441
Association between Glutathione S-Transferase ␲
Polymorphisms and Survival in Patients with
Advanced Nonsmall Cell Lung Carcinoma
Charles Lu, M.D.1
Margaret R. Spitz, M.D., M.P.H.2
Hua Zhao, Ph.D.2
Qiong Dong, M.S.2
Mylene Truong, M.D.3
Joe Y. Chang, M.D.4
1
George R. Blumenschein, Jr., M.D.
Waun K. Hong, M.D.1
Xifeng Wu, M.D., Ph.D.2
1
Department of Thoracic/Head and Neck Medical
Oncology, The University of Texas M. D. Anderson
Cancer Center, Houston, Texas.
2
Department of Epidemiology, The University of
Texas M. D. Anderson Cancer Center, Houston,
Texas.
3
Department of Diagnostic Radiology, The Univer-
sity of Texas M. D. Anderson Cancer Center, Hous-
ton, Texas.
4
Department of Radiation Oncology, The Univer-
sity of Texas M. D. Anderson Cancer Center, Hous-
ton, Texas.
Supported by National Cancer Institute Grant K12
CA088084.
Charles Lu is a recipient of the Clinical Oncology
Research Career Development Award from the
National Cancer Institute.
Address for reprints: Charles Lu, M.D., Department
of Thoracic/Head and Neck Medical Oncology, Unit
432, The University of Texas M. D. Anderson Can-
cer Center, 1515 Holcombe Boulevard, Houston,
TX 77030-4009; Fax: (713) 796-8655; E-mail:
clu@mdanderson.org
Received February 9, 2005; revision received July
19, 2005; accepted August 11, 2005.
© 2005 American Cancer Society
DOI 10.1002/cncr.21619
Published online 7 December 2005 in Wiley InterScience (www.interscience.wiley.com).
BACKGROUND. Glutathione S-transferase (GST) ␲ (GSTP1) is a detoxification en-
zyme with substrate specificity for both exogenous carcinogens and chemotherapy
agents. Genetic polymorphisms of GSTP1 exon 5 (Ile105Val) and exon 6 (Ala114Val)
appear to reduce this enzyme’s activity. Previously, the authors reported that the
exon 6 variant was associated with an increased risk of lung carcinoma, particularly
among men, younger patients, and ever smokers. In this study, the authors hy-
pothesized that variant GSTP1 genotype would result in reduced inactivation of
chemotherapy agents and improved survival in patients with advanced-stage non-
small cell lung carcinoma (NSCLC), a population that is likely to receive platinum-
based chemotherapy.
METHODS. Patients with Stage III and IV NSCLC who were enrolled in a molecular
epidemiology study were identified, and a polymerase chain reaction-restriction
fragment length polymorphism assay was used to genotype GSTP1 exons 5 and 6
in 424 patients and 425 patients, respectively.
RESULTS. Patients who had the exon 6 variant genotype (Ala/Val or Val/Val) had
significantly better survival compared with patients who had the wild type geno-
type (Ala/Ala; P ⫽ 0.037), with median survival of 16.1 months and 11.4 months,
respectively. Multivariate analysis revealed a reduced adjusted hazard ratio (HR) of
death associated with the exon 6 variant genotype of 0.75 (95% confidence interval
[95% CI], 0.54 –1.05). This protective association was observed in younger patients
(younger than age 62 yrs; HR, 0.59; 95% CI, 0.57– 0.97) and in males (HR, 0.64; 95%
CI, 0.41– 0.99). GSTP1 exon 5 genotype was not associated with survival.
CONCLUSIONS. GSTP1 exon 6 variant genotypes may be associated with improved
survival among patients with Stage III and IV NSCLC. Cancer 2006;106:441–7.
© 2005 American Cancer Society.
KEYWORDS: lung carcinoma, glutathione S-transferase, polymorphisms, prognostic,
predictive factor.
L ung carcinoma remains a worldwide public health issue of im-
mense proportions. In 2004, carcinomas of the lung and bronchus
are expected to continue to account for the highest proportion of
cancer deaths in the United States (160,440 deaths or 28.5%), more
than the estimated total number of deaths due to carcinomas of the
breast, prostate, colon, and rectum combined.1 Approximately 80% of
lung carcinomas will have nonsmall cell carcinoma histology.2
The majority of patients with nonsmall cell lung carcinoma
(NSCLC) present with locally advanced or metastatic disease.3 In this
population, standard treatment strategies include platinum-based
chemoradiotherapy4 and chemotherapy,5 respectively. Despite the
use of these aggressive and toxic therapies, patients with NSCLC have
442 CANCER January 15, 2006 / Volume 106 / Number 2
poor overall outcomes.6,7 In the absence of validated
biomarkers that can be used reliably to predict re-
sponse to therapy, oncologists lack the tools needed to
individualize and optimize patient therapies.8,9
Glutathione S-transferases (GSTs) are Phase II
metabolic enzymes that are involved in the detoxifi-
cation of mutagenic and cytotoxic, DNA-reactive mol-
ecules mediated by glutathione conjugation.10,11 Var-
ious cytosolic GST subclasses have been classified
according to their biochemical properties, including
GST ␣, GST ␮ (GSTM), GST ␲ (GSTP1), and GST ␪
(GSTT).12 GSTP1 is expressed in many human epithe-
lial tissues and is the most abundant GST isoform in
the lung.13,14 GSTP1 is a polymorphic gene located on
chromosome 11 with 2 single-nucleotide substitutions
in exon 5 and exon 6 that give rise to Ile105Val and
Ala114Val amino acid substitutions, respectively.15
These amino acid substitutions appear to be within
the GSTP1 active site for binding of hydrophobic elec-
trophiles,15,16 and studies suggest that the variant ge-
notype results in diminished enzymatic activity.17,18
Because reduced enzyme activity may lead to a de-
creased ability to detoxify carcinogenic and mutagenic
compounds, it is plausible that these polymorphisms
may confer an increase in cancer susceptibility. A
number of epidemiologic studies have explored pos-
sible associations between GSTP1 polymorphisms and
the risk of lung carcinoma, often yielding conflicting
results.19 –22 Our group recently reported the largest
case– control study to examine the association of
GSTP1 exon 5 and 6 polymorphisms and NSCLC risk.23
That study included 582 patients (cases) and 600
matched controls. The primary finding was that the
exon 6 polymorphism was associated with an elevated
risk of NSCLC (odds ratio, 1.4) that was not observed
with the exon 5 polymorphism. It is noteworthy that
subgroup analyses suggested that men, younger indi-
viduals, and ever smokers with the exon 6 polymor-
phism had the highest associated risk.
In addition to carcinogens, a number of chemo-
therapeutic agents appear to be substrates for GSTP1,
including cisplatin.24 –27 Several studies have reported
that elevated levels of GSTP1 in serum or tumor tissue
from patients with NSCLC were correlated with resis-
tance to platinum-based chemotherapy.28 –31 Building
on the results of our case– control study, we hypothe-
sized that the GSTP1 exon 6 variant genotype would be
associated with improved clinical outcome in the case
group of patients with NSCLC who were treated with
chemotherapy because of reduced chemotherapy in-
activation. Because it is the standard of care for pa-
tients with locally advanced and metastatic NSCLC
(Stages III and IV32) to receive platinum-based chemo-
therapy, we restricted our analysis to this patient pop-
ulation.
MATERIALS AND METHODS
Patients
The patients for this study were accrued from an on-
going, hospital-based, case– control study of epidemi-
ologic and genetic risk factors for the development of
lung carcinoma, as described previously.33 The overall
participation rate was 86%. Among the patients who
were enrolled between August 1995 and June 2000,
425 patients were identified with Stage III or IV, patho-
logically confirmed NSCLC diagnosed within the 4
months prior to enrollment. Follow-up was complete
through September 17, 2001. All patients were accrued
at the University of Texas M. D. Anderson Cancer
Center (Houston, TX). On entry into the study, each
patient had a personal interview based on a structured
questionnaire in which they were asked to provide
information that included sociodemographic vari-
ables and smoking history. An individual who had
smoked at least 100 cigarettes was defined as an ever
smoker. A former smoker had quit smoking at least 1
year prior to diagnosis. Ethnicity was self-reported.
Each patient had a 30-mL sample of blood drawn into
coded, heparinized tubes for immediate DNA isola-
tion. All patients provided written informed consent,
and the protocol was approved by The University of
Texas M. D. Anderson Cancer Center Institutional Re-
view Board. The American Joint Committee on Cancer
staging system was used. Vital status was obtained
from the medical record, the institution’s tumor reg-
istry, or the Social Security Death Index.
GSTP1 Genotyping
Genomic DNA was isolated from the lymphocytes of
whole blood samples using a proteinase-K, sodium
dodecyl sulfate, and ethylene diamine tetraacetic
acid-Tris approach. The polymorphic sites in exon 5
(Ile105Val) and exon 6 (Ala114Val) of the GSTP1 gene
were amplified by using polymerase chain reaction
(PCR) analysis, as described previously.23 Briefly, PCR
was performed in a 25 ␮L volume that contained 1
⫻ PCR buffer, 3.0 mM MgCl2, 0.25 mM dioxyribo-
nucleoside triphosphates, 1.5 units of Taq polymerase
(Promega, Madison, WI), and 0.3 ␮M of primers
GSTP1-5 forward (5⬘-GTAGTTTGCCCAAGGTCAAG-3⬘)
and GSTP1-5 reverse (5⬘-AGCCACCTGAGGGGTAAG-
3⬘) for exon 5 or primers GSTP1-6 forward (5⬘-GGGAG-
CAAGCAGAGGAGAAT-3⬘) and GSTP1-6 reverse (5⬘-
CAGGTTGTAGTCAGCGAAGGAG-3⬘) for exon 6. The
PCR conditions were 94 °C for 5 minutes, followed by
5 cycles in which the annealing temperature de-
creased by 1 °C each cycle (cycle 1: 30 sec at 94 °C, 30

sec at 64 °C, 30 sec at 72 °C). This was followed by
another 25 cycles at 94 °C for 30 seconds, 59 °C for 30
seconds, and 72 °C for 30 seconds, with a final exten-
sion step at 72 °C for 5 minutes. A 433-base pair (bp)
DNA fragment was amplified for exon 5, and a 420 bp
fragment was amplified for exon 6; this was followed
by overnight digestion with 5 units of BsmAI for exon
5 and AciI for exon 6 (New England Biolabs, Beverly,
MA). The fragments were separated on a 3% agarose
gel stained with ethidium bromide. The wild type (AA),
heterozygous genotype (A/G), and mutant genotype
(G/G) yielded 2 bands (328 bp and 105 bp), 4 bands
(328 bp, 222 bp, 106 bp, and 105 bp), and 3 bands (222
bp, 106 bp, and 105 bp), respectively, for the polymor-
phism in exon 5. For exon 6, the digested product
resolved bands at 246 bp, 116 bp, and 58 bp for the
wild type (C/C); 362 bp, 246 bp, 116 bp, and 58 bp for
the heterozygous genotype (C/T); and 362 bp and 58
bp for the mutant genotype (T/T).
Statistical Analysis
Chi-square analyses and Fisher exact tests were used
to compare the distribution of genotypes between
subgroups based on gender, ethnicity, smoking status,
age, disease stage, and tumor histology. Survival anal-
ysis methods were used to evaluate the effects of the
GSTP1 exon 5 and exon 6 genotypes on survival in
patients with lung carcinoma. We calculated survival
as the period from diagnosis to the date of death or the
date of last follow-up for each patient. We calculated
person-years at risk within each genotype category as
the sum of the survival of all patients in that category.
Overall survival in relation to GSTP1 exon 5 and exon
6 genotypes was evaluated by the Kaplan–Meier sur-
vival function and log-rank tests. Hazard ratios (HRs)
were estimated from a multivariate Cox proportional
hazards model, with adjustment for age, gender, eth-
nicity, smoking status, and tumor stage. Stratified
analysis was also carried out according to these ad-
justed variables. STATA software (STATA Corp., Col-
lege Station, TX) was used for statistical analyses.
RESULTS
Among the 425 patients in this study, 55.5% were
male, and 53.2% had Stage III disease, and their mean
age was 61.6 years. The distributions of GSTP1 geno-
types according to patient characteristics are shown in
Table 1. Genotypes for GSTP1 exon 5 and exon 6 were
available for 424 patients and 425 patients, respec-
tively. The distribution of genotypes was not related to
age, gender, smoking status, stage at diagnosis, or
tumor histology. There was a significant association
between exon 5 genotype and ethnicity: Hispanics had
a higher frequency of the homozygous exon 5 variant
GSTP1 and Nonsmall Cell Lung Carcinoma/Lu et al. 443
allele (Val/Val). In light of the multiple subgroup com-
parisons and the small number of Hispanic patients (n
⫽ 18 patients), the importance of this observation
remains to be determined. Because there were only 3
patients who were homozygous for the variant exon 6
allele (Val/Val), this group was combined with the
heterozygous (Ala/Val) group for all future analyses.
The Kaplan–Meier survival functions for overall
survival according to GSTP1 genotypes are presented
in Figure 1. In total, 312 deaths were observed during
follow-up. The median follow-up among patients who
were alive at the end of observation was 18 months
after diagnosis. Figure 1A shows that the exon 6 poly-
morphism was associated with improved overall sur-
vival (log-rank P ⫽ 0.037), with a median survival of
16.1 months and 11.4 months for patients with and
without the variant allele, respectively. The Kaplan–
Meier estimate of overall survival at 1 year, 2 years,
and 3 years was 0.64 (95% CI, 0.50 – 0.75), 0.32 (95% CI,
0.20 – 0.45), and 0.21 (95% CI, 0.09 – 0.36) for patients
with the GSTP1 variant genotype and 0.47 (95% CI,
0.41– 0.52), 0.22 (95% CI, 0.18 – 0.27), and 0.13 (95% CI,
0.09 – 0.18) for patients with the wild type genotype.
When they were stratified by disease stage, patients
who had the exon 6 variant demonstrated improved
survival, but the association was no longer statistically
significant (log-rank P ⫽ 0.14 and P ⫽ 0.19 for the
Stage III and IV subgroups, respectively). There was no
evidence of a survival difference by GSTP1 exon 5
genotype (Fig. 1B) (log-rank P ⫽ 0.35).
The adjusted HRs of death associated with GSTP1
genotypes are shown in Table 2. After adjustment for
age, gender, ethnicity, smoking status, disease stage,
and tumor histology, patients who had the GSTP1
exon 6 variant genotype had marginally longer sur-
vival, with an adjusted HR of 0.75 (95% CI, 0.54 –1.05),
compared with patients who had the wild type geno-
type. In stratified analyses, the protective effect was
evident among younger patients (younger than age 62
yrs), with an adjusted HR of 0.59 (95% CI, 0.57– 0.97),
but it was less evident among older patients (age 62
yrs and older; adjusted HR, 0.89; 95% CI, 0.56 –1.42).
The protective effect also was evident in men (ad-
justed HR, 0.64; 95% CI, 0.41– 0.99) but not in women
(adjusted HR, 0.93; 95% CI, 0.54 –1.60). For the GSTP1
exon 5 variant genotype, the adjusted Cox model in-
dicated no significant association with overall survival.
Patients with Stage III and IV NSCLC were se-
lected for this study, because the accepted standard of
care for these patients incorporates platinum-based
chemotherapy for those who are deemed eligible for
therapy. Although baseline patient data and blood
specimens were collected meticulously for patients
who were enrolled in this prospective molecular epi-
444 CANCER January 15, 2006 / Volume 106 / Number 2

TABLE 1
Selected Characteristics of Patients with Lung Carcinoma by Glutathione S-Transferase ␲ Genotype

No. of patients (%)

GSTP1 exon 5a GSTP1 exon 6

Characteristic All patients Ile/Ile Ile/Val Val/Val P value Ala/Ala Ala/Val Val/Val P value

Total 425 166 (39.2) 207 (48.8) 51 (12.0) 358 (84.2) 64 (15.1) 3 (0.7)
Gender
Men 236 (55.5) 94 (56.6) 111 (53.6) 30 (58.8) 196 (54.8) 37 (57.8) 3 (100.0)
Women 189 (44.5) 72 (43.4) 96 (46.4) 21 (41.2) 0.74 162 (45.3) 27 (42.3) 0 (0.00) 0.35
Ethnicity
Caucasian 360 (84.7) 146 (88.0) 176 (85.0) 37 (72.6) 296 (82.7) 61 (95.3) 3 (100.0)
Mexican American 18 (4.2) 4 (2.4) 8 (3.9) 6 (11.8) 17 (4.8) 1 (1.6) 0 (0.00)
African American 47 (11.1) 16 (9.6) 23 (11.1) 8 (15.7) 0.03 45 (12.5) 2 (3.1) 0 (0.00) 0.11
Smoking status
Never 44 (10.4) 18 (10.8) 24 (11.6) 2 (3.9) 38 (10.6) 6 (9.4) 0 (0.00)
Former 185 (43.5) 71 (42.8) 90 (43.5) 23 (45.1) 151 (42.2) 32 (50.0) 2 (66.7)
Current 196 (46.1) 77 (46.4) 93 (44.9) 26 (51.0) 0.60 169 (47.2) 26 (40.6) 1 (33.3) 0.74
Age
ⱕ 49 yrs 47 (11.1) 15 (9.0) 29 (14.0) 3 (5.9) 36 (10.1) 11 (17.2) 0 (0.00)
50–59 yrs 118 (27.8) 44 (26.5) 63 (30.4) 11 (21.6) 98 (27.4) 18 (28.1) 2 (66.7)
60–69 yrs 171 (40.2) 66 (40.0) 78 (37.7) 26 (51.0) 146 (40.8) 25 (39.1) 0 (0.00)
ⱖ 70 yrs 89 (20.9) 41 (24.7) 37 (17.9) 11 (21.6) 0.19 78 (21.8) 10 (15.6) 1 (33.3) 0.28
Stage at diagnosis
Stage III 226 (53.2) 83 (50.0) 111 (53.6) 31 (60.8) 187 (52.2) 39 (60.9) 0 (0.00)
Stage IV 199 (46.8) 83 (50.0) 96 (46.4) 20 (39.2) 0.39 171 (47.8) 25 (39.1) 3 (100.0) 0.07
Histology
Adeno CA 215 (50.5) 82 (49.4) 110 (53.4) 23 (45.1) 181 (50.7) 31 (48.4) 3 (100.0)
Squamous CA 106 (24.9) 45 (27.1) 51 (24.8) 15 (29.4) 86 (24.1) 20 (31.3) 0 (0.00)
Other 103 (24.2) 39 (23.5) 45 (21.8) 13 (25.5) 0.68 90 (25.2) 13 (20.3) 0 (0.00) 0.45

GSTP1: glutathione s-transferase ␲; CA: carcinoma.

a
GSTP1 exon 5 genotype data were available for 424 patients.

demiologic study, subsequent clinical follow-up and
treatment data remained incomplete. Initial treat-
ment-related data, however, were available for a sub-
group of 310 patients (73%). In this subgroup, 204
patients received chemotherapy as a component of
their initial therapy, and 106 patients did not receive
chemotherapy. Among the former group, there ap-
peared to be a trend toward improved survival for
patients who had the variant exon 6 allele (log-rank P
⫽ 0.13), whereas this trend was not evident in the
latter group (log-rank P ⫽ 0.88). A similar exploratory
analysis for the exon 5 polymorphism did not demon-
strate any associations with survival among patients
who received or did not receive initial chemotherapy
(log-rank P ⫽ 0.74 and P ⫽ 0.80, respectively). A pos-
sible factor that may have influenced the availability of
initial treatment data was the site of treatment, be-
cause it was more difficult to obtain this information
for patients who were not treated at our institution.
Data regarding whether or not patients ever re-
ceived chemotherapy were available for 423 patients
(99.5%). Two hundred thirty-seven patients received
chemotherapy, whereas 186 patients never received
chemotherapy. Among the former group, there ap-
peared to be a nonsignificant trend toward improved
survival for patients who had the variant exon 6 allele
(log-rank P ⫽ 0.17), whereas this trend was not evident
in the latter group (log-rank P ⫽ 0.46). A similar ex-
ploratory analysis for the exon 5 polymorphism did
not demonstrate significant associations with survival
among patients who received or did not receive che-
motherapy (log-rank P ⫽ 0.99 and P ⫽ 0.17, respec-
tively).
DISCUSSION
Based on data indicating that variant alleles are asso-
ciated with reduced enzymatic activity, we hypothe-
sized that GSTP1 genotype also would affect clinical
outcome in the patients with NSCLC who were most
likely to receive chemotherapy. Because it is the stan-
dard of care for patients with advanced NSCLC (Stage
III and IV) to receive platinum-based chemotherapy,
we decided to focus our analysis on this population.
We found that the exon 6 polymorphism was associ-

FIGURE 1. Overall survival is illustrated for patients with nonsmall cell lung
carcinoma according to glutathione S-transferase ␲ (GSTP1) genotype
(Kaplan–Meier function. (A) The GSTP1 exon 6 genotype. (B) The GSTP1 exon
5 genotype. Numbers in parentheses represent the number of deaths/the
number of patients.
ated with improved survival. The adjusted HR simi-
larly indicated a reduced risk of death, although the
95% CI included the null. It is noteworthy that our
subset analyses suggested that this association with
survival was restricted to younger patients and males,
the same groups that demonstrated increased lung
carcinoma risk with the variant genotype.
Other groups have investigated GSTP1 polymor-
phism in patients with lung carcinoma, although no
studies have been reported with data on the exon 6
variant allele to our knowledge. Sweeney et al. exam-
ined 274 patients with lung carcinoma (all histologies)
who were identified through a Washington State pop-
ulation-based cancer registry.34 Those authors found
no association between the GSTP1 exon 5 (Ile105Val)
or GSTT1 null genotype and survival in the overall
population nor in a subgroup of patients who were
treated with chemotherapy. An association between
the GSTM1 null genotype and shorter survival was
found; however, this effect was not modified by che-
GSTP1 and Nonsmall Cell Lung Carcinoma/Lu et al. 445
TABLE 2
Glutathione S-Transferase ␲ Genotypes in Patients with Lung
Carcinoma
Survival status (no. of
patients)
Genotype Dead Alive HR (95% CI)a
GSTP1 exon 5
Ile/Ile 120 46 Reference
Ile/Val 158 49 1.24 (0.97–1.58)
Val/Val 34 17 0.88 (0.60–1.30)
GSTP1 exon 6
Ala/Ala 269 89 Reference
Ala/Val ⫹ Val/Val 43 24 0.75 (0.54–1.05)
HR: hazard ratio; 95% CI: 95% confidence interval; GSTP1: glutathione S-transferase ␲.
a
HR and 95% CI values were determined by using a Cox proportional hazards model that was adjusted
for age, gender, ethnicity, smoking status, tumor stage, and histology.
motherapy but appeared to be strongest among pa-
tients who received radiotherapy. The biologic signif-
icance of these findings was unclear. One possible
explanation offered was that carcinomas in GSTM1-
null patients may be more aggressive due to increased
carcinogen-DNA adducts and mutations in p53, K-ras,
and other genes.35 Yang et al. examined 250 patients
with lung carcinoma in all stages of disease36 but
found no association between GSTP1 exon 5
(Ile105Val), GSTT1 null, or GSTM1 null genotypes and
1-year survival. The lack of an association between
GSTP1 exon 5 genotype and survival in patients with
lung carcinoma appears to be a consistent finding in
our study and in the 2 aforementioned reports. In a
study of patients with advanced colorectal carcinoma
who received oxaliplatin-based chemotherapy, how-
ever, the exon 5 variant allele was associated with
improved survival.37
The current data also suggest that the exon 6
polymorphism is associated with a gender and age
effect. The biologic significance of these findings re-
mains unclear. It is intriguing that, in our prior case–
control study, we also found an increased risk of lung
carcinoma associated with the exon 6 variant allele
that was especially evident in males and younger in-
dividuals and not in females and older individuals.
The consistency of these results suggests that the exon
6 polymorphism may have a real biologic effect that
can affect clinical outcome. It is noteworthy that gen-
der has been identified as a prognostic factor in pa-
tients with NSCLC.38 and it is possible to speculate
that gender-specific differences in metabolic enzymes
involved in the detoxification of chemotherapy may be
a possible explanation for this observation. These data
must be interpreted with caution, however, because it
446 CANCER January 15, 2006 / Volume 106 / Number 2
remains possible that subgroup analyses may result in
misleading artifactual findings secondary to multiple
comparisons. Future prospective validation studies in
other patient populations are needed.
There are some important limitations of this re-
search. The patients in this study were part of a larger
molecular epidemiologic study of risk factors for lung
carcinoma development. Although blood samples and
initial clinical, stage, and demographic data were col-
lected prospectively, follow-up clinical and treatment
information were not primary endpoints; thus, the
data were incomplete, and the study’s primary end-
point was overall survival. Therefore, we cannot con-
clude that the GSTP1 exon 6 polymorphism is associ-
ated with differences in response to chemotherapy. An
alternative explanation is that the polymorphism is a
favorable prognostic factor that influences clinical
outcome independent of treatment status. We did ex-
plore this issue further by examining patients with
early-stage NSCLC, because, during the study period,
the standard of care for these patients was surgical
resection alone. In a cohort of 162 patients with Stage
I and II NSCLC, we did not detect an association
between the exon 6 polymorphism and survival (data
not shown). This finding would support the hypothe-
sis that this polymorphism may function as a predic-
tor of response to chemotherapy. Because, currently,
there are no useful biomarkers to guide therapeutic
decisions for patients with advanced NSCLC, the de-
velopment of validated predictive biomarkers would
have significant clinical importance.
In summary, the current results suggest that the
GSTP1 exon 6 variant genotype is associated with im-
proved survival among patients with Stage III and IV
NSCLC. Further studies incorporating treatment and
response data are needed to validate these findings
and to determine the predictive and prognostic signif-
icance of GSTP1 genotype in patients with advanced
NSCLC. Ultimately, future pharmacogenomic studies
analyzing multiple functional polymorphisms will be
required to identify biomarkers that will guide the
selection and delivery of individualized therapy.
REFERENCES
1. Jemal A, Tiwari RC, Murray T, et al. Cancer statistics, 2004.
CA Cancer J Clin. 2004;54:8 –29.
2. Travis W, Travis, LB, Devesa, SS. Lung cancer incidence and
survival by histologic type. Cancer. 1995;75(1 Suppl):191–
202.
3. Fry WA, Phillips JL, Menck HR. Ten-year survey of lung
cancer treatment and survival in hospitals in the United
States: a national cancer data base report. Cancer. 1999;86:
1867–1876.
4. Green MR, Rocha Lima CM, Sherman CA. Radiation and
chemotherapy for patients with Stage III non-small cell lung
cancer. Semin Radiat Oncol. 2000;10:289 –295.
5. Bunn PA Jr. Chemotherapy for advanced non-small-cell
lung cancer: who, what, when, why? J Clin Oncol. 2002;20:
23s–33s.
6. Non-Small Cell Lung Cancer Collaborative Group. Chemo-
therapy in non-small cell lung cancer: a meta-analysis using
updated data on individual patients from 52 randomised
clinical trials. BMJ. 1995;311:899 –909.
7. Schiller JH, Harrington D, Belani CP, et al. Comparison of
four chemotherapy regimens for advanced non-small-cell
lung cancer. N Engl J Med. 2002;346:92–98.
8. Gandara DR, Lara PN, Lau DH, Mack P, Gumerlock PH.
Molecular-clinical correlative studies in non-small cell lung
cancer: application of a three-tiered approach. Lung Cancer.
2001;34(Suppl 3):S75–S80.
9. Rosell R, Taron M, Alberola V, Massuti B, Felip E. Genetic
testing for chemotherapy in non-small cell lung cancer.
Lung Cancer. 2003;41(Suppl 1):S97–S102.
10. Pickett CB, Lu AYH. Glutathione S-transferases: gene struc-
ture, regulation, and biological function. Annu Rev Biochem.
1989;58:743–764.
11. Hayes JD, Pulford DJ. The glutathione S-transferase super-
gene family: regulation of GST and the contribution of the
isoenzymes to cancer chemoprotection and drug resistance.
Crit Rev Biochem Mol Biol. 1995;30:445– 600.
12. Seidegard J, Ekstrom G. The role of human glutathione
transferases and epoxide hydrolases in the metabolism of
xenobiotics. Environ Health Perspect. 1997;105(Suppl
4):791–799.
13. Terrier P, Townsend AJ, Coindre JM, Triche TJ, Cowan KH.
An immunohistochemical study of pi class glutathione S-
transferase expression in normal human tissue. Am J Pathol.
1990;137:845– 853.
14. Moscow JA, Fairchild CR, Madden MJ, et al. Expression of
anionic glutathione-S-transferase and P-glycoprotein genes
in human tissues and tumors. Cancer Res. 1989;49:1422–
1428.
15. Ali-Osman F, Akande O, Antoun G, Mao JX, Buolamwini J.
Molecular cloning, characterization, and expression in
Escherichia coli of full-length cDNAs of three human gluta-
thione S-transferase Pi gene variants. Evidence for differen-
tial catalytic activity of the encoded proteins. J Biol Chem.
1997;272:10004 –10012.
16. Reinemer P, Dirr HW, Ladenstein R, et al. Three-dimen-
sional structure of class pi glutathione S-transferase from
human placenta in complex with S-hexylglutathione at 2.8 A
resolution. J Mol Biol. 1992;227:214 –226.
17. Zimniak P, Nanduri B, Pikula S, et al. Naturally occurring
human glutathione S-transferase GSTP1–1 isoforms with
isoleucine and valine in position 104 differ in enzymic prop-
erties. Eur J Biochem. 1994;224:893– 899.
18. Watson MA, Stewart RK, Smith GB, Massey TE, Bell DA.
Human glutathione S-transferase P1 polymorphisms: rela-
tionship to lung tissue enzyme activity and population fre-
quency distribution. Carcinogenesis. 1998;19:275–280.
19. Ryberg D, Skaug V, Hewer A, et al. Genotypes of glutathione
transferase M1 and P1 and their significance for lung DNA
adduct levels and cancer risk. Carcinogenesis. 1997;18:1285–
1289.
20. Jourenkova-Mironova N, Wikman H, Bouchardy C, et al.
Role of glutathione S-transferase GSTM1, GSTM3, GSTP1
and GSTT1 genotypes in modulating susceptibility to smok-
ing-related lung cancer. Pharmacogenetics. 1998;8:495–502.

21. To-Figueras J, Gene M, Gomez-Catalan J, et al. Genetic
polymorphism of glutathione S-transferase P1 gene and
lung cancer risk. Cancer Causes Control. 1999;10:65–70.
22. Harris MJ, Coggan M, Langton L, Wilson SR, Board PG.
Polymorphism of the Pi class glutathione S-transferase in
normal populations and cancer patients. Pharmacogenetics.
1998;8:27–31.
23. Wang Y, Spitz MR, Schabath MB, Ali-Osman F, Mata H, Wu
X. Association between glutathione S-transferase p1 poly-
morphisms and lung cancer risk in Caucasians: a case-
control study. Lung Cancer. 2003;40:25–32.
24. Nakagawa K, Saijo N, Tsuchida S, et al. Glutathione-S-trans-
ferase pi as a determinant of drug resistance in transfectant
cell lines. J Biol Chem. 1990;265:4296 – 4301.
25. Ban N, Takahashi Y, Takayama T, et al. Transfection of
glutathione S-transferase (GST)-pi antisense complemen-
tary DNA increases the sensitivity of a colon cancer cell line
to Adriamycin, cisplatin, melphalan, and etoposide. Cancer
Res. 1996;56:3577–3582.
26. Goto S, Iida T, Cho S, Oka M, Kohno S, Kondo T. Overex-
pression of glutathione S-transferase pi enhances the ad-
duct formation of cisplatin with glutathione in human can-
cer cells. Free Radical Res. 1999;31:549 –558.
27. Matsunaga T, Sakamaki S, Kuga T, et al. GST-pi gene-trans-
duced hematopoietic progenitor cell transplantation over-
comes the bone marrow toxicity of cyclophosphamide in
mice. Hum Gene Ther. 2000;11:1671–1681.
28. Hida T, Kuwabara M, Ariyoshi Y, et al. Serum glutathione
S-transferase-pi level as a tumor marker for non-small cell
lung cancer. Potential predictive value in chemotherapeutic
response. Cancer. 1994;73:1377–1382.
29. Bai F, Nakanishi Y, Kawasaki M, et al. Immunohistochemi-
cal expression of glutathione S-transferase-Pi can predict
GSTP1 and Nonsmall Cell Lung Carcinoma/Lu et al. 447
chemotherapy response in patients with nonsmall cell lung
carcinoma. Cancer. 1996;78:416 – 421.
30. Inoue T, Ishida T, Sugio K, Maehara Y, Sugimachi K. Gluta-
thione S transferase Pi is a powerful indicator in chemother-
apy of human lung squamous-cell carcinoma. Respiration.
1995;62:223–227.
31. Nakanishi Y, Kawasaki M, Bai F, et al. Expression of p53 and
glutathione S-transferase-Pi relates to clinical drug resistance
in non-small cell lung cancer. Oncology. 1999;57:318 –323.
32. Fleming ID, Cooper JS, Henson DE, et al., editors. AJCC
cancer staging manual, 5th ed. Philadelphia: Lippincott-
Raven, 1998.
33. Spitz MR, Shi H, Yang F, et al. Case-control study of the D2
dopamine receptor gene and smoking status in lung cancer
patients. J Natl Cancer Inst. 1998;90:358 –363.
34. Sweeney C, Nazar-Stewart V, Stapleton PL, Eaton DL,
Vaughan TL. Glutathione S-transferase M1, T1, and P1 poly-
morphisms and survival among lung cancer patients. Can-
cer Epidemiol Biomarkers Prev. 2003;12:527–533.
35. Goto I, Yoneda S, Yamamoto M, Kawajiri K. Prognostic
significance of germ line polymorphisms of the CYP1A1 and
glutathione S-transferase genes in patients with non-small
cell lung cancer. Cancer Res. 1996;56:3725–3730.
36. Yang P, Yokomizo A, Tazelaar HD, et al. Genetic determi-
nants of lung cancer short-term survival: the role of gluta-
thione-related genes. Lung Cancer. 2002;35:221–229.
37. Stoehlmacher J, Park DJ, Zhang W, et al. Association be-
tween glutathione S-transferase P1, T1, and M1 genetic
polymorphism and survival of patients with metastatic colo-
rectal cancer. J Natl Cancer Inst. 2002;94:936 –942.
38. Olak J, Colson Y. Gender differences in lung cancer: have we
really come a long way, baby? J Thorac Cardiovasc Surg.
2004;128:346 –351.