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November 29, 2010

Fuel Lines of Tumors Are New Target

By ANDREW POLLACK

For the last decade cancer drug developers have tried to jam the accelerators that cause tumors to
grow. Now they want to block the fuel line.
Cancer cells, because of their rapid growth, have a voracious appetite for glucose, the main nutrient
used to generate energy. And tumors often use glucose differently from healthy cells, an
observation first made by a German biochemist in the 1920s.
That observation is already used to detect tumors in the body using PET scans. A radioactive form
of glucose is injected into the bloodstream and accumulates in tumors, lighting up the scans.
Now, efforts are turning from diagnosis to treating the disease by disrupting the special
metabolism of cancer cells to deprive them of energy.
The main research strategy of the last decade has involved so-called targeted therapies, which
interfere with genetic signals that act like accelerators, causing tumors to grow. But there tend to
be redundant accelerators, so blocking only one with a drug is usually not enough.
In theory, however, depriving tumors of energy should render all the accelerators ineffective.
The accelerators still need the fuel source, said Dr. Chi Dang, a professor of medicine and
oncology at Johns Hopkins University. Indeed, he said, recent discoveries show that the genetic
growth signals often work by influencing cancer cells metabolism.
The efforts to exploit cancers sweet tooth are in their infancy, with few drugs in clinical trials. But
interest is growing among pharmaceutical companies and academic researchers.
Nutrient supply and deprivation is becoming potentially the next big wave, said Dr. David
Schenkein, chief executive of Agios Pharmaceuticals, a company formed two years ago to develop
drugs that interfere with tumor metabolism. Among its founders was Dr. Craig B. Thompson, the
new president of Memorial Sloan-Kettering Cancer Center in New York City.
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Other small companies, like Cornerstone Pharmaceuticals and Myrexis, are pursuing the approach,
and big drug companies are also jumping in. Earlier this year, AstraZeneca agreed to work with
Cancer Research UK, a British charity, on drugs that interfere with cancer metabolism.
One factor spurring interest in cancer metabolism is the intriguing interplay between cancer and
diabetes, a metabolic disease marked by high levels of blood glucose. The possible link between the
two great scourges has garnered so much attention that the American Cancer Society and the
American Diabetes Association jointly published a consensus statement this summer summarizing
the evidence.
People with Type 2 diabetes tend to have a higher risk of getting certain cancers. And preliminary
evidence suggests that metformin, the most widely used diabetes pill, might be effective in treating
or preventing cancer.
It is still not clear if high blood glucose is the reason diabetics have a higher cancer risk. A more
likely explanation is that people with Type 2 diabetes have high levels of insulin, a hormone that is
known to promote growth of certain tumors, according to the consensus statement.
Similarly, metformin might fight cancer by lowering insulin levels, not blood sugar levels. But there
is some evidence that the drug works in part by inhibiting glucose metabolism in cancer cells.
Even if blood sugar levels fuel tumor growth, however, experts say that trying to lower the bodys
overall level of blood sugar like by starving oneself would probably not be effective. That is
because, at least for people without diabetes, the body is very good at maintaining a certain blood
glucose level despite fluctuations in diet.
When a patient with cancer is calorically restricted, the amount of glucose in the blood until they
are almost dead is close to normal, said Dr. Michael Pollak, professor of medicine and oncology at
McGill University in Montreal. Also, Dr. Pollak said, tumors are adept at extracting glucose from
the blood. So even if glucose is scarce, he said, the last surviving cell in the body would be the
tumor cell.
So efforts are focusing not on reducing the bodys overall glucose level but on interfering
specifically with how tumors use glucose.
This gets to the Warburg effect, named after Otto Warburg, the German biochemist and Nobel
Prize winner who first noticed the particular metabolism of tumors in the 1920s.

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Most healthy cells primarily burn glucose in the presence of oxygen to generate ATP, a chemical
that serves as a cells energy source. But when oxygen is low, glucose can be turned into energy by
another process, called glycolysis, which produces lactic acid as a byproduct. Muscles undergoing
strenuous exercise use glycolysis, with the resultant buildup of lactic acid.
What Dr. Warburg noticed was that tumors tended to use glycolysis even when oxygen was
present. This is puzzling because glycolysis is far less efficient at creating ATP.
One theory is that cancer cells need raw materials to build new cells as much as they need ATP.
And glycolysis can help provide those building blocks.
You can have energy that turns on the lights in your house, but that energy cant build anything,
said Matthew G. Vander Heiden, assistant professor of biology at the Massachusetts Institute of
Technology.
Still, as with everything else about cancer, metabolism is complex. Not all tumor cells use
glycolysis, and some normal cells do. So it could be challenging to develop drugs that can hurt
tumors but not normal cells.
Two early efforts by a company called Threshold Pharmaceuticals to interfere with glucose
metabolism did not work well in clinical trials. One of Thresholds drugs, called 2DG, is the same
form of glucose used in PET imaging, but without the radioactivity. Because of a slight chemical
modification, this form of glucose cannot be metabolized by cells, so it accumulates.
But much less 2DG buildup is needed to spot a tumor on a scan than to destroy it by gumming up
its works. Large amounts of the drug were needed because 2DG lasted only a short time in the body
and because it had to compete with the natural glucose that is abundant in the bloodstream.
Efforts have not ended, however. Waldemar Priebe, a professor of medicinal chemistry at the M.D.
Anderson Cancer Center, said he had developed a way to deliver up to 10 times as much 2DG to a
tumor. It has been licensed to a startup called Intertech Bio.
The other Threshold drug, glufosfamide, consisted of glucose linked to a standard chemotherapy
agent. The idea was that, as with the Trojan horse, the tumors would eagerly ingest the glucose
only to then be poisoned.
In a late-stage clinical trial involving more than 300 patients with advanced pancreatic cancer,
glufosfamide prolonged lives compared with no treatment, but not by a statistically significant
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amount.
A new company, Eleison Pharmaceuticals, plans to repeat the trial. Dr. Forrest Anthony, Eleisons
chief medical officer, said the original trial would have succeeded had it excluded 43 diabetics who
were taking insulin, which is known to impede PET scanning for tumors. Insulin sends glucose
into skeletal muscle and fat tissue and away from the cancer, he said.
Many other companies and scientists are trying to develop drugs that inhibit enzymes for
example, pyruvate kinase M2, involved in tumor metabolism.
Yet another approach is not to starve a tumor of energy but to give it more energy, and that is the
idea behind a substance called dichloroacetate, or DCA. Dr. Evangelos Michelakis of the University
of Alberta, who came up with the idea, says there is a mechanism by which cells that become
defective can commit suicide for the greater good of the body.
But cancer cells usually do not kill themselves. Dr. Michelakis says this could be because they lack
sufficient energy.
DCA, a simple chemical that is formed in small quantities when drinking water is chlorinated, has
long been used to treat certain rare diseases in which lactic acid builds up in the body. DCA inhibits
an enzyme called pyruvate dehydrogenase kinase. The effect of that inhibition is to move
metabolism away from lactic acid-producing glycolysis and toward more normal oxidation of
glucose in the mitochondria, the energy factories of the cell.
In 2007, Dr. Michelakis and colleagues published a paper showing that DCA, when put in drinking
water, could slow the growth of human lung tumors implanted into rats. It seemed the DCA did not
affect normal cells.
Some patients began clamoring for it. Within days, an amateur chemist had synthesized DCA and
began offering it for sale. Some clinics still offer it. Dr. Michelakis cautioned that in high doses DCA
can cause nerve damage and that it takes months for enough to build up in the body to have any
effect.
This spring, in the journal Science Translational Medicine, Dr. Michelakis reported results of the
first human testing of DCA, in five patients with glioblastoma multiforme, a deadly brain cancer.
There was no control group, making it hard to judge the drugs effectiveness, though some patients
lived longer than might have been expected. There was evidence that the drug bolstered the activity
of mitochondria and promoted cell suicide.
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Since DCA is not a novel compound, it cannot be patented, making it unlikely a pharmaceutical
company would pay for clinical trials. So Dr. Michelakis has been raising money from foundations
and governments to conduct larger clinical trials.
We have only assumptions and theoretical excitement, Dr. Michelakis said. Still, he added,
theres no question that this is a new direction that is logical and very appealing.

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