Self versus non-self – and the relationship of being able to develop this sense effectively to the preservation of the community
Effective communication among members of a community – involving appropriate sending and receiving of signals and the ability to respond to them in appropriate ways (as well as genetics considerations and understanding the regulation of basic functioning processes of our cells)

   As a society, we are learning to reframe our understanding of cancer.
Cancer does not involve cells that are inherently alien and bad, but cells that are working as intensely as they can to respond appropriately to the signals they are receiving – the problems relate to specific errors in the nature and receipt of those signals.
The challenge is to look for specific ways to reprogram early on in the development of a specific tumor so that it will not become seriously destructive and we will not have to use methods that are terribly destructive to the whole system to eliminate it.

In this, I see many parallels to our criminal justice system.
I think that deviant behavior often reflects personal, familial and societal problems in communication and effective functioning.
Our current main methods of responding are much like the sledge-hammer approach of chemotherapy.  Developing much better ways to identify and help manipulate the mental and social underlying problems is absolutely key to helping people function more effectively in society.  Only in that way do we have a chance of getting away from having this insanely large fraction of our people in prison, trying to cut them out of our society  – and in the process making it more and more difficult for them to ever be effectively integrated.
 Cancer -- Dec., 1991,  Jan. 1993 and Nov. 1999

The word "Cancer" evokes images of alien invasion, betrayal by our own body, cells totally out of control, fear of the unknown.
Until very recently, our only ways to fight these cells gone astray involved massive frontal attack -- surgery as long as it was still (largely) in one place and accessible, radiation and chemicals that would damage or destroy any rapidly-growing cells, including, unfortunately, the linings of our body and the natural defences provided by the immune system.

We knew no way to treat our cancer cells except as incorrigible criminals, enemies capable of infiltrating and destroying every aspect of our system, evil traitors.  Especially frightening was the realization that the initial events in tumor formation had generally happened 25 years earlier, and this potential betrayal is going on in all of us all the time, with no way to know when or where our immune systems will fail in their work to keep such delinquent cells in check.
Nixon's "war on cancer" led to little change in the mortality rates for most cancers, despite agressive treatment.
 
Our understanding of the cell changes involved in the development of cancer (and the normal regulation of growth) is increasing enormously using the techniques of molecular biology.  This increased understanding is now affecting both efforts at cancer prevention and the development of much more tightly targeted methods of cancer detection and treatment.

The major causes of cancer are things where each of us has substantial control, such as smoking, dietary fats and lack of antioxidents, alcohol and hormone use.  These act by causing mutations (i. e., free radicals and radiation), stimulating cell division directly (hormones), or both (tobacco), with broader environmental problems playing a smaller role.  I will summarize the basic principles and factors now seen to be involved, in terms of what we're learning, along with a more detailed discussion of a couple of specific examples.  I hope that most of you will never need a more detailed level of understanding, but with the high odds that someone you know will be affected by cancer and the high potential rate of advances in therapy related to knowledge, I want to at least supply you with these tools to be able to track down needed information as well as choosing steps toward prevention and early detection.

 MODEL:
CARCINOGENESIS IS A MULTISTEP PROCESS.
IT INVOLVES A SERIES OF DEFINABLE GENETIC CHANGES THAT ACCUMULATE IN THE GENOME OF THE EVOLVING CANCER CELL.  THESE INCLUDE:
     (1) THE ACTIVATION OF ONCOGENES AND
     (2) THE INACTIVATION OF SUPPRESSOR GENES, generally through
     (3) SOMATIC MUTATIONS -- i.e., mutations in individual body cells.  Some genes involved in cancer, including both main breast cancer genes, are now known to affect DNA REPAIR ENZYMESand thus the rate of accumulation of other mutations.

THE MOST SERIOUS FORMS OF CANCER AND THE GENERAL CAUSES OF DEATH INVOLVE METASTASIS -- that is, the abilitity of some cells to leave the primary tumor, move elsewhere in the body, and establish themselves and divide in the new place.

METASTASIS ALSO INVOLVES MUTATIONS IN SPECIFIC GENES.
      Some of them affect the activity of protein-dissolving enzymes that the cancer cells need to secrete to escape from a localized tumor.
      Some affect signaling molecules used by groups of cells from slime molds on up to humans to say "we belong together here”.
      Some make the cancer cells less susceptible to killing by the immune system.
      And at least one affects an important intracellular regulatory pathway and is related to a developmental gene in fruit flies, etc.
 

THE PROGRESS OF A TUMOR CAN ALSO BE AFFECTED THROUGH "TUMOR PROMOTERS" -- chemicals, hormones, etc. which are affecting the normal regulatory processes and rate of growth, without themselves causing mutations – AND THROUGH NATURAL SIGNALING PROCESSES IN THE BODY.

 Thus, cancer is a result of malfunctioning of the normal growth-regulating signals or the response to them.  Individual cells in a tissue must receive 2 types of growth-regulating signals from their environment:

1. Growth-promoting, mitogenic signals, carried largely by polypeptide growth factors -- nerve growth factor (NGF), epidermal growth factor (EGF), platelet-derived growth factor (PDGF) --that interact with membrane receptors.

The proteins encoded by cellular oncogenes affect these pathways so that they function constitutively (with their switch locked in “on” position”).
The oncogene-bearing cell thus continually "thinks" it is being told to grow by signals from outside.
This can be a result of mutation of protooncogenes -- genes controlling normal cell regulatory factors -- and/or of infection by a virus carrying the oncogene.
 
These oncogenes have a dominant phenotype
Changes in a number of steps in the pathway are needed to produce cancer
There are many built-in checks and balances.

The need to accumulate many changes is why it usually takes so long for a cancer to develop, and why there are many things we can do to help reduce the probability -- things we are just starting to understand.

Important observation: If the cancer cells can just manage to get on past a specific point and DIFFERENTIATE (specialize), then they generally aren’t cancerous any more.

(Bob Weinberg’s Her-2/neu gene is an example of an oncogene – with a change in only 1 of its 1600 amino acids, or with the multiple copies seen by Slamon in some of the most aggressive human breast cancers – making up to 10,000 times as many copies of the surface receptor!)
 
2. GROWTH-INHIBITING SIGNALS, which also exert their effects on the cells through specific intracellular signaling pathways.  When a cell looses critical pieces of this network, it may loose the ability to respond to inhibitory signals originating inside or outside the cell.  This defines "tumor suppressor genes" as genes whose loss or inactivation leads to growth deregulation and cancer.
Tumor suppressor genes generally have a recessive phenotype, since having even one good copy is sufficient to keep the process in check.
Familial susceptibility to certain cancers: only one functional copy of one of these genes --  and a daughter cell looses the other good copy

Example: retinoblastoma -- the first tumors to appear are pinpoint ones of the retina in children.
involves inherited recessive mutations of the "RB" gene on chromosome 13;
each tumor is precipitated by a somatic mutation.

Can we fight cancer by using appropriate genetically engineered viruses to insert wild-type suppressor genes into tumor cells that lack them?
There is already some encouraging work with cells in tissue culture, but it will take time.
Part of the goal of the human genome project is to figure out exactly what these various genes involved in cancer are and how they work!
   Example: COLON CANCER:

Colonoscopy -- looking at the inside of the colon with a sort of light pipe – lets us see successive stages of tumorigenesis in the colon in ways not possible in most other tissues.  (see HB pg. 103-107)
Biopsies of the tissue allow identification of somatic mutations that apparently underly each stage of the conversions. Steps include:
   1)  "hyperplastic" (overgrown), but otherwise normal-appearing epithelium
   2)  "adenomatous" polyps.  Of the large (but not small) adenomas, 60% carry a mutated, activated allele of the oncogene K-ras, a protein kinase.  Most of the rest show changes on chromosome 5, in a gene now called APC ("adenomatous polyposis coli").
   3) noninvasive carcinomas.  This step of the evolution of colon cancer is usually accompanied by inactivation of
a. the chromosome 18 DCC (“deleted in colon cancer”) tumor suppressor gene
b. the chromosome 17 p53 suppressor gene;
often, deletions can actually be seen under a microscope when the chromosomes are properly stained in dividing cells (a karyotype).

   4) invasive carcinomas.  The specific mutations leading to this final step had not yet been identified when I did this research in 1999.

The DCC gene encodes a 1700-amino-acid transmembrane protein.
This protein gets phosphorylated and looks like a cell surface receptor.
It is related to a family of cell adhesion molecules involved in binding cells to an extracellular matrix or basement membrane

The DCC gene is more than 1,000,000 base pairs long, with the coding parts broken up by multiple introns.
DCC is expressed on a large number of cell types and Loss Of Heterogeneity in this gene is seen in other tumor types, but the extracellular ligand (signaling molecule) it binds/signal it receives was not yet known when I researched this, at least.  There are indications that it may have a far broader role in human carcinogenesis than was initially suspected.

 The chromosome 17 p53 suppressor gene is the gene most frequently found to be mutated in human cancers, including those of the bladder, liver, brain, breast, lung, colon and the blood-forming system.
It is involved in regulating apoptosis in response to DNA damage and certain other signals.  p53 is a nuclear, DNA-binding protein. Its relationship to cervical cancer is especially clear.
 HPV (human papilloma virus), warts and cervical cancer:

When you have a PAP Smear, you are having a test for signs of HPV infection.

HPV multiplication depends on the active DNA synthesizing equipment of the cell.  However, epithelial (surface) cells normally make p53 and stop dividing when they leave the stem-cell, basement layer.
The papilloma (wart) virus oncoprotein E6 depletes these cells of p53 by binding to it and tagging it for destruction by proteolytic enzymes.
This lets the virus-infected cell think it is supposed to keep dividing after it leaves the stem-cell area, which in turn allows the virus to keep multiplying
This leads to the formation of a visible wart.

The retinoblastoma gene, RB, is also involved in cervical cancer.
It encodes an almost 1000 amino acid nuclear protein which can bind to DNA help regulate transcription. Free pRB can bind to a key cell cycle-specific transcriptional regulatory factor called "E2F" and trap it.
RB is found in a complex with human papillomavirus oncoprotein E7 in transformed cells.

The somatic mutational inactivation of RB has been observed in most small cell lung carcinomas, as well as some bladder, breast and other lung cancers.
These mutations almost always affect a protein pocket that binds the viral oncogene-coded proteins, suggesting that in both cases binding with the normal intracellular regulatory element is thus blocked.
The RB gene, with introns, includes 180,000 base pairs mapping to the  chromosome 13 q14 region.
 Model: the RB protein, bound to a control factor(s), is normally involved in blocking the start of DNA replication until time for a new cell cycle.

Wheh pRB is phosphorylated in the normal cycle, it releases factor(s) which regulate the transcriptional events necessary to start DNA replication.
When it is permanently removed through mutation or binding these viral oncogenic proteins, normal controls are bypassed and the next cycle of cell division is not delayed as it should be.

Some evidence for this:
The RB-encoded protein undergoes changes through the cell cycle.
Very few of the molecules are phophorylated in G1
It becomes highly phosphorylated in S – the DNA synthesis phase -- reverting back just before the M(itosis) -G1 transition
The viral oncoproteins bind only to the unphosphorylated form, which also is the form able to bind to transcription factor E2F.

 SPECIFIC HPV STRAINS AND CERVICAL CANCER

A variety of strains of HPV have been isolated;
HPV 16 and 18 have a high risk for causing cancer eventually (and the HPV is found, integrated in the host DNA, in 90% of cervical tumors)
Other common ones like HPV 6 and HPV 11 almost never cause invasive tumors and "are considered low risk".
Pap smears look at the changes in the cervix induced by HPV, not which type is involved.
New tests allow simple measurement of which strain of HPV is involved in abnormal Pap smears, giving information as to the probability of cancer and how aggressively it is necessary to treat.

What is the difference in the strains?
HPV genes E6 and E7 are highly expressed in the cells that turn cancerous.  Cloning these genes from the high-risk, but not the low-risk, strains can "immortalize" cells in tissue culture -- i. e., turn them into cells that keep growing indefinitely.
These cells can cause tumors in mice only if they first grow a long time in tissue culture, accumulating  more mutations, before implanting them
adding the v-ras oncogene allows them to immediately cause tumors.

Encouraging Facts:
Ongoing expression of these viral genes is needed to maintain the malignant (potentially cancerous) phenotype.
It takes years of their expression before these cell changes turn into cancer of the cervix.
Fusion of HPV-positive cervical cancer cells with normal human cells results in non-malignant hybrids even though E6-E7 gene expression still occurs.
Factors like sites of integration of the HPV DNA into the host DNA, general cell status and some inhibitory factor on chromosome 11 all affect viral gene expression and the rate of progression to tumors.
Factors like EGF also help maintain more normal regulation and inhibit the progression to cervical cancer.

HPV viruses are fastidious in their tissue specificity, and do not spread beyond the appropriate epithelial cells.  Very different members of the broad papilloma virus family are involved in the warts you see on your skin.
 BREAST CANCER GENES: BRCA 1 and 2

These 2 genes encode neither tumor suppressor genes nor oncogenes, but rather genes involved in DNA repair in different ways.
     BRCA 2 helps cells repair double-strand DNA breaks, which are caused by ionizing radiation and occasionally by oxidative damage, such as from smoking.
     BRCA 1, which increases the risk of breast cancer 8 to 10 fold over the general population, is less well understood. It is mutated to a shorter form in half of familial breast cancers.
It is a so-called “zinc finger” protein that binds
a. to DNA
b. to many proteins involved in transcription activation, including tumor suppressor p53, RNA polymerase,
c. to DNA repair proteins BRCA-2 ,Rad50 and Rad51, localizing with them at sites of damage;

it seems to be required for transcription-associated DNA repair.
 Inactivation of the homologous gene in mouse stem cells leads to increased cell sensitivity to agents that damage DNA;
mice completely missing the gene die early in embryonic development unless p53 is also missing – apparently so much DNA damage occurs that too many cells commit apoptosis.

Chen, Lee and Chew, (Dec.1999): J. Cell. Physiol. 181:385-92.
Gowen et al (1998) Science 281:1009-12; Abbott et al, (1999)  J. Biol. Chem. 274:1808-12
 
 METASTASIS CLUE: Working with mouse melanoma cells in 1987, Patricia Steeg's lab at NCI (National Cancer Institute) identified and cloned a gene they called "NM23" which was consistently expressed much more extensively in cells that don't metastasize readily than in those that do.

In 1989, they found that it was 78% identical to a fruit fly gene involved in a variety of lethal developmental defects, studied by Allen Shearn at Johns Hopkins.
The key to how it worked came from a 1990 discovery that it is 62% identical with a gene from slime molds, involved in their aggregation to form fruiting bodies, studied by Michel Veron at the Pasteur Institute.
This gene is an NDP kinase; it may be associated with membrane GTP-binding "G proteins", involved in many kinds of signal transduction from surface receptors, and/or with microtubules.
Anne-Marie Gilles (Pasteur) and Ion Lascu (Romania) now find a human NDP kinase in red blood cells which is identical to NM23.  The activity seems to first go up in cancer cells and then decrease as they become metastatic.

Both cancer cells and such immune-system cells as macrophages have receptors for many neuropeptides and growth factors.  Thus, it is not hard to understand that regulation of their growth can be effected by emotions, stress and the general well-being of the body, in many cases.   Presumably, this is a major key to that aspect of psychoneuroimmunology and many of the observations we will explore later that are discussed in Love and Survival.