P e r s pec t i v e s

63. Helmlinger, G., Yuan, F., Dellian, M. & Jain, R.K.

Interstitial pH and pO2 gradients in solid tumors
invivo: high-resolution measurements reveal a lack
of correlation. Nature Med. 3, 177182 (1997).
64. Plas, D.R. & Thompson, C.B. Akt-dependent
transformation: there is more to growth than just
surviving. Oncogene 24, 74357442 (2005).
65. Kim, J.W. & Dang, C.V. Cancers molecular sweet
tooth and the Warburg effect. Cancer Res. 66,
89278930 (2006).
66. Dewhirst, M.W. Intermittent hypoxia furthers the
rationale for hypoxia-inducible factor-1 targeting.
Cancer Res. 67, 854855 (2007).
67. Gazit, Y. etal. Fractal characteristics of tumor
vascular architecture during tumor growth and
regression. Microcirculation 4, 395402 (1997).
68. Gatenby, R.A. & Gillies, R.J. Why do cancers have
high aerobic glycolysis? Nature Rev. Cancer 4,
891899 (2004).
69. Tatsumi, M., Cohade, C., Nakamoto, Y., Fishman, E.K.
& Wahl, R.L. Direct comparison of FDG PET and CT
findings in patients with lymphoma: initial
experience. Radiology 237, 10381045 (2005).
70. Kim, J.W. & Dang, C.V. Multifaceted roles of
glycolytic enzymes. Trends Biochem. Sci. 30,
142150 (2005).
71. Bonnet, S. etal. A mitochondria-K+ channel axis is
suppressed in cancer and its normalization promotes
apoptosis and inhibits cancer growth. Cancer Cell 11,
3751 (2007).
72. Fantin, V.R., St-Pierre, J. & Leder, P. Attenuation of
LDH-A expression uncovers a link between glycolysis,
mitochondrial physiology, and tumor maintenance.
Cancer Cell 9, 425434 (2006).

Nature Reviews Cancer | AOP, published online 6 December 2007; doi:10.1038/nrc2255

73. ODonnell, K.A. etal. Activation of transferrin

receptor 1 by c-Myc enhances cellular proliferation
and tumorigenesis. Mol. Cell Biol. 26, 23732386
(2006).
74. Tacchini, L., Bianchi, L., Bernelli-Zazzera, A. & Cairo, G.
Transferrin receptor induction by hypoxia. HIF-1mediated transcriptional activation and cell-specific
post-transcriptional regulation. J. Biol. Chem. 274,
2414224146 (1999).
75. Pandey, M.K. etal. Gambogic acid, a novel ligand for
transferrin receptor, potentiates TNF-induced
apoptosis through modulation of the nuclear factor-B
signaling pathway. Blood 110, 35173525 (2007).
76. Kasibhatla, S. etal. A role for transferrin receptor in
triggering apoptosis when targeted with gambogic
acid. Proc. Natl Acad. Sci. USA 102, 1209512100
(2005).
77. Louro, I.D. etal. Comparative gene expression
profile analysis of GLI and c-MYC in an epithelial
model of malignant transformation. Cancer Res. 62,
58675873 (2002).

DATABASES
Entrez Gene: http://www.ncbi.nlm.nih.gov/entrez/query.
fcgi?db=gene
CDKN1A | CDKN1B | CDKN2A | COX4I1 | COX4I2 | EPAS1 |
GAPDH | HIF1 | HIF3A | HK2 | LDHA | MAX | MSH2 | MSH6 |
MXD1 | MXI1 | MYC | NBN | p53 | PDK1 | Sp1 | TFRC | VEGFA |
VHL | ZBTB17

FURTHER INFORMATION
MYC target genes website: http://www.myccancergene.org
All links are active in the online pdf

H y p o x ia and metabo l ism o p inion

A microenvironmental model of
carcinogenesis
Robert A. Gatenby and Robert J. Gillies

Abstract | We propose that carcinogenesis requires tumour populations to

surmount six distinct microenvironmental proliferation barriers that arise in the
adaptive landscapes of normal and premalignant populations growing from
epithelial surfaces. Somatic evolution of invasive cancer can then be viewed as a
sequence of phenotypical adaptations to these barriers. The genotypical and
phenotypical heterogeneity of cancer populations is explained by an equivalence
principle in which multiple strategies can successfully adapt to the same barrier.
This model provides a theoretical framework in which the diverse cancer genotypes
and phenotypes can be understood according to their roles as adaptive strategies
to overcome specific microenvironmental growth constraints.
Carcinogenesis is a complex, multistep,
multipath process often described as
somatic evolution. Models of carcinogenesis
are typically based on the Darwinian principle that evolution requires genetic and/or
epigenetic changes that generate new
phenotypes13. For example, Fearon and
Vogelstein depict a sequence of specific
heritable events that cause corresponding
changes in tumour size and morphology during colorectal carcinogenesis4.
Hanahan and Weinberg emphasized the
final evolutionary outcomes by distilling

the properties of transformed cells to six

phenotypical hallmarks that are necessary
for an invasive cancer5.
These approaches correspond to empirical observations but do not necessarily offer
insight into the evolutionary dynamics
that determined the nature and sequence
of the observed phenotypical changes.
In other words, the current cell-centric
models do not typically address why these
specific phenotypical and genotypical
changes are necessary for carcinogenesis
or why they occur in a sequence such as

 | advance online publication

that depicted in the FearonVogelstein

diagram. This reflects the limits of models
that are focused on just one component
of the evolutionary process adaptive
changes observed in evolving populations.
In fact, Darwinian dynamics consist of the
interactions of individual phenotypes with
environmental selection forces that govern
fitness and, therefore, proliferation. In the
adaptive landscapes governing somatic
evolution, microenvironmental barriers
to proliferation represent crucial selection forces that control the proliferative
capability of any new phenotype that is
generated by genetic or epigenetic events.
Thus, the consistent phenotypical changes
that emerge during carcinogenesis must
always represent successful adaptations to
these microenvironmental selection forces.
Furthermore, these selection pressures are
not static but will dynamically change as
a result of tumour population growth and
evolution.
Here, we propose a theoretical model
of carcinogenesis based on the microenvironmental proliferative barriers that will
arise as tumour populations proliferate on
basement membranes. By acting as growth
inhibitors, the barriers determine the fitness
and, therefore, clonal growth of each new
population generated by random mutations
or epigenesis. As such, they select for specific
adaptive cellular properties during the different stages of carcinogenesis and ultimately
determine the phenotypical properties of
invasive cancers. Through this model we
hope to provide insight into the evolutionary
forces that produce the specific phenotypical
and genotypical changes that are hallmarks
of malignant populations and a rationale for
the sequence with which these changes may
occur during carcinogenesis.
Adaptive landscapes in carcinogenesis
We propose that the microenvironmental
selection forces during early carcinogenesis are determined by the anatomy and
physiology of epithelial surfaces6, and the
phenotypical properties of the normal and
tumour cells present. As shown in FIG.1,
epithelial cells are separated from the
underlying mesenchyma, including blood
vessels, by an intact basement membrane.
Substrates, metabolites and signalling
molecules exchanged between epithelial
cells and the mesenchyma (that is, fibro
blasts, extracellular matrix, immune cells
and blood vessels) must diffuse across this
basement membrane. As shown in FIG.1a,b,
the average diffusion length between
proliferating cells and the parenchyma
www.nature.com/reviews/cancer

2007 Nature Publishing Group

P e r s pec t i v e s
a Normal epithelium

b Dysplastic epithelium
H+

O2
Transduction
Gap junction

Growth factor
receptor
Basement
membrane

Integrins

H+

O2
O2

H+

H+
H+

H+

H+

O2
H+

O2

H+

H+

H+

H+

H+

Glucose

O2

H+

O2

Blood
vessel
H+

O2

H+
H+

Transduction
Growth
factor

O2

H+

O2

O2

Glucose
transporter
(GLUT1)

c Microinvasion

H+

H+

H+

H+

VEGF

H+

O2

H+
H+

Fibroblast

H+

Figure 1 | Cartoons of the three distinctive adaptive landscapes during

evolution of invasive cancer. a | A normal mucosal surface with a
single layer of epithelial cells connected to each other and the basement membrane by integral proteins (such as integrins) and communicating through gap junctions. Growth is restricted by anoikis and
contact inhibition. Growth factors and substrates diffuse from the
blood vessels and mesenchymal cells across the basement membrane
to the epithelium. This landscape will allow excess proliferation only
of phenotypes in which mutations confer resistance to anoikis and
contact inhibition. These changes, therefore, will be the first genetic
and phenotypical events observed in carcinogenesis. b | The adaptive
landscape after initial mutations allows some proliferation away from
the basement membrane. This landscape is dominated by diffusion
reaction kinetics as growth factors and substrate must diffuse over
increasingly large distances to reach the proliferating cells, which are
now several cell layers distant from the basement membrane. The
consequent decrease of growth promoter concentration is a barrier to
proliferation that requires adaptations including paracrine or autocrine production of growth factors, increased numbers of membrane
receptors (as shown) or upregulation of transduction pathways. These
represent functionally equivalent adaptive strategies: any of them may
serve the same purpose but at least one must be observed in all cancers. Increased substrate diffusion distance creates regions of hypoxia

varies during carcinogenesis. In normal

epithelium (FIG.1a) a short diffusion distance permits physiological levels of growth
factors, substrate and metabolites. However,
the diffusion length increases as the hyperproliferation following initial mutations
carries cells away from the basement
membrane. Because tumour cells remove
growth factors and substrates and produce
metabolites, diffusionreaction kinetics will
create significant gradients along the axis
perpendicular to the membrane. This forms
the adaptive landscape of FIG.1b, in which
cells proliferating into the lumen experience
decreased local concentrations of vascular
or mesenchyma-derived growth factors and
vital substrates such as glucose and oxygen.

and acidosis that must be overcome by upregulation of

glycolysis
and
Nature
Reviews | Cancer
resistance to acid-mediated toxicity. c | The adaptive landscape following transition from insitu to invasive cancer (microinvasion). Here
tumour growth is limited primarily by insufficient blood flow (ischaemia). In the absence of angiogenesis, growth is limited by diffusion to
a few hundred micrometres. Clinically significant tumour formation
requires cooperative interactions in which the mesenchyma promotes
tumour growth through angiogenesis and various other mechanisms
such as fibroblast production of growth promoters and proteolytic
enzymes that degrade the extracellular matrix. Tumour cells must
adapt in ways that allow them to co-opt normal mesenchymal cells.
Strategies include constitutive upregulation of vascular endothelial
growth factor (VEGF, shown). This adaptive landscape also promotes
evolution of the invasive phenotype: cells with increased motility are
able to move from the cancer adaptive landscape, where proliferation
is inhibited by substrate limitations and competition with other cancer
cells, into adjacent normal tissue where these constraints are absent.
Increased motility is rewarded with rapid proliferation which promotes
evolution of the invasive phenotype. Note that the adaptive landscapes
in a and b are avascular so that the delivery of substrate and growth
factors from the blood supply requires diffusionreaction kinetics. The
adaptive landscape in c involves direct interaction of tumour cells with
blood vessels and other elements of the mesenchyma.

We propose that a different and profoundly important adaptive landscape

emerges during microinvasion (FIG.1c).
This is a crucial period in the evolution of
an invasive cancer because it involves, for
the first time, direct contact between the
epithelial tumour cells and the surrounding
stroma. In this novel adaptive landscape,
the Darwinian dynamics of pre-malignant
tumours will persist as the transformed
epithelial cells continue to compete with
each other and with the local mesenchymal
cells for space and resources. However,
some degree of cooperation is also necessary because unrestricted tumour growth
requires stromal support for angiogenesis
and formation of the extracellular matrix.

nature reviews | cancer

Thus, delivery of substrate and growth

factors requires vascularization of the
tumour mass, and evolution of a clinically
significant invasive cancer from a focus of
microinvasion requires not simply growth
of the cancer population but rather an active
collaboration of malignant epithelial cells
and normal mesenchymal cells.
Barriers to carcinogenesis
The dynamics of invivo cellular proliferation on a basement membrane have been
described7 through the equation in BOX1.
We have explored this model extensively
in prior publications610 and found that
it provides important insights into the
evolutionary dynamics of carcinogenesis,
advance online publication | 

2007 Nature Publishing Group

P e r s pec t i v e s
Box 1 | Mathematical model
We can describe dynamics of in vivo cellular proliferation on a basement membrane using the
equation below, where i phenotypes are present within the cellular population, each with a
distinctive range of properties that have developed owing to heritable changes.
dxi
= xi (bi(y,r) di(t))
dt

n
i=1

Ki

ijxi
(Si(y,r) mi )

xi represents the number of cells with phenotype i. At any given time, the
total Reviews
population
and,
Nature
| Cancer
therefore, the size and morphology of the corresponding malignant or premalignant lesion is xi.
All parameters with subscript i can be altered by the phentoypical properties of the cell. For
example, the proliferation rate, bi(y, r), is influenced by local concentrations of growth factors
which vary by spatial location (y, the distance from the basement membrane or nearest blood
vessel) and blood flow (r). However, the phenotype may, through autrocrine production of growth
factors or upregulation of transduction pathways, become relatively independent of these factors.
(bi(y, r) di(t)) is the net proliferation rate of the population (the death rate subtracted from the
proliferation rate).
di(t) is the death rate. This is a function of time (t) because of senescence (that is, telomere
shortening), so that older populations will generally have a greater death rate.
bi(y, r) is the proliferation rate. This is a measure of growth promoters in the microenvironment.
As noted in the text, the proliferation rate bi is influenced by local concentrations of growth
factors, which are typically derived from the blood or mesenchyma. In preinvasive tumors, this
concentration is spatially dependent because of the diffusion distance of the cell from the
basement membrane (y). In invasive cancer this will be dependent on blood flow (r) as well as the
diffusion distance from the nearest vessel.
[1 ijxi]/Ki is a LotkaVoltera term defining the cellular interactions where (Ki) is the carrying
capacity, determined by the interaction of each cell with other cells and the basement membrane.
For example, the number of normal epithelial cells lining a duct is maintained by limits on crowding
(contact inhibition) and the requirement for continuous contact with the basement membrane.
ij is the proliferative consequence for members of one phenotype due to the presence of other
members of the same populaton (ij, i = j) or members of another population (ij, i j). This includes
the effect of consuming space and resources as well as growth promotion or inhibition through
the production of positive and negative growth factors.
Si(y) mi is the substrate availability. Assume that each cell has a basal substrate requirement (mi)
to maintain viability. Substrate uptake, Si(y, r), must be greater than mi to allow proliferation. In
premalignant lesions, substrate and metabolite concentrations are spatially dependent (y)
because the diffusionreaction kinetics produce a decrease in substrate concentration with
distance from the basement membrane. In invasive tumours, substrate delivery is dependent on
blood flow (r) as well as the distance of the tumour cells from the nearest blood vessel.

particularly in analysing the role of substrate

limitation in carcinogenesis6,7,10. Here, we
wish to propose a general theoretical model
of carcinogenesis based on the barriers to
proliferation that develop as tumours grow
and evolve on epithelial surfaces. We demonstrate that these barriers also correspond
to crucial parameters within this mathematical model of in vivo tissue growth.
Although many insights have been obtained
from these quantitative methods, our goal
is to present this work to a general scientific
audience and refer the mathematically
inclined reader to prior publications69.
At any given time, the total population
and, therefore, size and morphology of the
corresponding malignant or premalignant
lesion is a summation of all extant populations. The right side of the equation defines
the barriers to cellular proliferation. All
parameters with the subscript i can be
affected by the phenotype of the population.

FIGURE1a demonstrates that normal

epithelium possesses physiological amounts
of substrate and growth factors. The lumen
provides a large potential space into which
the epithelial cells may proliferate. However,
growth into this empty volume is prevented
by anoikis (detachment-induced apoptosis)
and proliferation of cells along the basement
membrane is limited by contact inhibition
generated by neighbouring cells. These barriers are represented by the ij and Ki terms
in the equation. As these are the dominant
proliferation barriers in normal epithelium,
the first genetic changes in carcinogenesis
must produce a phenotypical adaptation to
anoikis or contact inhibition.
Thus, genotypical changes in early carcinogenesis must involve pathways that control these proliferative barriers (FIG.2). This
prediction is consistent with experimental
observations that pathways that affect
anoikis and/or contact inhibition are altered

 | advance online publication

in early carcinogenesis. Genetic changes in

phosphatidylinositol 3-kinase11, E-cadherin
(encoded by CDH1)12, Ras13, p63 (REF.14),
adenomatosis polyposis coli (APC),
-catenin (encoded by CTNNB1)15 and
oestrogen receptors have been suggested
to have roles in these adaptations16. The
number and diversity of these control pathways exemplifies a governing principle of
our model that of functional equivalence.
That is, each parameter in the equation that
constitutes a barrier to carcinogenesis is a
general phenomenological term affected by
multiple biological pathways, each typically
consisting of many signalling biomolecules
that often exhibit cross-talk and interdependence. The stochastic nature of genetic
mutations will result in random alteration of
multiple different gene products that could
potentially serve as strategies to overcome
any given barrier. The functional equivalence principle states that various mutations
and epigenetic changes can alter the value
of parameters in the equation and serve
as adaptations to growth barriers. These
changes, therefore, are both mathematically
and biologically equivalent. This principle
allows a large number of genotypes to be
tumorigenic because alterations in many
different pathways or components of
pathways may produce phenotypes that are
adapted to a given proliferation barrier. The
principle of functional equivalence accounts
for the observed genetic differences between
tumours. Furthermore, multiple genetic
clones may adapt to the same proliferation
barrier within the same tumour in different
regions or at different times. This will result
in intratumoral genetic diversity. However,
all invasive cancer populations must possess
at least one strategy that overcomes each
barrier.
Note that random mutations affecting
other parameters in the equation will not
produce clonal expansion. For example,
increased growth-factor production may
induce proliferation, but the cell will die
through anoikis once it detaches from the
basement membrane, so that clone will be
lost. Thus, the temporal sequence of cellular
changes in carcinogenesis is determined by
changing environmental selection forces.
FIGURE1b depicts the adaptive landscape
following the initial adaptation as proliferation carries cells away from the basement
membrane. This increases the diffusion
distance between the outermost epithelial
cells and the mesenchyma. The consequent
diffusionreaction kinetics will reduce the
concentration of serum or mesenchymaproduced growth factors and, therefore,
www.nature.com/reviews/cancer

2007 Nature Publishing Group

P e r s pec t i v e s
decrease the bi term, halting proliferation.
This new barrier is overcome through
various strategies, including autocrine or
paracrine production of growth factors17,
increased expression of membrane receptors18 or upregulation of elements within
signal-transduction pathways19. The equivalence principle is again evident in that multiple phenotypical strategies may overcome
the same proliferation barrier.
This stage also introduces the principle
of multibarrier effects. For example, mutations in Ras can affect both proliferation
and senescence20. Similarly, apoptosis can
be a common pathway for the cell death
caused by anoikis, hypoxia and acidosis. If
the tumour cells become resistant to anoikis
through evasion of apoptosis in the early
carcinogenesis, this property may also confer
resistance to hypoxia and acidosis during the
later stages. Thus, in some cases, an adaptive
strategy to one barrier may increase, lower
or eliminate subsequent barriers.
As the tumour cells proliferate, they will
eventually be constrained by senescence
at the Hayflick limit21, a result of telomere
shortening (50100bp per cell division)
during mitosis. After a number of generations, the loss of telomere protection
of chromosomal ends leads to end-to-end
chromosomal fusions that trigger apoptosis
(senescence). This barrier is placed arbitrarily in FIG.2 but could occur at a number
of different points during carcinogenesis.
Regardless of the timing, it will impose a
limit to tumour growth. Subsequent evolution requires an adaptation that confers
immortality. Strategies include upregulation
of telomerase but, consistent with the multibarrier principle, may also involve changes
in oncogenes such as Ras22.
We have previously pointed out that the
increased diffusion distances in the adaptive
landscape of FIG.1b will result in regional
hypoxia6. This produces an additional
barrier to proliferation as ATP production
from aerobic glucose metabolism falls below
maintenance requirement10, leading to an
upregulation of anaerobic ATP production
through glycolysis. We have also pointed
out that this phenotype can become fixed
through the stabilization of hypoxia-inducible
factor123 and/or upregulation of phosphoMYC (I.F. Robey et al., unpublished results)
so that elevated glycolysis is maintained,
even under aerobic conditions. This
metabolism of glucose to lactic acid in the
presenceof oxygen despite its inefficiency in
ATP yield and increased production of acid
(the Warburg effect) has been proposed as
an additional hallmark of cancer24.

Hallmark

Insensitivity Self-sufficient Limitless

to anti-growth in growth
replication
signals
signals

Phenotypical Resistance Upregulation Upregulation

to anoikis
of growth of telomerase
strategy
and contact factors or
inhibition
receptors

Abnormally
high glucose
uptake

Resistance to
Invasion and
acid-mediated metastases
toxicity
with sustained
angiogenesis

Increased
glycolysis

Upregulation
Increased
of NHE, p53
VEGF and
mutation MMP production

Carcinogenesis
pathways

Normal

Barrier

Hyperplasia

Apoptosis
with loss
of basement
membrane
contact

Model
parameters

Severe
atypia

Atypia

Microinvasion

DCIS

Invasive
cancer

Inadequate
growth
promotion

Senescence

Hypoxia

Acidosis

Ischaemia

bi

S i ( y)m i

ij

Figure 2 | Proposed barriers to carcinogenesis based on the adaptive landscapes

in Figure
1.
Nature Reviews
| Cancer
The lower row represents crucial mathematical parameters governing the barriers from the equation
in Box1. The phenotypical strategy to each barrier is shown along with general population hallmarks.
The height of the curved arrows reflects growing cell populations. All cancers must overcome all of
the barriers but, as stated in the equivalence principle, this can be accomplished using a number of
different strategies and combinations of strategies. Furthermore, alterations in a single multifunctional
protein such as Ras or hypoxia-inducible factor 1 may initially serve to overcome one barrier but then
accelerate the subsequent pace of somatic evolution by lowering other barriers. The specific sequence
of barriers is based on changes in the adaptive landscapes of premalignant lesions shown in FIG. 1. This
should not be regarded as invariant as the adaptive landscapes shown in FIG. 1b may generate more
than one barrier simultaneously. DCIS, ductal carcinoma insitu; MMP, matrix metalloproteinase; NHE,
Na+/H+ exchangers; VEGF, vascular endothelial growth factor.

The glycolytic adaptation results in

increased acid production and regional
acidosis, which produces a new growth barrier by inducing apoptosis via p53-dependent pathways through increased caspase
activity25. In the equation this increases the
value of the interference term () forthe
glycolytic population. Adaptations to limit
acid-mediated toxicity can include equivalent strategies, such as increased activity
of Na+/H+ exchangers, p53 mutations and
the interruption of caspase pathways. We
propose that these adaptations confer a
significant growth advantage because they
allow the cancer population to alter its
environment (through the production of
increased acid) in a way that is toxic to other
populations but not to itself 6,10. In addition,
the acidic extracellular pH leads to increased
motility and invasion26, which will promote
breaching of the basement membrane and

nature reviews | cancer

movement of tumour cells into the adjacent

normal tissue26,27. This promotes adoption of
the invasive phenotype as discussed below.
Our theoretical model explicitly predicts
that these phenotypical changes should be
seen in the later stages of carcinogenesis.
This is consistent with clinical observations
that increased glucose uptake or GLUT1
(also known as SLC2A1) expression is seen
in the late stages of insitu cancers in the
oesophagus, colon and breast10,2830.
Finally, as the invasive cancer grows it
creates a new adaptive landscape in which
tumour cells are in direct contact with mesenchymal cells (FIG.2). In this microenvironment, growth is limited primarily by vascular
delivery of substrate (ischaemia) as noted
by Folkman31. This barrier requires angio
genesis through, for example, upregulation of
vascular endothelial growth factor (VEGF).
Adaptation to this final barrier (that is,
advance online publication | 

2007 Nature Publishing Group

P e r s pec t i v e s
after the basement membrane is breached)
is observed experimentally in the transition from limited growth in an avascular
state to rapid tumour expansion following
acquisition of the angiogenic phenotype32.
Consistent with the multibarrier principle,
this may be affected by prior adaptive
strategies such as MYC and p53 mutations33.
Even in well vascularized tumours,
cellular proliferation alone will eventually
be limited by volume constraints imposed
by the extracellular matrix and normal
tissue structures. This is undoubtedly
governed by tissue characteristics so that,
for example, tumour growth from proliferation alone may be greater in relatively
acellular, pliable tissue such as fat than
in the kidney or liver. In other words,
non-invasive tumour growth will eventually produce only self-limited, benign
lesions, and the unrestricted proliferation
that is characteristic of invasive cancers
requires additional adaptations to promote
invasive growth. These include increased
tumour cell motility and degradation of the
extracellular matrix. Consistent with the
equivalence principle, these adaptations can
be accomplished through a number of pheno
typical strategies, including upregulation
of production and release of extracellular
matrix-degrading proteolytic enzymes.
In addition, as another example of the
multibarrier effect, invasion might also be
promoted by upregulation of glycolysis and
microenvironmental acidification34.
We note that the evolutionary pressures
for the invasive phenotype do not emerge
directly from the equation. However, this
adaptation must be consistent with the fundamental principle of Darwinian dynamics
individual properties evolve only if they
increase fitness and, therefore, proliferation.
Interestingly, increased motility requires
significant expenditure of energy and
substrates, reducing their availability for
proliferation. So, in the absence of some
proliferative reward, invasiveness will actually tend to reduce fitness. We propose that
an evolutionary advantage for increased
motility occurs only if it permits cells to
move from the tumour adaptive landscape
in which growth is restricted by limited substrates and competition with other cancer
cells to adjacent normal tissue in which substrates are relatively abundant and competing tumour populations are absent. In other
words, the energy and substrate cost of the
invasive phenotype is rewarded because
mobile tumour cells are able to leave a
region in which their fitness is relatively
low and enter the relatively idyllic adaptive

landscape of adjacent normal tissue, in

which their fitness is high, allowing them
to proliferate rapidly. This self-perpetuating
cycle of cellular movement followed by proliferation promotes evolution of the invasive
phenotype and promotes continuous influx
of cancer cells into normal tissue, including
blood and lymphatic vessels. This yields the
most lethal of cancer hallmarks tissue
invasion and metastases.
Conclusion
We propose a theoretical model of
carcinogenesis that identifies six microenvironmental barriers to somatic evolution
of malignant phenotypes and corresponding principles that govern phenotypical
adaptation to these constraints (FIG.2). The
barriers represent key parameters in the
state equations describing in vivo adaptive
landscapes of cell growth on epithelial
surfaces. These parameters are closely
linked to the anatomy and physiology of
basement membranes, which separate
supporting mesenchyma from normal and
premalignant epithelial populations, and
will change substantially as tumour cells
proliferate and evolve. An invasive cancer
emerges only after all of these barriers are
overcome. Somatic evolution is, thus, the
sequence of cellular adaptations to these
changing barriers.
There are several general principles of
carcinogenesis that emerge from this analysis. First, microenvironmental dominance
the nature and sequence of heritable
changes during carcinogenesis are determined by the specific microenvironmental
properties that prevent proliferation within
changing adaptive landscapes. Second,
phenotypical necessity phenotypical
properties observed in cancer populations
do not arise by accident or as epiphenomena. Rather they represent adaptive strategies and will always confer a proliferative
advantage within the microenvironment
of that tumour. Third, the equivalence
principle the environment selects for
phenotypes, not genotypes, and multiple
different mutations or epigenetic changes
may produce similar phenotypes. The same
adaptive advantage may be gained through
multiple different phenotypical changes
or strategies. Thus, a number of genetic
and phenotypical changes may serve as
adaptations to the same proliferation
barrier. Fourth, gradualism a cancer
is not observed until all tissue barriers to
proliferation are overcome. Although a
number of different phenotypical strategies may serve as adaptations to the same

 | advance online publication

barrier, all cancers must exhibit at least

one adaptation to every barrier. Finally, the
multibarrier principle adaptation to one
barrier may decrease or increase the height
of subsequent barriers.
The model demonstrates that all invasive epithelial cancer populations must
possess traits that overcome all proliferation barriers and that these adaptations
generate the hallmarks of the malignant
phenotype. Through the equivalence and
multibarrier principles, it also accommodates the diversity and inconsistency of
genetic properties in cancer populations
that are demonstrated by the remarkable
genotypical, epigenetic and transcriptomic
heterogeneity within cancers that have
presumably evolved through common barriers. This approach allows the disparate
observed phenotypical changes in cancer
populations to be categorized through their
role in overcoming specific proliferation
barriers.
Robert A. Gatenby and Robert J. Gillies are at the
Department of Radiology, University of Arizona,
1501 N Campbell Avenue, Tucson,
Arizona 85724, USA.
Robert A. Gatenby is also at the Department of
Applied Mathematics, University of Arizona,
1041 East Lowell Street, Tucson,
Arizona 857721, USA.
Robert J. Gillies is also at the Department of
Biochemistry & Molecular Biophysics, University of
Arizona, 617 N Santa Rita Avenue, Tucson,
Arizona 85721, USA.
Correspondence to R.A.G.
e-mail: rgatenby@radiology.arizona.edu
doi: 10.1038/nrc2255
Published online 6 December 2007
Garcia, S.B., Novelli, M. & Wright, N.A. The clonal
origin and clonal evolution of epithelial tumors. Int. J.
Exp. Path. 81, 89116 (2000).
2. Nowell, P.C. The clonal evolution of tumor cell
populations. Science 194, 2328 (1976).
3. Ilyas, M., Straub, J., Tomlinson, I.P. M. &
Bodmer, W.F. Genetic pathways in colorectal and
other cancers. Eur. J. Cancer 35, 335351 (1999).
4. Fearon, E. R. & Vogelstein, B. A genetic model for
colorectal tumorigenesis. Cell 61, 759767 (1990).
5. Hanahan, D. & Weinberg, R.A. The hallmarks of
cancer. Cell 100, 5770 (2000).
6. Gatenby, R.A. & Gillies, R.J. Why do cancers have
high aerobic glycolysis? Nature Rev. Cancer 4,
891899 (2004).
7. Gatenby, R.A. & Vincent, T.L. An evolutionary model of
carcinogenesis. Cancer Res. 63, 62126220 (2003).
8. Gatenby, R.A., Vincent, T. & Gillies, R. Evolutionary
dynamics in carcinogenesis. Math. Models Methods
Appl. Sci. 15, 120 (2005).
9. Vincent, T.L. & Gatenby, R.A. Modeling cancer as an
evolutionary game. Int. Game Theor. Rev. 7, 331346
(2005).
10. Gatenby, R. etal. Cellular adaptations to hypoxia and
acidosis during somatic evolution of breast cancer.
Br. J. Cancer 97, 646653 (2007).
11. Isakoff, S.J. etal. Breast cancer-associated PIK3CA
mutations are oncogenic in mammary epithelial cells.
Cancer Res. 65, 1099211000 (2005).
12. Derksen, P.W.B. etal. Somatic inactivation of
E-cadherin and p53 in mice leads to metastatic lobular
mammary carcinoma through induction of anoikis
resistance and angiogenesis. Cancer Cell 10, 437449
(2006).

1.

www.nature.com/reviews/cancer
2007 Nature Publishing Group

P e r s pec t i v e s
13. Eckert, L.B. etal. Involvement of Ras activation in
human breast cancer cell signaling, invasion, and
anoikis. Cancer Res. 64, 45854592 (2004).
14. Carroll, D.K. etal. p63 regulates an adhesion
program and cell survival in epithelial cells. Nature
Cell Biol. 8, 551560 (2006).
15. Hofmann, C. etal. Cellcell contacts prevent anoikis in
primary human colonic epithelial cells.
Gastroenterology 132, 587600 (2007).
13. Ishida, H. etal. Critical role of estrogen receptor on
anoikis and invasion of squamous cell carcinoma.
Cancer Sci. 98, 636643 (2007).
16. Sporn, M.B. & Roberts, A.B. Autocrine growth factors
and cancer. Nature 313, 745747 (1985).
17. Arteag, C.L. Epidermal growth factor receptor
dependence in human tumors: more than just
expression? Oncologist 4, 3139 (2002).
18. Cantley, L.C. etal. Oncogenes and signal
transduction. Cell 64, 281302 (1991).
19. Sarkisian, C.J. etal. Dose-dependent oncogeneinduced senescence invivo and its evasion during
mammary tumorigenesis. Nature Cell Biol. 9, 493505
(2007).
20. Smallbone, K., Gatenby, R.A., Gillies, R., Maini, P. &
Gavaghan, D. Metabolic changes during
carcinogenesis: potential impact on invasiveness.
J. Theor. Biol. 244, 703713 (2007).
21. Rubin, H. Multistage carcinogenesis in cell culture.
Dev. Biol. 106, 6166 (2001).
22. Burger, A.M. etal. Effect of oncogene expression on
telomerase activation and telomere length in human
endothelial, fibroblast and prostate epithelial cells. Int.
J. Oncol. 19, 10431048 (1998).
23. Robey, I.F., Lien, A.D., Welsh, S.J., Baggett, B.K. &
Gillies, R.J. Hypoxia-inducible factor-1 and the
glycolytic phenotype in tumors. Neoplasia 7, 324330
(2005).
24. Gillies, R.J. & Gatenby, R.A. Hypoxia and adaptive
landscapes in the evolution of carcinogenesis. Cancer
Metastasis Rev. 26, 311317 (2007).
25. Park, H.J., Lyons, J.C., Ohtsubo, T. & Song, C. W.
Acidic environment causes apoptosis by increasing

26.

27.

28.

29.
30.

31.
32.

33.

34.

caspase activity. Br. J. Cancer 80, 18921897

(1999).
Gatenby, R.A. & Gawlinski, E.T. A reaction-diffuse
model of acid-mediated invasion of normal tissue by
neoplastic tissue. Cancer Res. 56, 57455753
(1996).
Rohzin, J., Sameni, M., Ziegler, G. & Sloane, B.F.
Pericellular pH affects distribution and secretion of
cathepsin B in malignant cells. Cancer Res. 54,
65176525 (1994).
Abbey, C.K. etal. Invivo PET imaging of
progression of transformation in a mouse model of
mammary neoplasia. Proc. Natl Acad. Sci. USA 101,
1143811443 (2005).
Yasuda, S. etal. 18F-FDG PET detection of colonic
adenomas. J. Nucl. Med. 42, 989992 (2001).
Younes, M., Ertan, A., Lechago, L.V., Somoano, J. &
Lechago, J. Human erythrocyte glucose transporter
(Glut1) is immunohistochemically detected as a late
event during malignant progression in Barretts
metaplasia. Cancer Epidemiol. Biomarkers Prev. 6,
303305 (1997).
Folkman, J. Role of angiogenesis in tumor growth and
metastasis. Semin. Oncol. 29, 1518 (2002).
Naumov, G.N. etal. A model of human tumor
dormancy: an angiogenic switch from the
nonangiogenic phenotype. J. Natl Cancer Inst. 98,
316325 (2006).
Giuriato, S. etal. Sustained regression of tumors upon
MYC inactivation requires p53 or thrombospondin-1
to reverse the angiogenic switch. Proc. Natl Acad. Sci.
USA 103, 1626616271 (2006).
Gatenby, R.A. etal. Acid-mediated tumor invasion: a
multidisciplinary study. Cancer Res. 66, 52165223
(2006).

DATABASES
Entrez Gene: http://www.ncbi.nlm.nih.gov/entrez/query.
fcgi?db=gene
APC | CDH1 | CTNNB1 | MYC | p53 | p63 | SLC2A1
All links are active in the online pdf

nature reviews | cancer

advance online publication | 

2007 Nature Publishing Group