c-Jun Javvadi et al. (2008); Singh et al. (2009); Sreekanth et al. (2011); Bava et al. (2011)
pathways regulation F.A.
EGCG ERK 1/2; p90RSK Sah et al. (2003); Li et al. (2007); Zhang et al. (2007)
Resveratrol ERK; JNK; PKC-δ Woo et al. (2004)
HPV suppression Curcumin E6/E7; HPV-18 mRNA Prysty et al. (2005); Divya et al. (2006); Maher et al. (2011)
F.A.
EGCG E6/E7 Qiao et al. (2009); Zou et al. (2010)
Resveratrol
Cyclooxygenase Curcumin COX-2; Divya et al. (2006); Singh et al. (2009); Madden et al. (2009); Sreekanth et al. (2011);
inhibition F.A. Bava et al. (2011)
EGCG
Resveratrol COX-1; COX-2 Zoberi et al. (2002); Sexton et al. (2006)
Cell redox status/cell Curcumin iNOS; HSP7; TRX-R; ROS Javvadi et al. (2008); Singh et al. (2009); Javvadi et al. (2010); Karthikeyan et al. (2011)
stress response F.A. production
EGCG
Resveratrol
Other effects Curcumin MMP-9, -2; ICAM-1; Sreekanth et al. (2011); Bava et al. (2011)
F.A. survivin
EGCG IGF-IR; EGFR; aromatase; Sah et al. (2003); Li et al. (2007); Qiao et al. (2009); Bonfili et al. (2011)
ER α, β; proteasome
inhibition
Resveratrol MMP-9; autophagy Woo et al. (2004); Hsu et al. (2009)

activities in various in vitro and in vivo tumor models [103–109]
(Fig. 2). It has also been reported that there exists a threshold level
of EGCG that induces apoptosis and growth inhibition in cancer cell
lines, but not in normal cells [110, 111]. EGCG acts as a potent antiox-
idant and can scavenge ROS, such as lipid free radicals, superoxide
radicals, hydroxyl radicals, hydrogen peroxide and singlet oxygen
[112–115].
EGCG has been shown to inhibit several critical signal transduc-
tion pathways as well the activation of the redox-sensitive transcrip-
tion factors, NF-κB and AP-1 in cultured cells [116–118].
One of the first study about the effect of EGCG on the HPV-16 as-
sociated cervical cancer cell line CaSki, by Ahn et al. [119] demon-
strated that an EGCG antiproliferative effect depends by the arrest
of cell cycle in G1 phase that precedes in time the consequent pro-
grammed cell death by apoptosis. Furthermore, antitumor effects of
EGCG were also observed in nude mice challenged with CaSki cells
and then treated orally with EGCG. Siddiqui et al. [120], in a recent
study on cervical cancer cells extracted from fresh tissue, observed
apoptosis induction by EGCG, confirming results previously obtained.
Afterwards, Khun et al. [121] showed that EGCG potently inhibits the
proteasomal activity in HeLa cells, as evident by accumulation of
ubiquitinated proteins and three natural proteasome targets (p27,
IκB-α and Bax). Sah et al. [116] investigated the effect of EGCG on
EGFR signaling in several cervical cells lines, demonstrating that
EGCG inhibits EGFR, the initial kinase in the EGF signaling cascade,
while activating the ERK1/2 and AKT activity. This inhibition is associ-
ated with reduced phosphorylation, levels and activity of ERK1/2 and
AKT downstream substrates, which lead again to G1 arrest and in-
creased apoptosis. Yokoyama et al. and Noguchi et al. [122, 123] indi-
cated that EGCG, beyond cell growth and apoptosis, target also
telomerase, inhibiting its activity required for the initiation and pro-
gression of cervical lesions. It is well recognize that angiogenesis is a
key step in the progression cervical cancer. Zhang et al. [124] reported
that EGCG exhibit anti-angiogenic activities for the suppression of
HIF-1a protein accumulation and the decrease of VEGF expression at
both mRNA and protein levels, through the enhancement of protea-
some system activity and the blocking of PI3K/AKT and ERK1/2 sig-
naling pathways. The anti-angiogenic effect of EGCG was shown
recently also by Tudoran et al. [125] through the analysis on the alter-
ations of the expression pattern of 84 genes known to be involved in
the angiogenesis process. Li et al. [126] showed that EGCG abrogates
anchorage-independent growth and inhibits cell proliferation and

Please cite this article as: F. Di Domenico, et al., Antioxidants in cervical cancer: Chemopreventive and chemotherapeutic effects of polyphe-
nols, Biochim. Biophys. Acta (2011), doi:10.1016/j.bbadis.2011.10.005
 F. Di Domenico et al. / Biochimica et Biophysica Acta xxx (2011) xxx–xxx
transformation induced by IGF-IR overexpression by competing with
ATP, that result in a prevention of IGF-IR downstream signaling and
expression of cervical cancer cell phenotype. Another target of EGCG
anti-proliferative activity in cervical cancer cells is RNA pol III tran-
scription, as reported by Jacob et al. [127]. The authors found that
EGCG treatment inhibits transcription by RNA pol III, from both
gene internal (tRNA) and gene external (U6 snRNA) promoters.
Moreover EGCG inhibits expression of the TFIIIB subunits Brf1 and
Brf2, and inhibits the activity of the human Brf2 promoter. An essen-
tial effect of EGCG on cervical cancer cell lines is represented by the
inhibition of HPV oncogenes E6/E7 expression. Quiao et al. [128] ob-
served that EGCG, in cervical cancer cells, could suppress mRNA and
protein expression of ERα and aromatase limiting in this way the ex-
pression of E6/E7, and indirectly inhibiting cervical cancer cell growth
and inducing apoptosis. Zou et al. [129] achieved a similar result
showing decreased expression of E7 oncogene, increased apoptosis
coupled with increased expression levels and increased cell growth
inhibition during treatment of cervical cancer cells with EGCG. Re-
cently, Bonfili et al. [130] sustained that the observed EGCG effects
on proteasome functionality and on pro-apoptotic protein intracellu-
lar concentrations in cervical cancer cells may be the result of a com-
bined action of EGCG and its oxidation product. In fact the authors
observed that EGCG, under a common experimental condition un-
dergoes modification, involving the hydrolysis of the gallate ester,
and the disruption of the catechin A ring, with the formation of a bi-
ologically active product with inhibitory activity towards cellular
proteasomes.
Green tea represents, for its common use, one of the most studied
antioxidant compounds. From the aforementioned studies, it is clear
that EGCG, a green tea major constituent, holds great potential in
the prevention and therapy of cervical cancer. Taken together, these
data support the idea that EGCG provides an additional option for a
new and potential drug approach for cervical cancer patients.
5.3. Resveratrol
Resveratrol (trans-3,5,4′-trihydroxy-trans-stilbene) is a natural
polyphenolic phytoalexin most commonly found in nuts, berries,
grapes, and red wine. In several plants, including grapevine, resvera-
trol is synthesized in response to stress, injury, ultraviolet irradiation,
and fungal infection.
After the discovery of resveratrol pronounced pharmacological ef-
fects, it became a topic of intense investigations. It has been proposed
to prevent or counteract cardiovascular diseases (result from a mod-
erate wine drinking known as “The French Paradox”) [131, 132] and
inhibit cellular events associated with tumor initiation, promotion
and progression as a result of anti-inflammatory, proapoptotic, anti-
angiogenic, chemo-, and radio-sensitizing properties [132–139]
(Fig. 2). Numerous reports also indicate that resveratrol has antiviral
effects against HIV-1 and the herpes simplex virus [140, 141]. The
high concentration of resveratrol in grape skin (50–100 mg/g) and
thereby the high amounts in red wine (from 0.2 mg/l to 7.7 mg/l)
suggests that wine consumption might be protective against several
pathologies. However, the amount of resveratrol consumed daily by
a person drinking one glass of red wine is considerably lower than
the dose needed to benefit of resveratrol activity as antitumoral
agent [131, 142]. Studies focused on resveratrol anti-tumor activity
showed that this multi-hit compound exerts its action interacting
with numerous molecular targets involved in tumor progression,
such as Fas pathway, Rb-E2F/DP pathway, NF-κB and AP-1 transcrip-
tional factors, MAPK and many others [142]. However just few of
them were investigated in cervical cancer (Table 1). Recently a num-
ber of studies were conducted to investigate the effects of resveratrol
intake during cervical cancer development and the results are
reviewed below. Zoberi et al. [60] showed that resveratrol pretreat-
ment, in cervical cancer cell lines, has the ability to inhibit cell
Please cite this article as: F. Di Domenico, et al., Antioxidants in cervical cancer: Chemopreventive and chemotherapeutic effects of polyphe-
nols, Biochim. Biophys. Acta (2011), doi:10.1016/j.bbadis.2011.10.005
7
division inducing an early S-phase arrest, suggesting a role for resver-
atrol in the regulation of cell cycle progression. Kramer et al. [131]
using a double dose of resveratrol confirmed this result adding that
resveratrol-induced S-phase block was transient and reversible. Cy-
clooxygenase (COX) is well recognized as one of the main targets of
the resveratrol mechanism of action [142] [143]; in their study Zoberi
et al. showed that COX-1 is overexpressed in cervical cancer cells
while resveratrol treatment inhibits COX-1 activity. PGs are implicat-
ed in the response of tumor cells to ionizing radiation and other cyto-
toxic insults; COX-1 inhibition suppresses PGs biosynthesis,
suggesting that COX-1 inhibition by resveratrol might alter how
tumor cells respond to the cytotoxicity of ionizing radiation. Zoberi
et al. supported this hypothesis demonstrating that HeLa and SiHa
cell line cytotoxicity was enhanced by pretreatment with resveratrol
prior to ionizing radiation exposure. Sexton et al. [144] showed, in
six different human uterine cancer cell lines, that treatment with res-
veratrol decrease endogenous COX-2 protein levels, concomitant
with a decrease in production of COX metabolites PGE2 and PGF2α.
They suggest in their study that resveratrol regulates COX expression
not directly but possibly thru other enzymes involved in prostaglan-
din synthesis that act downstream of the COXs. Moreover they also
showed that resveratrol reduced cellular levels of the phosphorylat-
ed/active form of anti-apoptotic kinase AKT. Lin et al. obtained similar
results, about COX-2 suppression by resveratrol, in ovarian and breast
cancer cells supporting the role of resveratrol on cervical cancer cells
[145–147]. Another recognized mechanism of resveratrol chemopre-
vention is represented by the inhibition of metalloproteinases
(MMPs). A positive correlation between the expression of MMP-9
and tumor metastasis for several types of cancer was recently
shown [148, 149]. Woo et al. [150] demonstrated, in a CaSki cervical
cancer cell line, a decreased expression of MMP-9 during treatment
with resveratrol that exerts its actions through a tight regulation of
MMP-9 transcription. The authors also show that reduced MMP-9
levels depend by reduced PKC-δ activity, JNK activation as well as
diminished NF-κB and AP-1 activity during treatment with
resveratrol.
The progression of cervical cancer relies on tumor angiogenic ac-
tivity and several studies showed that HPV-16 oncoproteins, E5, E6,
and E7, induce VEGF expression in several established cervical cancer
cells lines [151–153], suggesting that high-risk HPV-16 oncoproteins
can promote tumor angiogenesis possibly via HIF-1α. Tang et al.
[154] revealed that overexpression of HPV-16 E6 and E7 oncoproteins
significantly promoted HIF-1α protein accumulation and VEGF ex-
pression in human cervical cancer cells. However activation of HIF-
1α and VEGF can be reverted by resveratrol through the inhibition
of AKT and ERK1/2 in cervical cancer cells, conceivably via the PI3K/
AKT and ERK1/2 signaling pathways. These results suggest that res-
veratrol can suppress tumor angiogenic activity in vitro and thereby
tumor progression and proliferation. Recently Hsu et al. [155] indicat-
ed that resveratrol induces autophagy, inhibits proliferation and in-
duces apoptotic death in HeLa and SiHa cervical cancer cell lines.
The authors showed that resveratrol destabilize lysosomes, which
cause lysosomal leakage, increased cytosol translocation, and enzymatic
activity of cathepsin L (cat L). The increased cat L activity in cytosol in-
duces cytochrome c release from mitochondria, and subsequently re-
sults in apoptotic cell death. An essential event in the pathway is the
lysosomal membrane permeabilization led by resveratrol induced
autophagy and the release of lysosomal proteases to the cytosol. The re-
leased cathepsins may trigger caspase-dependent cell death through
cleavage of bid and antiapoptotic Bcl-2 homologues, and induce cyto-
chrome c release.
Studies by Rezk et al. [156] on the chemotherapic use of resvera-
trol showed that this compound used with cisplatin or doxorubicin
demonstrated an additive growth-inhibitory anticancer effect on
uterine cancer cells supporting its possible use in the treatment of
cervical cancer.
8 F. Di Domenico et al. / Biochimica et Biophysica Acta xxx (2011) xxx–xxx
In conclusion, all these studies demonstrated that resveratrol is ca-
pable of: regulating cell cycle, progression, suppressing angiogenesis,
inhibiting MMP activities, inducing autophagy with consequent pro-
grammed cell death and increasing IR-induced cytotoxicity (Table 1).
These properties strongly support the beneficial effects of resveratrol
as a chemopreventive, a chemotherapeutic and a radiosensitizing com-
pound in the treatment of high-risk HPV-associated human cervical
cancers as well as other tumors [157]. However supplementary studies
to elucidate all the molecular mechanisms activated by resveratrol
treatment during cervical cancer are needed. Moreover, the lack of spe-
cific clinical trials to prove the efficiency of resveratrol for the treatment
of cervical cancer still raises the question about its real suitability.
6. Clinical trial in cervical cancer
The effects and molecular mechanisms of action of curcumin,
EGCG and resveratrol clearly sustain the chemopreventive and che-
motherapic properties of these phenolic compounds, as well as their
chemosensitizer and radiosensitizer abilities in cervical cancer
models. However, despite the confirmed beneficial effect of these an-
tioxidant compounds on cervical cancer progression, only few clinical
studies have been conducted until now.
Cheng et al. in 2001 [76] piloted a prospective phase-I study to
evaluate anticancer properties and also toxicology, pharmacokinetics
and biologically effective dose of curcumin in patients with uterine
CIN. The study demonstrated that curcumin is not toxic to humans
up to 8 mg/d when taken by mouth for 3 months and suggested a bi-
ologic effect of curcumin in the chemoprevention of cancer lesions at
least in 25% of the cases under treatment. A curcumin testing started
in 2008 for the investigation of its safety and efficacy against HPV in-
fection, in a Phase II multicentric clinical trial on 280 women enrolled
on the basis of clinical examination, cytology, histo-pathology and
presence of HPV [158].
Ahn et al. in 2003 [159] investigated clinical efficacy of EGCG and an-
other green tea component, poly E, delivered vaginally, orally, or both,
in patients with HPV-infected cervical lesions. Fifty-one patients with
such lesions, ranging from chronic cervicitis through mild and moderate
dysplasia to severe dysplasia, were divided into four groups and com-
pared with 39 controls. For oral delivery, a 200 mg of EGCG or Poly E
capsules was taken every day for eight to 12 weeks while Poly E oint-
ment was applied locally to 27 patients twice a week. The 60% of sub-
jects under EGCG capsule therapy, the 50% under poly E capsule
therapy, the 74% under poly E ointment therapy and the 75% under
poly E ointment plus poly E capsule therapy showed a response. Overall,
a 69% response rate was noted for treatment with green tea extracts, as
compared with a 10% response rate in untreated controls. These results
indicate that green tea extracts used orally and/or vaginally are effective
for treating HPV-related cervical lesions suggesting that green tea ex-
tracts can be a potential therapy routine for patients with HPV infected
cervical lesions
As previously stated, despite the promising results in preclinical
models, clinical trials, focusing on the health promoting effect of res-
veratrol, in subjects with cervical neoplasia are currently missing
[160]. To date most of the available clinical studies in humans are fo-
cused on resveratrol bioavailability, pharmacokinetics and metabolism
[161] and so far only two recently reports showed that resveratrol
could represent a promising agent in the treatment of cancerogenesis
[162, 163].
7. Conclusions
Cervical cancer is the second most common cancer among women
worldwide. Thus, it still represents a major concern for public health
although current screening methods are already available to allow
early diagnosis and treatment. Several therapeutic strategies are
being explored which can effectively target various phases of viral
Please cite this article as: F. Di Domenico, et al., Antioxidants in cervical cancer: Chemopreventive and chemotherapeutic effects of polyphe-
nols, Biochim. Biophys. Acta (2011), doi:10.1016/j.bbadis.2011.10.005
infection and its oncogenic expression. However, apart from the cur-
rent pharmacological intervention it becomes essential to explore al-
ternative approach. In recent years there has been increasing interest
in the potential cancer chemopreventive properties of diet-derived
agents. Among these, polyphenolic compounds, such as curcumin,
resveratrol and ECGC, received much attention for prevention and
treatment of cervical cancer.
Polyphenols were demonstrated to inhibit the proliferation of
HPV-immortalized and HPV-positive cancer cells, through induction
of apoptosis, growth arrest, inhibition of DNA synthesis and modula-
tion of signal transduction pathways. They are able to act at several
steps in the cascade of cell transformation promoted by HPV infec-
tion. However, further studies will likely provide additional insights
into the mechanism of redox control of cancerogenesis events.
From the studies reviewed in this paper, it is clear that dietary
polyphenols hold a great potential in the prevention and therapy of
cervical cancer. Encouraging data as a safe and effective antitumoral
and chemo- and radiosensitizer agent have been demonstrated in
clinical trials. Further, considering that curcumins, EGCG and resvera-
trol present peculiar targets of action the synergistic use of these
polyphenols might favor their anticarcinogenic effect, however no
such studies has been conducted yet on cervical cancer models. In ad-
dition, they also prevent depression, fatigue, lack of appetite and most
of the symptoms induced by cancer.
References
[1] H. zur Hausen, W. Meinhof, W. Scheiber, G.W. Bornkamm, Attempts to detect
virus-specific DNA in human tumors. I. Nucleic acid hybridizations with
complementary RNA of human wart virus, Int. J. Cancer 13 (1974) 650–656.
[2] M. Narisawa-Saito, T. Kiyono, Basic mechanisms of high-risk human
papillomavirus-induced carcinogenesis: roles of E6 and E7 proteins, Cancer
Sci. 98 (2007) 1505–1511.
[3] A.C. Bharti, S. Shukla, S. Mahata, S. Hedau, B.C. Das, Anti-human papillomavirus
therapeutics: facts & future, Indian J. Med. Res. 130 (2009) 296–310.
[4] J.P. Baak, A.J. Kruse, S.J. Robboy, E.A. Janssen, B. van Diermen, I. Skaland, Dynamic
behavioural interpretation of cervical intraepithelial neoplasia with molecular
biomarkers, J. Clin. Pathol. 59 (2006) 1017–1028.
[5] N.A. Hamid, C. Brown, K. Gaston, The regulation of cell proliferation by the pap-
illomavirus early proteins, Cell Mol. Life Sci. 66 (2009) 1700–1717.
[6] C.A. Moody, L.A. Laimins, Human papillomavirus oncoproteins: pathways to
transformation, Nat. Rev. Cancer 10 (2010) 550–560.
[7] R.S. Jayshree, A. Sreenivas, M. Tessy, S. Krishna, Cell intrinsic & extrinsic factors
in cervical carcinogenesis, Indian J. Med. Res. 130 (2009) 286–295.
[8] M. Scheffner, J.M. Huibregtse, R.D. Vierstra, P.M. Howley, The HPV-16 E6 and E6-AP
complex functions as a ubiquitin-protein ligase in the ubiquitination of p53, Cell 75
(1993) 495–505.
[9] P. Massimi, A. Shai, P. Lambert, L. Banks, HPV E6 degradation of p53 and PDZ
containing substrates in an E6AP null background, Oncogene 27 (2008)
1800–1804.
[10] M. Vogt, K. Butz, S. Dymalla, J. Semzow, F. Hoppe-Seyler, Inhibition of Bax activity is
crucial for the antiapoptotic function of the human papillomavirus E6 oncoprotein,
Oncogene 25 (2006) 4009–4015.
[11] M. Thomas, L. Banks, Inhibition of Bak-induced apoptosis by HPV-18 E6, Oncogene
17 (1998) 2943–2954.
[12] M.A. James, J.H. Lee, A.J. Klingelhutz, Human papillomavirus type 16 E6 activates
NF-kappaB, induces cIAP-2 expression, and protects against apoptosis in a PDZ
binding motif-dependent manner, J. Virol. 80 (2006) 5301–5307.
[13] H. Yuan, F. Fu, J. Zhuo, W. Wang, J. Nishitani, D.S. An, I.S. Chen, X. Liu, Human
papillomavirus type 16 E6 and E7 oncoproteins upregulate c-IAP2 gene expres-
sion and confer resistance to apoptosis, Oncogene 24 (2005) 5069–5078.
[14] N. Dyson, The regulation of E2F by pRB-family proteins, Genes Dev. 12 (1998)
2245–2262.
[15] M. Giarre, S. Caldeira, I. Malanchi, F. Ciccolini, M.J. Leao, M. Tommasino, Induc-
tion of pRb degradation by the human papillomavirus type 16 E7 protein is es-
sential to efficiently overcome p16INK4a-imposed G1 cell cycle arrest, J. Virol.
75 (2001) 4705–4712.
[16] R. Balan, C. Amalinei, S.E. Giusca, D. Ditescu, V. Gheorghita, E. Crauciuc, I.D.
Caruntu, Immunohistochemical evaluation of COX-2 expression in HPV-
positive cervical squamous intraepithelial lesions, Rom. J. Morphol. Embryol.
52 (2011) 39–43.
[17] K. Subbaramaiah, A.J. Dannenberg, Cyclooxygenase-2 transcription is regulated
by human papillomavirus 16 E6 and E7 oncoproteins: evidence of a corepres-
sor/coactivator exchange, Cancer Res. 67 (2007) 3976–3985.
[18] S.H. Kim, J.M. Oh, J.H. No, Y.J. Bang, Y.S. Juhnn, Y.S. Song, Involvement of NF-kappaB
and AP-1 in COX-2 upregulation by human papillomavirus 16 E5 oncoprotein, Carci-
nogenesis 30 (2009) 753–757.
 F. Di Domenico et al. / Biochimica et Biophysica Acta xxx (2011) xxx–xxx
[19] S.R. Sudarshan, R. Schlegel, X. Liu, The HPV-16 E5 protein represses expression
of stress pathway genes XBP-1 and COX-2 in genital keratinocytes, Biochem.
Biophys. Res. Commun. 399 (2010) 617–622.
[20] A. Moktar, R. Singh, M.V. Vadhanam, S. Ravoori, J.W. Lillard, C.G. Gairola, R.C.
Gupta, Cigarette smoke condensate-induced oxidative DNA damage and its re-
moval in human cervical cancer cells, Int. J. Oncol. 39 (2011) 941–947.
[21] S.S. Beevi, M.H. Rasheed, A. Geetha, Evidence of oxidative and nitrosative stress
in patients with cervical squamous cell carcinoma, Clin. Chim. Acta 375 (2007)
119–123.
[22] T. Finkel, Oxidant signals and oxidative stress, Curr. Opin. Cell Biol. 15 (2003)
247–254.
[23] D. Darr, I. Fridovich, Free radicals in cutaneous biology, J. Invest. Dermatol. 102
(1994) 671–675.
[24] B.A. Jurkiewicz, G.R. Buettner, Ultraviolet light-induced free radical formation in skin:
an electron paramagnetic resonance study, Photochem. Photobiol. 59 (1994) 1–4.
[25] K.B. Beckman, B.N. Ames, Oxidative decay of DNA, J. Biol. Chem. 272 (1997)
19633–19636.
[26] J. Cadet, T. Delatour, T. Douki, D. Gasparutto, J.P. Pouget, J.L. Ravanat, S. Sauvaigo,
Hydroxyl radicals and DNA base damage, Mutat. Res. 424 (1999) 9–21.
[27] M.M. Vilenchik, A.G. Knudson, Endogenous DNA double-strand breaks: produc-
tion, fidelity of repair, and induction of cancer, Proc. Natl. Acad. Sci. U. S. A. 100
(2003) 12871–12876.
[28] J.M. Mates, C. Perez-Gomez, I. Nunez de Castro, Antioxidant enzymes and human
diseases, Clin. Biochem. 32 (1999) 595–603.
[29] S. Maynard, S.H. Schurman, C. Harboe, N.C. de Souza-Pinto, V.A. Bohr, Base exci-
sion repair of oxidative DNA damage and association with cancer and aging, Car-
cinogenesis 30 (2009) 2–10.
[30] P. Storz, Reactive oxygen species in tumor progression, Front. Biosci. 10 (2005)
1881–1896.
[31] R.H. Burdon, Superoxide and hydrogen peroxide in relation to mammalian cell
proliferation, Free Radic. Biol. Med. 18 (1995) 775–794.
[32] S. Toyokuni, K. Okamoto, J. Yodoi, H. Hiai, Persistent oxidative stress in cancer,
FEBS Lett. 358 (1995) 1–3.
[33] T.B. Kryston, A.B. Georgiev, P. Pissis, A.G. Georgakilas, Role of oxidative stress
and DNA damage in human carcinogenesis, Mutat. Res. 711 (2011) 193–201.
[34] G.Y. Liou, P. Storz, Reactive oxygen species in cancer, Free. Radic. Res. 44 (2010)
479–496.
[35] A. Sgambato, G.F. Zannoni, B. Faraglia, A. Camerini, E. Tarquini, D. Spada, A.
Cittadini, Decreased expression of the CDK inhibitor p27Kip1 and increased
oxidative DNA damage in the multistep process of cervical carcinogenesis,
Gynecol. Oncol. 92 (2004) 776–783.
[36] M. Perluigi, A. Giorgi, C. Blarzino, F. De Marco, C. Foppoli, F. Di Domenico, D.A.
Butterfield, M.E. Schinina, C. Cini, R. Coccia, Proteomics analysis of protein ex-
pression and specific protein oxidation in human papillomavirus transformed
keratinocytes upon UVB irradiation, J. Cell. Mol. Med. 13 (2009) 1809–1822.
[37] R.A. Cairns, I.S. Harris, T.W. Mak, Regulation of cancer cell metabolism, Nat. Rev.
Cancer 11 (2011) 85–95.
[38] F. De Marco, M. Perluigi, C. Foppoli, C. Blarzino, C. Cini, R. Coccia, A. Venuti, UVB
irradiation down-regulates HPV-16 RNA expression: implications for malignant
progression of transformed cells, Virus Res. 130 (2007) 249–259.
[39] M.L. Looi, A.Z. Mohd Dali, S.A. Md Ali, W.Z. Wan Ngah, Y.A. Mohd Yusof, Oxida-
tive damage and antioxidant status in patients with cervical intraepithelial neo-
plasia and carcinoma of the cervix, Eur. J. Cancer Prev. 17 (2008) 555–560.
[40] S.Y. Kim, J.W. Kim, Y.S. Ko, J.E. Koo, H.Y. Chung, Y.C. Lee-Kim, Changes in lipid
peroxidation and antioxidant trace elements in serum of women with cervical
intraepithelial neoplasia and invasive cancer, Nutr. Cancer 47 (2003) 126–130.
[41] T.L. Goncalves, F. Erthal, C.L. Corte, L.G. Muller, C.M. Piovezan, C.W. Nogueira, J.B.
Rocha, Involvement of oxidative stress in the pre-malignant and malignant
states of cervical cancer in women, Clin. Biochem. 38 (2005) 1071–1075.
[42] S.C. Thomasset, D.P. Berry, G. Garcea, T. Marczylo, W.P. Steward, A.J. Gescher,
Dietary polyphenolic phytochemicals—promising cancer chemopreventive agents
in humans? A review of their clinical properties, Int. J. Cancer 120 (2007) 451–458.
[43] M. D'Archivio, C. Santangelo, B. Scazzocchio, R. Vari, C. Filesi, R. Masella, C.
Giovannini, Modulatory effects of polyphenols on apoptosis induction:
relevance for cancer prevention, Int. J. Mol. Sci. 9 (2008) 213–228.
[44] H.J. Forman, M. Torres, J. Fukuto, Redox signaling, Mol. Cell. Biochem. 234–235
(2002) 49–62.
[45] S. Nair, W. Li, A.N. Kong, Natural dietary anti-cancer chemopreventive com-
pounds: redox-mediated differential signaling mechanisms in cytoprotection
of normal cells versus cytotoxicity in tumor cells, Acta Pharmacol. Sin. 28
(2007) 459–472.
[46] A. Gopalakrishnan, A.N. Tony Kong, Anticarcinogenesis by dietary phytochemi-
cals: cytoprotection by Nrf2 in normal cells and cytotoxicity by modulation of
transcription factors NF-kappa B and AP-1 in abnormal cancer cells, Food
Chem. Toxicol. 46 (2008) 1257–1270.
[47] J.M. Hansen, W.H. Watson, D.P. Jones, Compartmentation of Nrf-2 redox control:
regulation of cytoplasmic activation by glutathione and DNA binding by
thioredoxin-1, Toxicol. Sci. 82 (2004) 308–317.
[48] M. Karin, The regulation of AP-1 activity by mitogen-activated protein kinases,
J. Biol. Chem. 270 (1995) 16483–16486.
[49] J.R. Matthews, W. Kaszubska, G. Turcatti, T.N. Wells, R.T. Hay, Role of cysteine62
in DNA recognition by the P50 subunit of NF-kappa B, Nucleic Acids Res. 21
(1993) 1727–1734.
[50] J.M. Hansen, Y.M. Go, D.P. Jones, Nuclear and mitochondrial compartmentation
of oxidative stress and redox signaling, Annu. Rev. Pharmacol. Toxicol. 46
(2006) 215–234.
Please cite this article as: F. Di Domenico, et al., Antioxidants in cervical cancer: Chemopreventive and chemotherapeutic effects of polyphe-
nols, Biochim. Biophys. Acta (2011), doi:10.1016/j.bbadis.2011.10.005
9
[51] M.B. Sporn, Carcinogenesis and cancer: different perspectives on the same dis-
ease, Cancer Res. 51 (1991) 6215–6218.
[52] R. Hu, S. Zhou, X. Li, Altered Bcl-2 and Bax expression is associated with cultured
first trimester human cytotrophoblasts apoptosis induced by hypoxia, Life Sci.
79 (2006) 351–355.
[53] W.S. Jeong, Y.S. Keum, C. Chen, M.R. Jain, G. Shen, J.H. Kim, W. Li, A.N. Kong, Dif-
ferential expression and stability of endogenous nuclear factor E2-related factor
2 (Nrf2) by natural chemopreventive compounds in HepG2 human hepatoma
cells, J. Biochem. Mol. Biol. 38 (2005) 167–176.
[54] S. Nair, C. Xu, G. Shen, V. Hebbar, A. Gopalakrishnan, R. Hu, M.R. Jain, W. Lin, Y.S.
Keum, C. Liew, J.Y. Chan, A.N. Kong, Pharmacogenomics of phenolic antioxidant
butylated hydroxyanisole (BHA) in the small intestine and liver of Nrf2 knock-
out and C57BL/6J mice, Pharm. Res. 23 (2006) 2621–2637.
[55] G. Shen, W.S. Jeong, R. Hu, A.N. Kong, Regulation of Nrf2, NF-kappaB, and AP-1
signaling pathways by chemopreventive agents, Antioxid. Redox Signal. 7
(2005) 1648–1663.
[56] G. Shen, C. Xu, R. Hu, M.R. Jain, A. Gopalkrishnan, S. Nair, M.T. Huang, J.Y. Chan,
A.N. Kong, Modulation of nuclear factor E2-related factor 2-mediated gene ex-
pression in mice liver and small intestine by cancer chemopreventive agent cur-
cumin, Mol. Cancer Ther. 5 (2006) 39–51.
[57] E.M. Siegel, J.L. Salemi, L.L. Villa, A. Ferenczy, E.L. Franco, A.R. Giuliano, Dietary
consumption of antioxidant nutrients and risk of incident cervical intraepithelial
neoplasia, Gynecol. Oncol. 118 (2010) 289–294.
[58] L.Y. Tomita, A. Longatto Filho, M.C. Costa, M.A. Andreoli, L.L. Villa, E.L. Franco, M.A.
Cardoso, Brazilian Investigation into Nutrition and Cervical Cancer Prevention
(BRINCA) Study Team, Diet and serum micronutrients in relation to cervical neoplasia
and cancer among low-income Brazilian women, Int. J. Cancer 126 (2010) 703–714.
[59] A. Goel, B.B. Aggarwal, Curcumin, the golden spice from Indian saffron, is a che-
mosensitizer and radiosensitizer for tumors and chemoprotector and radiopro-
tector for normal organs, Nutr. Cancer 62 (2010) 919–930.
[60] I. Zoberi, C.M. Bradbury, H.A. Curry, K.S. Bisht, P.C. Goswami, J.L. Roti Roti, D.
Gius, Radiosensitizing and anti-proliferative effects of resveratrol in two
human cervical tumor cell lines, Cancer Lett. 175 (2002) 165–173.
[61] I. Brouet, H. Ohshima, Curcumin, an anti-tumour promoter and anti-inflammatory
agent, inhibits induction of nitric oxide synthase in activated macrophages, Bio-
chem. Biophys. Res. Commun. 206 (1995) 533–540.
[62] Sreejayan, M.N. Rao, Nitric oxide scavenging bCBEy curcuminoids, J. Pharm.
Pharmacol. 49 (1997) 105–107.
[63] R. Srivastava, M. Dikshit, R.C. Srimal, B.N. Dhawan, Anti-thrombotic effect of cur-
cumin, Thromb. Res. 40 (1985) 413–417.
[64] N. Venkatesan, Curcumin attenuation of acute adriamycin myocardial toxicity in
rats, Br. J. Pharmacol. 124 (1998) 425–427.
[65] S.D. Deodhar, R. Sethi, R.C. Srimal, Preliminary study on antirheumatic activity of
curcumin (diferuloyl methane), Indian J. Med. Res. 71 (1980) 632–634.
[66] M.M. Chan, N.S. Adapala, D. Fong, Curcumin overcomes the inhibitory effect of
nitric oxide on Leishmania, Parasitol. Res. 96 (2005) 49–56.
[67] A. Khafif, S. Lev-Ari, A. Vexler, I. Barnea, A. Starr, V. Karaush, S. Haif, R. Ben-Yosef,
Curcumin: a potential radio-enhancer in head and neck cancer, Laryngoscope
119 (2009) 2019–2026.
[68] J.K. Lin, S.Y. Lin-Shiau, Mechanisms of cancer chemoprevention by curcumin,
Proc. Natl. Sci. Counc. Repub. China B 25 (2001) 59–66.
[69] G. Kang, P.J. Kong, Y.J. Yuh, S.Y. Lim, S.V. Yim, W. Chun, S.S. Kim, Curcumin sup-
presses lipopolysaccharide-induced cyclooxygenase-2 expression by inhibiting
activator protein 1 and nuclear factor kappab bindings in BV2 microglial cells,
J. Pharmacol. Sci. 94 (2004) 325–328.
[70] S.S. Han, Y.S. Keum, H.J. Seo, Y.J. Surh, Curcumin suppresses activation of NF-
kappaB and AP-1 induced by phorbol ester in cultured human promyelocytic
leukemia cells, J. Biochem. Mol. Biol. 35 (2002) 337–342.
[71] J.Y. Liu, S.J. Lin, J.K. Lin, Inhibitory effects of curcumin on protein kinase C activity
induced by 12-O-tetradecanoyl-phorbol-13-acetate in NIH 3T3 cells, Carcino-
genesis 14 (1993) 857–861.
[72] S.M. Plummer, K.A. Holloway, M.M. Manson, R.J. Munks, A. Kaptein, S. Farrow, L.
Howells, Inhibition of cyclo-oxygenase 2 expression in colon cells by the chemo-
preventive agent curcumin involves inhibition of NF-kappaB activation via the
NIK/IKK signalling complex, Oncogene 18 (1999) 6013–6020.
[73] S.M. Plummer, K.A. Hill, M.F. Festing, W.P. Steward, A.J. Gescher, R.A. Sharma,
Clinical development of leukocyte cyclooxygenase 2 activity as a systemic bio-
marker for cancer chemopreventive agents, Cancer Epidemiol. Biomarkers
Prev. 10 (2001) 1295–1299.
[74] L.I. Lin, Y.F. Ke, Y.C. Ko, J.K. Lin, Curcumin inhibits SK-Hep-1 hepatocellular car-
cinoma cell invasion in vitro and suppresses matrix metalloproteinase-9 secre-
tion, Oncology 55 (1998) 349–353.
[75] R. Mohan, J. Sivak, P. Ashton, L.A. Russo, B.Q. Pham, N. Kasahara, M.B. Raizman,
M.E. Fini, Curcuminoids inhibit the angiogenic response stimulated by fibroblast
growth factor-2, including expression of matrix metalloproteinase gelatinase B,
J. Biol. Chem. 275 (2000) 10405–10412.
[76] A.L. Cheng, C.H. Hsu, J.K. Lin, M.M. Hsu, Y.F. Ho, T.S. Shen, J.Y. Ko, J.T. Lin, B.R. Lin,
W. Ming-Shiang, H.S. Yu, S.H. Jee, G.S. Chen, T.M. Chen, C.A. Chen, M.K. Lai, Y.S.
Pu, M.H. Pan, Y.J. Wang, C.C. Tsai, C.Y. Hsieh, Phase I clinical trial of curcumin,
a chemopreventive agent, in patients with high-risk or pre-malignant lesions,
Anticancer. Res. 21 (2001) 2895–2900.
[77] C.V. Rao, A. Rivenson, B. Simi, B.S. Reddy, Chemoprevention of colon carcinogen-
esis by dietary curcumin, a naturally occurring plant phenolic compound, Can-
cer Res. 55 (1995) 259–266.
[78] T. Kawamori, R. Lubet, V.E. Steele, G.J. Kelloff, R.B. Kaskey, C.V. Rao, B.S. Reddy,
Chemopreventive effect of curcumin, a naturally occurring anti-inflammatory
10 F. Di Domenico et al. / Biochimica et Biophysica Acta xxx (2011) xxx–xxx
agent, during the promotion/progression stages of colon cancer, Cancer Res. 59
(1999) 597–601.
[79] M. Venkatraman, R.J. Anto, A. Nair, M. Varghese, D. Karunagaran, Biological and
chemical inhibitors of NF-kappaB sensitize SiHa cells to cisplatin-induced apo-
ptosis, Mol. Carcinog. 44 (2005) 51–59.
[80] S.V. Bava, V.T. Puliappadamba, A. Deepti, A. Nair, D. Karunagaran, R.J. Anto, Sen-
sitization of taxol-induced apoptosis by curcumin involves down-regulation of
nuclear factor-kappaB and the serine/threonine kinase Akt and is independent
of tubulin polymerization, J. Biol. Chem. 280 (2005) 6301–6308.
[81] B.K. Prusty, B.C. Das, Constitutive activation of transcription factor AP-1 in cervi-
cal cancer and suppression of human papillomavirus (HPV) transcription and
AP-1 activity in HeLa cells by curcumin, Int. J. Cancer 113 (2005) 951–960.
[82] C.S. Divya, M.R. Pillai, Antitumor action of curcumin in human papillomavirus
associated cells involves downregulation of viral oncogenes, prevention of
NFkB and AP-1 translocation, and modulation of apoptosis, Mol. Carcinog. 45
(2006) 320–332.
[83] M. Singh, N. Singh, Molecular mechanism of curcumin induced cytotoxicity in
human cervical carcinoma cells, Mol. Cell. Biochem. 325 (2009) 107–119.
[84] M. Singh, N. Singh, Curcumin counteracts the proliferative effect of estradiol and
induces apoptosis in cervical cancer cells, Mol. Cell. Biochem. 347 (2011) 1–11.
[85] K. Madden, L. Flowers, R. Salani, I. Horowitz, S. Logan, K. Kowalski, J. Xie, S.I.
Mohammed, Proteomics-based approach to elucidate the mechanism of antitu-
mor effect of curcumin in cervical cancer, Prostaglandins Leukot. Essent. Fatty
Acids 80 (2009) 9–18.
[86] D.M. Maher, M.C. Bell, E.A. O'Donnell, B.K. Gupta, M. Jaggi, S.C. Chauhan, Curcu-
min suppresses human papillomavirus oncoproteins, restores p53, Rb, and
PTPN13 proteins and inhibits benzo[a]pyrene-induced upregulation of HPV E7,
Mol. Carcinog. 50 (2011) 47–57.
[87] P. Javvadi, A.T. Segan, S.W. Tuttle, C. Koumenis, The chemopreventive agent cur-
cumin is a potent radiosensitizer of human cervical tumor cells via increased re-
active oxygen species production and overactivation of the mitogen-activated
protein kinase pathway, Mol. Pharmacol. 73 (2008) 1491–1501.
[88] P. Javvadi, L. Hertan, R. Kosoff, T. Datta, J. Kolev, R. Mick, S.W. Tuttle, C. Koumenis,
Thioredoxin reductase-1 mediates curcumin-induced radiosensitization of
squamous carcinoma cells, Cancer Res. 70 (2010) 1941–1950.
[89] C.N. Sreekanth, S.V. Bava, E. Sreekumar, R.J. Anto, Molecular evidences for the
chemosensitizing efficacy of liposomal curcumin in paclitaxel chemotherapy in
mouse models of cervical cancer, Oncogene 30 (2011) 3139–3152.
[90] S.V. Bava, C.N. Sreekanth, A.K. Thulasidasan, N.P. Anto, V.T. Cheriyan, V.T.
Puliyappadamba, S.G. Menon, S.D. Ravichandran, R.J. Anto, Akt is upstream and
MAPKs are downstream of NF-kappaB in paclitaxel-induced survival signaling
events, which are down-regulated by curcumin contributing to their synergism,
Int. J. Biochem. Cell Biol. 43 (2011) 331–341.
[91] R. Sultana, A. Ravagna, H. Mohmmad-Abdul, V. Calabrese, D.A. Butterfield, Feru-
lic acid ethyl ester protects neurons against amyloid beta-peptide(1–42)-in-
duced oxidative stress and neurotoxicity: relationship to antioxidant activity, J.
Neurochem. 92 (2005) 749–758.
[92] H. Mohmmad Abdul, D.A. Butterfield, Protection against amyloid beta-peptide
(1–42)-induced loss of phospholipid asymmetry in synaptosomal membranes
by tricyclodecan-9-xanthogenate (D609) and ferulic acid ethyl ester: implica-
tions for Alzheimer's disease, Biochim. Biophys. Acta 1741 (2005) 140–148.
[93] G. Joshi, M. Perluigi, R. Sultana, R. Agrippino, V. Calabrese, D.A. Butterfield, In
vivo protection of synaptosomes by ferulic acid ethyl ester (FAEE) from oxida-
tive stress mediated by 2,2-azobis(2-amidino-propane) dihydrochloride
(AAPH) or Fe(2+)/H(2)O(2): insight into mechanisms of neuroprotection and
relevance to oxidative stress-related neurodegenerative disorders, Neurochem.
Int. 48 (2006) 318–327.
[94] M. Perluigi, G. Joshi, R. Sultana, V. Calabrese, C. De Marco, R. Coccia, C. Cini, D.A.
Butterfield, In vivo protective effects of ferulic acid ethyl ester against amyloid-
beta peptide 1–42-induced oxidative stress, J. Neurosci. Res. 84 (2006) 418–426.
[95] F. Di Domenico, M. Perluigi, C. Foppoli, C. Blarzino, R. Coccia, F. De Marco, D.A.
Butterfield, C. Cini, Protective effect of ferulic acid ethyl ester against oxidative
stress mediated by UVB irradiation in human epidermal melanocytes, Free.
Radic. Res. 43 (2009) 365–375.
[96] B. Jayaprakasam, M. Vanisree, Y. Zhang, D.L. Dewitt, M.G. Nair, Impact of alkyl es-
ters of caffeic and ferulic acids on tumor cell proliferation, cyclooxygenase en-
zyme, and lipid peroxidation, J. Agric. Food Chem. 54 (2006) 5375–5381.
[97] L.F. Zheng, F. Dai, B. Zhou, L. Yang, Z.L. Liu, Prooxidant activity of hydroxycin-
namic acids on DNA damage in the presence of Cu (II) ions: mechanism and
structure–activity relationship, Food Chem. Toxicol. 46 (2008) 149–156.
[98] S. Karthikeyan, G. Kanimozhi, N.R. Prasad, R. Mahalakshmi, Radiosensitizing effect
of ferulic acid on human cervical carcinoma cells in vitro, Toxicol. In Vitro (2011).
[99] G.P. Yu, C.C. Hsieh, L.Y. Wang, S.Z. Yu, X.L. Li, T.H. Jin, Green-tea consumption and
risk of stomach cancer: a population-based case–control study in Shanghai,
China, Cancer Causes Control 6 (1995) 532–538.
[100] B.T. Ji, W.H. Chow, A.W. Hsing, J.K. McLaughlin, Q. Dai, Y.T. Gao, W.J. Blot, J.F.
Fraumeni Jr., Green tea consumption and the risk of pancreatic and colorectal
cancers, Int. J. Cancer 70 (1997) 255–258.
[101] H.N. Graham, Green tea composition, consumption, and polyphenol chemistry,
Prev. Med. 21 (1992) 334–350.
[102] N. Horie, N. Hirabayashi, Y. Takahashi, Y. Miyauchi, H. Taguchi, K. Takeishi, Syn-
ergistic effect of green tea catechins on cell growth and apoptosis induction in
gastric carcinoma cells, Biol. Pharm. Bull. 28 (2005) 574–579.
[103] M. Nihal, N. Ahmad, H. Mukhtar, G.S. Wood, Anti-proliferative and proapoptotic ef-
fects of (−)-epigallocatechin-3-gallate on human melanoma: possible implica-
tions for the chemoprevention of melanoma, Int. J. Cancer 114 (2005) 513–521.
Please cite this article as: F. Di Domenico, et al., Antioxidants in cervical cancer: Chemopreventive and chemotherapeutic effects of polyphe-
nols, Biochim. Biophys. Acta (2011), doi:10.1016/j.bbadis.2011.10.005
[104] M.S. Baliga, S. Meleth, S.K. Katiyar, Growth inhibitory and antimetastatic effect of
green tea polyphenols on metastasis-specific mouse mammary carcinoma 4T1
cells in vitro and in vivo systems, Clin. Cancer Res. 11 (2005) 1918–1927.
[105] T. Kondo, T. Ohta, K. Igura, Y. Hara, K. Kaji, Tea catechins inhibit angiogenesis in
vitro, measured by human endothelial cell growth, migration and tube forma-
tion, through inhibition of VEGF receptor binding, Cancer Lett. 180 (2002)
139–144.
[106] G. Fassina, R. Vene, M. Morini, S. Minghelli, R. Benelli, D.M. Noonan, A. Albini,
Mechanisms of inhibition of tumor angiogenesis and vascular tumor growth
by epigallocatechin-3-gallate, Clin. Cancer Res. 10 (2004) 4865–4873.
[107] S. Qanungo, M. Das, S. Haldar, A. Basu, Epigallocatechin-3-gallate induces mito-
chondrial membrane depolarization and caspase-dependent apoptosis in pan-
creatic cancer cells, Carcinogenesis 26 (2005) 958–967.
[108] N. Ahmad, P. Cheng, H. Mukhtar, Cell cycle dysregulation by green tea polyphe-
nol epigallocatechin-3-gallate, Biochem. Biophys. Res. Commun. 275 (2000)
328–334.
[109] Y.C. Liang, S.Y. Lin-Shiau, C.F. Chen, J.K. Lin, Inhibition of cyclin-dependent ki-
nases 2 and 4 activities as well as induction of Cdk inhibitors p21 and p27 during
growth arrest of human breast carcinoma cells by (−)-epigallocatechin-3-gal-
late, J. Cell. Biochem. 75 (1999) 1–12.
[110] N. Ahmad, D.K. Feyes, A.L. Nieminen, R. Agarwal, H. Mukhtar, Green tea constit-
uent epigallocatechin-3-gallate and induction of apoptosis and cell cycle arrest
in human carcinoma cells, J. Natl. Cancer Inst. 89 (1997) 1881–1886.
[111] Z.P. Chen, J.B. Schell, C.T. Ho, K.Y. Chen, Green tea epigallocatechin gallate shows
a pronounced growth inhibitory effect on cancerous cells but not on their nor-
mal counterparts, Cancer Lett. 129 (1998) 173–179.
[112] F. Nanjo, M. Honda, K. Okushio, N. Matsumoto, F. Ishigaki, T. Ishigami, Y. Hara,
Effects of dietary tea catechins on alpha-tocopherol levels, lipid peroxidation,
and erythrocyte deformability in rats fed on high palm oil and perilla oil diets,
Biol. Pharm. Bull. 16 (1993) 1156–1159.
[113] T. Nakagawa, T. Yokozawa, Direct scavenging of nitric oxide and superoxide by
green tea, Food Chem. Toxicol. 40 (2002) 1745–1750.
[114] G.R. Haenen, J.B. Paquay, R.E. Korthouwer, A. Bast, Peroxynitrite scavenging by
flavonoids, Biochem. Biophys. Res. Commun. 236 (1997) 591–593.
[115] B.C. Scott, J. Butler, B. Halliwell, O.I. Aruoma, Evaluation of the antioxidant ac-
tions of ferulic acid and catechins, Free. Radic. Res. Commun. 19 (1993)
241–253.
[116] J.F. Sah, S. Balasubramanian, R.L. Eckert, E.A. Rorke, Epigallocatechin-3-gallate
inhibits epidermal growth factor receptor signaling pathway. Evidence for direct
inhibition of ERK1/2 and AKT kinases, J. Biol. Chem. 279 (2004) 12755–12762.
[117] N. Khan, F. Afaq, M. Saleem, N. Ahmad, H. Mukhtar, Targeting multiple signaling
pathways by green tea polyphenol (−)-epigallocatechin-3-gallate, Cancer Res.
66 (2006) 2500–2505.
[118] H.K. Na, Y.J. Surh, Intracellular signaling network as a prime chemopreventive
target of (−)-epigallocatechin gallate, Mol. Nutr. Food Res. 50 (2006)
152–159.
[119] W.S. Ahn, S.W. Huh, S.M. Bae, I.P. Lee, J.M. Lee, S.E. Namkoong, C.K. Kim, J.I. Sin, A
major constituent of green tea, EGCG, inhibits the growth of a human cervical
cancer cell line, CaSki cells, through apoptosis, G(1) arrest, and regulation of
gene expression, DNA Cell Biol. 22 (2003) 217–224.
[120] F. Asif Siddiqui, M. Naim, N. Islam, Apoptotic effect of green tea polyphenol
(EGCG) on cervical carcinoma cells, Diagn. Cytopathol. 39 (2011) 482–488.
[121] D.J. Kuhn, A.C. Burns, A. Kazi, Q.P. Dou, Direct inhibition of the ubiquitin-
proteasome pathway by ester bond-containing green tea polyphenols is associ-
ated with increased expression of sterol regulatory element-binding protein 2
and LDL receptor, Biochim. Biophys. Acta 1682 (2004) 1–10.
[122] M. Noguchi, M. Yokoyama, S. Watanabe, M. Uchiyama, Y. Nakao, K. Hara, T.
Iwasaka, Inhibitory effect of the tea polyphenol, (−)-epigallocatechin gallate,
on growth of cervical adenocarcinoma cell lines, Cancer Lett. 234 (2006)
135–142.
[123] M. Yokoyama, M. Noguchi, Y. Nakao, A. Pater, T. Iwasaka, The tea polyphenol,
(−)-epigallocatechin gallate effects on growth, apoptosis, and telomerase activ-
ity in cervical cell lines, Gynecol. Oncol. 92 (2004) 197–204.
[124] Q. Zhang, X. Tang, Q. Lu, Z. Zhang, J. Rao, A.D. Le, Green tea extract and (−)-epi-
gallocatechin-3-gallate inhibit hypoxia- and serum-induced HIF-1alpha protein
accumulation and VEGF expression in human cervical carcinoma and hepatoma
cells, Mol. Cancer Ther. 5 (2006) 1227–1238.
[125] O. Tudoran, O. Soritau, O. Balacescu, L. Balacescu, C. Braicu, M. Rus, C. Gherman,
P. Virag, F. Irimie, I. Berindan-Neagoe, Early transcriptional pattern of angio-
genesis induced by EGCG treatment in cervical tumor cells, J. Cell. Mol. Med.
(2011).
[126] M. Li, Z. He, S. Ermakova, D. Zheng, F. Tang, Y.Y. Cho, F. Zhu, W.Y. Ma, Y. Sham,
E.A. Rogozin, A.M. Bode, Y. Cao, Z. Dong, Direct inhibition of insulin-like growth
factor-I receptor kinase activity by (−)-epigallocatechin-3-gallate regulates cell
transformation, Cancer Epidemiol. Biomarkers Prev. 16 (2007) 598–605.
[127] J. Jacob, S. Cabarcas, I. Veras, N. Zaveri, L. Schramm, The green tea component
EGCG inhibits RNA polymerase III transcription, Biochem. Biophys. Res. Com-
mun. 360 (2007) 778–783.
[128] Y. Qiao, J. Cao, L. Xie, X. Shi, Cell growth inhibition and gene expression regula-
tion by (−)-epigallocatechin-3-gallate in human cervical cancer cells, Arch.
Pharm. Res. 32 (2009) 1309–1315.
[129] C. Zou, H. Liu, J.M. Feugang, Z. Hao, H.H. Chow, F. Garcia, Green tea compound in
chemoprevention of cervical cancer, Int. J. Gynecol. Cancer 20 (2010) 617–624.
[130] L. Bonfili, M. Cuccioloni, M. Mozzicafreddo, V. Cecarini, M. Angeletti, A.M. Eleu-
teri, Identification of an EGCG oxidation derivative with proteasome modulatory
activity, Biochimie 93 (2011) 931–940.
 F. Di Domenico et al. / Biochimica et Biophysica Acta xxx (2011) xxx–xxx
[131] M.P. Kramer, J. Wesierska-Gadek, Monitoring of long-term effects of resveratrol
on cell cycle progression of human HeLa cells after administration of a single
dose, Ann. N. Y. Acad. Sci. 1171 (2009) 257–263.
[132] A.Y. Sun, A. Simonyi, G.Y. Sun, The “French Paradox” and beyond: neuroprotec-
tive effects of polyphenols, Free Radic. Biol. Med. 32 (2002) 314–318.
[133] M. Jang, L. Cai, G.O. Udeani, K.V. Slowing, C.F. Thomas, C.W. Beecher, H.H. Fong,
N.R. Farnsworth, A.D. Kinghorn, R.G. Mehta, R.C. Moon, J.M. Pezzuto, Cancer che-
mopreventive activity of resveratrol, a natural product derived from grapes, Sci-
ence 275 (1997) 218–220.
[134] M. Alkhalaf, A. El-Mowafy, W. Renno, O. Rachid, A. Ali, R. Al-Attyiah, Resveratrol-
induced apoptosis in human breast cancer cells is mediated primarily through
the caspase-3-dependent pathway, Arch. Med. Res. 39 (2008) 162–168.
[135] M. Alkhalaf, Resveratrol-induced apoptosis is associated with activation of p53
and inhibition of protein translation in T47D human breast cancer cells, Pharma-
cology 80 (2007) 134–143.
[136] E. Pozo-Guisado, J.M. Merino, S. Mulero-Navarro, M.J. Lorenzo-Benayas, F.
Centeno, A. Alvarez-Barrientos, P.M. Fernandez-Salguero, Resveratrol-induced
apoptosis in MCF-7 human breast cancer cells involves a caspase-independent
mechanism with downregulation of Bcl-2 and NF-kappaB, Int. J. Cancer 115
(2005) 74–84.
[137] H.Y. Tang, A. Shih, H.J. Cao, F.B. Davis, P.J. Davis, H.Y. Lin, Resveratrol-induced
cyclooxygenase-2 facilitates p53-dependent apoptosis in human breast cancer
cells, Mol. Cancer Ther. 5 (2006) 2034–2042.
[138] Y. Hu, C.Y. Sun, J. Huang, L. Hong, L. Zhang, Z.B. Chu, Antimyeloma effects of resvera-
trol through inhibition of angiogenesis, Chin. Med. J. (Engl) 120 (2007) 1672–1677.
[139] N. Ahmad, V.M. Adhami, F. Afaq, D.K. Feyes, H. Mukhtar, Resveratrol causes
WAF-1/p21-mediated G(1)-phase arrest of cell cycle and induction of apoptosis
in human epidermoid carcinoma A431 cells, Clin. Cancer Res. 7 (2001)
1466–1473.
[140] A. Heredia, C. Davis, R. Redfield, Synergistic inhibition of HIV-1 in activated and
resting peripheral blood mononuclear cells, monocyte-derived macrophages, and
selected drug-resistant isolates with nucleoside analogues combined with a natu-
ral product, resveratrol, J. Acquir. Immune Defic. Syndr. 25 (2000) 246–255.
[141] J.J. Docherty, M.M. Fu, B.S. Stiffler, R.J. Limperos, C.M. Pokabla, A.L. DeLucia, Resvera-
trol inhibition of herpes simplex virus replication, Antiviral Res. 43 (1999) 145–155.
[142] B.B. Aggarwal, A. Bhardwaj, R.S. Aggarwal, N.P. Seeram, S. Shishodia, Y. Takada,
Role of resveratrol in prevention and therapy of cancer: preclinical and clinical
studies, Anticancer. Res. 24 (2004) 2783–2840.
[143] K.B. Harikumar, B.B. Aggarwal, Resveratrol: a multitargeted agent for age-
associated chronic diseases, Cell Cycle 7 (2008) 1020–1035.
[144] E. Sexton, C. Van Themsche, K. LeBlanc, S. Parent, P. Lemoine, E. Asselin, Resver-
atrol interferes with AKT activity and triggers apoptosis in human uterine cancer
cells, Mol. Cancer 5 (2006) 45.
[145] H.Y. Lin, M. Sun, H.Y. Tang, T.M. Simone, Y.H. Wu, J.R. Grandis, H.J. Cao, P.J. Davis,
F.B. Davis, Resveratrol causes COX-2- and p53-dependent apoptosis in head and
neck squamous cell cancer cells, J. Cell. Biochem. 104 (2008) 2131–2142.
[146] C. Lin, D.R. Crawford, S. Lin, J. Hwang, A. Sebuyira, R. Meng, J.E. Westfall, H.Y.
Tang, P.Y. Yu, P.J. Davis, H.Y. Lin, Inducible COX-2-dependent apoptosis in
human ovarian cancer cells, Carcinogenesis 32 (2011) 19–26.
[147] H.Y. Lin, H.Y. Tang, F.B. Davis, P.J. Davis, Resveratrol and apoptosis, Ann. N. Y.
Acad. Sci. 1215 (2011) 79–88.
[148] P.P. Lee, J.J. Hwang, G. Murphy, M.M. Ip, Functional significance of MMP-9 in
tumor necrosis factor-induced proliferation and branching morphogenesis of
mammary epithelial cells, Endocrinology 141 (2000) 3764–3773.
Please cite this article as: F. Di Domenico, et al., Antioxidants in cervical cancer: Chemopreventive and chemotherapeutic effects of polyphe-
nols, Biochim. Biophys. Acta (2011), doi:10.1016/j.bbadis.2011.10.005
11
[149] E.T. Waas, R.M. Lomme, J. DeGroot, T. Wobbes, T. Hendriks, Tissue levels of active
matrix metalloproteinase-2 and − 9 in colorectal cancer, Br. J. Cancer 86 (2002)
1876–1883.
[150] J.H. Woo, J.H. Lim, Y.H. Kim, S.I. Suh, D.S. Min, J.S. Chang, Y.H. Lee, J.W. Park, T.K.
Kwon, Resveratrol inhibits phorbol myristate acetate-induced matrix
metalloproteinase-9 expression by inhibiting JNK and PKC delta signal transduc-
tion, Oncogene 23 (2004) 1845–1853.
[151] E. Toussaint-Smith, D.B. Donner, A. Roman, Expression of human papillomavi-
rus type 16 E6 and E7 oncoproteins in primary foreskin keratinocytes is suffi-
cient to alter the expression of angiogenic factors, Oncogene 23 (2004)
2988–2995.
[152] O. Lopez-Ocejo, A. Viloria-Petit, M. Bequet-Romero, D. Mukhopadhyay, J. Rak,
R.S. Kerbel, Oncogenes and tumor angiogenesis: the HPV-16 E6 oncoprotein ac-
tivates the vascular endothelial growth factor (VEGF) gene promoter in a p53
independent manner, Oncogene 19 (2000) 4611–4620.
[153] S.H. Kim, Y.S. Juhnn, S. Kang, S.W. Park, M.W. Sung, Y.J. Bang, Y.S. Song, Human
papillomavirus 16 E5 up-regulates the expression of vascular endothelial
growth factor through the activation of epidermal growth factor receptor,
MEK/ERK1,2 and PI3K/Akt, Cell. Mol. Life Sci. 63 (2006) 930–938.
[154] X. Tang, Q. Zhang, J. Nishitani, J. Brown, S. Shi, A.D. Le, Overexpression of human
papillomavirus type 16 oncoproteins enhances hypoxia-inducible factor 1 alpha
protein accumulation and vascular endothelial growth factor expression in
human cervical carcinoma cells, Clin. Cancer Res. 13 (2007) 2568–2576.
[155] K.F. Hsu, C.L. Wu, S.C. Huang, C.M. Wu, J.R. Hsiao, Y.T. Yo, Y.H. Chen, A.L. Shiau,
C.Y. Chou, Cathepsin L mediates resveratrol-induced autophagy and apoptotic
cell death in cervical cancer cells, Autophagy 5 (2009) 451–460.
[156] Y.A. Rezk, S.S. Balulad, R.S. Keller, J.A. Bennett, Use of resveratrol to improve the
effectiveness of cisplatin and doxorubicin: study in human gynecologic cancer
cell lines and in rodent heart, Am. J. Obstet. Gynecol. 194 (2006) e23–e26.
[157] S.C. Gupta, R. Kannappan, S. Reuter, J.H. Kim, B.B. Aggarwal, Chemosensitization
of tumors by resveratrol, Ann. N. Y. Acad. Sci. 1215 (2011) 150–160.
[158] G.P. Talwar, A clinical study on the clearance of human papilloma virus (HPV)
infection in uterine cervix by Basant (a polyherbal cream) and curcumin soft
gelatin capsule in females infected with HPV Clinical Trial Registry — India, Na-
tional Institute of Medical Statistics (ICMR, India, 2008 CTRI/2008/091/000095).
[159] W.S. Ahn, J. Yoo, S.W. Huh, C.K. Kim, J.M. Lee, S.E. Namkoong, S.M. Bae, I.P. Lee,
Protective effects of green tea extracts (polyphenon E and EGCG) on human cer-
vical lesions, Eur. J. Cancer Prev. 12 (2003) 383–390.
[160] O. Vang, N. Ahmad, C.A. Baile, J.A. Baur, K. Brown, A. Csiszar, D.K. Das, D. Delmas,
C. Gottfried, H.Y. Lin, Q.Y. Ma, P. Mukhopadhyay, N. Nalini, J.M. Pezzuto, T. Rich-
ard, Y. Shukla, Y.J. Surh, T. Szekeres, T. Szkudelski, T. Walle, J.M. Wu, What is new
for an old molecule? Systematic review and recommendations on the use of res-
veratrol, PLoS One 6 (2011) e19881.
[161] K.R. Patel, E. Scott, V.A. Brown, A.J. Gescher, W.P. Steward, K. Brown, Clinical tri-
als of resveratrol, Ann. N. Y. Acad. Sci. 1215 (2011) 161–169.
[162] K.R. Patel, V.A. Brown, D.J. Jones, R.G. Britton, D. Hemingway, A.S. Miller, K.P.
West, T.D. Booth, M. Perloff, J.A. Crowell, D.E. Brenner, W.P. Steward, A.J.
Gescher, K. Brown, Clinical pharmacology of resveratrol and its metabolites in
colorectal cancer patients, Cancer Res. 70 (2010) 7392–7399.
[163] V.A. Brown, K.R. Patel, M. Viskaduraki, J.A. Crowell, M. Perloff, T.D. Booth, G.
Vasilinin, A. Sen, A.M. Schinas, G. Piccirilli, K. Brown, W.P. Steward, A.J. Gescher,
D.E. Brenner, Repeat dose study of the cancer chemopreventive agent resvera-
trol in healthy volunteers: safety, pharmacokinetics, and effect on the insulin-
like growth factor axis, Cancer Res. 70 (2010) 9003–9011.