INTRODUCTION

A cCarcinogen are is any substances, radionuclides, or radiations that promotes carcinogenesis

development, the formation of cancer. This may be due to their ability to damage the genome or

to the disruption of cellular metabolic processes. Several radioactive substances are considered

carcinogens, but their carcinogenic activity is attributed to the radiation from either , for example

the gamma rays and alpha particles, which they emit. Some specific Common examples of non-

radioactive carcinogens includesare inhaled asbestos, certain dioxins, and tobacco smoke.

Although, the public generally associates carcinogenicity with synthetic chemicals, it is equally

likely to arise in both natural and synthetic substances. Carcinogens are not necessarily

immediately toxic; thus, their effect can be insidious. (Birkett et al., 2019).

Though, Cancer is any disease in which normal cells are damaged and do not undergo

programmed cell death as fast as they divide via mitosis. Carcinogens may increase the risk of

cancer by altering cellular metabolism or damaging DNA directly in cells, which interferes with

biological processes, and induces the uncontrolled, malignant division, ultimately leading to the

formation of tumors. Usually, severe DNA damage leads to programmed cell death, but if the

programmed cell death pathway is damaged, then the cell cannot prevent itself from becoming a

cancer cell. (Barrett and & Shelby, 1992)

There are many natural carcinogens these includes. Aflatoxin B1, which is produced by the

fungus Aspergillus flavus growing on stored grains, nuts and peanut butter which serve as , is an

example of a potent, naturally occurring microbial carcinogen. Also, Ccertain viruses such as

hepatitis B and human papilloma virus have been found to cause cancer in humans. The first one

shown to cause cancer in animals is Rous sarcoma virus, discovered in 1910 by Peyton Rous.

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Other infectious organisms which cause cancer in humans include some bacteria (e.g.

Helicobacter pylori) and helminths (e.g. Opisthorchis viverrini and Clonorchis sinensis).

Dioxins and dioxin-like compounds, benzene, ketpone, EDB, and asbestos have all been

classified as carcinogenic. As far back as the 1930s, iIndustrial smoke and tobacco smoke were

identified as sources of numerousdozens of carcinogens like , including benzopyrene, tobacco-

specific nitrosamines such as nitrosonornicotine, and reactive aldehydes such as formaldehyde,

which is also a hazard in embalming and making plastics (Grimmer., 1983). Vinyl chloride, from

which PVC is manufactured, is also a carcinogen and thus a hazard in PVC production.

However, Cco-carcinogens are chemicals that do not necessarily cause cancer on their own, but

promote the activity of other carcinogens in causing cancer. After the carcinogen enters the body,

the body makes an attempt to eliminate it through a process called biotransformation. The

purpose of these reactions is to make the carcinogen more water-soluble so that it can be

removed from the body. However, in some cases, these reactions can also convert a less toxic

carcinogen into a more toxic carcinogen. (Sataloff et al., n.d.)

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 CHAPTER ONE1

1.1 CLASSIFICATION OF CARCINOGENS

1.1.1 IARC CLASSIFICATION

The International Agency for Research on Cancer (IARC) is an intergovernmental agency

established in 1965, which forms part of the World Health Organization of the United Nations. It

is based in Lyon, France. Since 1971 it has published a series of Monographs on the Evaluation

of Carcinogenic Risks to Humans that have been highly influential in the classification of

possible carcinogens.(Sataloff et al., n.d.)

Group 1: the agent (mixture) is definitely carcinogenic to humans. The exposure circumstance

entails exposures that are carcinogenic to humans.

Group 2A: the agent (mixture) is probably (product more likely to be) carcinogenic to humans.

The exposure circumstance entails exposures that are probably carcinogenic to humans.

Group 2B: the agent (mixture) is possibly (chance of product being) carcinogenic to humans.

The exposure circumstance entails exposures that are possibly carcinogenic to humans.

Group 3: the agent (mixture or exposure circumstance) is not classifiable as to its carcinogenicity

to humans.

Group 4: the agent (mixture) is probably not carcinogenic to humans.

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1.1.2 GLOBALLY HARMONIZED SYSTEM

The Globally Harmonized System of Classification and Labelling of Chemicals (GHS) is a

United Nations initiative to attempt to harmonize the different systems of assessing chemical risk

which currently exist (as of March 2009) around the world. It classifies carcinogens into two

categories, of which the first may be divided again into subcategories if so desired by the

competent regulatory authority:

Category 1: known or presumed to have carcinogenic potential for humans

Category 1A: the assessment is based primarily on human evidence

Category 1B: the assessment is based primarily on animal evidence

Category 2: suspected human carcinogens

1.1.3 U.S. NATIONAL TOXICOLOGY PROGRAM

The National Toxicology Program of the U.S. Department of Health and Human Services is

mandated to produce a biennial Report on Carcinogens. As of June 2011, the latest edition was

the 12th report (2011). It classifies carcinogens into two groups:

 Known to be a human carcinogen

 Reasonably anticipated being a human carcinogen

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1.1.4 AMERICAN CONFERENCE OF GOVERNMENTAL INDUSTRIAL HYGIENISTS

The American Conference of Governmental Industrial Hygienists (ACGIH) is a private

organization best known for its publication of threshold limit values (TLVs) for occupational

exposure and monographs on workplace chemical hazards. It assesses carcinogenicity as part of

a wider assessment of the occupational hazards of chemicals.

Group A1: Confirmed human carcinogen

Group A2: Suspected human carcinogen

Group A3: Confirmed animal carcinogen with unknown relevance to humans

Group A4: Not classifiable as a human carcinogen

Group A5: Not suspected as a human carcinogen

1.1.5 EUROPEAN UNION

The European Union classification of carcinogens is contained in the Regulation (EC) No

1272/2008. It consists of three categories:

Category 1A: Carcinogenic

Category 1B: May cause cancer

Category 2: Suspected of causing cancer

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The former European Union classification of carcinogens was contained in the Dangerous

Substances Directive and the Dangerous Preparations Directive. It also consisted of three

categories:

Category 1: Substances known to be carcinogenic to humans.

Category 2: Substances which should be regarded as if they are carcinogenic to humans.

Category 3: Substances which cause concern for humans, owing to possible carcinogenic effects

but in respect of which the available information is not adequate for making a satisfactory

assessment.

This assessment scheme is being phased out in favor of the GHS scheme, to which it is very

close in category definitions.

1.1.6 SAFE WORK AUSTRALIA

Under a previous name, the NOHSC, in 1999 Safe Work Australia published the Approved

Criteria for Classifying Hazardous Substances [NOHSC:1008(1999)]. Section 4.76 of this

document outlines the criteria for classifying carcinogens as approved by the Australian

government. This classification consists of three categories:

Category 1: Substances known to be carcinogenic to humans.

Category 2: Substances that should be regarded as if they were carcinogenic to humans.

(Grimmer., 1983)

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Category 3: Substances that have possible carcinogenic effects in humans but about which there

is insufficient information to make an assessment. (Grimmer., 1983)

1.2 SOURCES OF CARCINOGENS

Sources of carcinogens include:

 Chemical (including those from biological sources) source

 Physical source

 Oncogenic (cancer-causing) viruses.

Most carcinogens, singly or in combination, produce cancer by interacting with DNA in cells and

thereby interfering with normal cellular function. This ultimately results in the formation of a

tumour (an abnormal tissue growth) that has the ability to spread (metastasize) from its site of

origin and invade and cause dysfunction of other tissues, culminating in organ failure and death.

The two primary mechanisms by which carcinogens initiate the formation of such tumours is via

alterations in DNA that encourage cell division and that prevent cells from being able to self-

destruct when stimulated by normal triggers, such as DNA damage or cellular injury (a process

known as apoptosis). There also exist carcinogens that induce cancer through nongenotoxic

mechanisms, such as immunosuppression and induction of tissue-specific inflammation.

Sources of carcinogens include:

 Chemical (including those from biological sources) source

 Physical source

 Oncogenic (cancer-causing) viruses.

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1.2.1 CHEMICAL SOURCE

More than 400 chemical agents have been listed as carcinogenic, probably carcinogenic, or

possibly carcinogenic by the International Agency for Research on Cancer (IARC), a branch of

the World Health Organization that monitors cancer occurrence worldwide and performs

epidemiological and laboratory investigations to understand the causes of cancer. Among the

carcinogenic substances listed by IARC are a variety of chemical effluents from industry and

environmental pollutants from automobiles, residences, and factories. One such example is

acrylamide, which is considered a probable carcinogen in humans and is produced as a result of

industrial processes and cooking certain foods at high temperatures. It can be released into the

environment through its application in wastewater treatment and its use in grout and soil-

stabilizer products. Other examples of chemical carcinogens include nitrosamines and polycyclic

aromatic hydrocarbons, which are found in tobacco smoke and are associated with the

development of lung cancer.

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Fig 1: Chemical carcinogenesis stages and the occurrences involved in each one

1.2.2 PHYSICAL SOURCE

Physical carcinogens include ultraviolet rays from sunlight and ionizing radiation from X-rays

and from radioactive materials in industry and in the general environment. Repeated local injury

(e.g., wounding) or recurring irritation (e.g., chronic inflammation) to a part of the body are other

examples of potential physical carcinogens.

Exposure to UV light from the sun overtime can cause skin cancer. This is a well-documented

type of physical carcinogen. The UV light actually changes the structure of amino acids. This

type of change can lead to cancer formation. Radiation is also considered a physical carcinogen

and acts in a similar manner to UV light with respect to altering the genome. Asbestos is another

very common physical carcinogen with a unique method to induce cancer. Asbestos fibers

actually interfere with chromosome alignment during cellular division ultimately causing uneven

numbers of chromosomes in the sister cells. Any material or particle that can induce cancer

formation when implanted in a mouse model is classified as a physical carcinogen.

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Fig 2: UV induced carcinogenesis in the skin

1.2.3 ONCOGENIC VIRUSES

A number of viruses are suspected to induce of causing cancer in animals, this includeing

humans, and are frequently referred to as oncogenic viruses. Examples of such are include

human papillomaviruses, the Epstein-Barr virus, and the hepatitis B virus, all of which have

genomes made up of DNA. Human T-cell leukemia virus type I (HTLV-I), which is a retrovirus

(a type of RNA virus), is linked to tumour formation in humans.

When viruses cause an infection, they spread their DNA, affecting healthy cells' genetic makeup

and potentially causing them to turn into cancer. HPV infections, for instance, cause the virus'

DNA to combine with the host's DNA, disrupting the normal function of cells.

Common virus linked to cancer include

 The Epstein-Barr virus (EBV), which is a type of herpes virus most commonly associated

with causing infectious mononucleosis, or “mono.” EBV infections increase the risk

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 of nasopharyngeal cancer, some types of fast-growing lymphomas and some stomach

cancers. Like HPV, EBV infections are common, but EBV-related cancer is not.

 Hepatitis B virus (HBV) and HCV, which cause viral hepatitis, a kind of liver infection.

HBV- and HCV-induced chronic liver infections are rare, but when they occur, they raise

the risk of liver cancer. Less than half of liver cancers in the United States are linked to

HBV or HCV infection.

 HIV, which causes acquired immune deficiency syndrome (AIDS). HIV increases the

risk for several types of cancer, including Kaposi sarcoma, cervical

Fig 3: Viral induced carcinogenesis in the skin

Consequently, Ssome cancers are heritable in the sense that a predisposition exists, awaiting a

convergence of carcinogenic influences for cancer to manifest itself. The identification and

timely elimination of carcinogens can reduce the incidence of cancer.

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1.3 CARCINOGENS AND BIOCHEMICAL DISORDERS

Research over the past fifty years or so has uncovered an increasing array of environmental

agents that may induce cancer under the proper circumstances. Hundreds of diverse chemical

compounds, some fairly simple and some complex, dozens of viruses with either DNA or RNA

as their nucleic acid, and various forms of radiation are each capable of initiating carcinogenesis.

On the basis of current concepts and from the point of view of the mechanisms of

carcinogenesis, all of these may be divided into one of two large groups:

(a) Agents that carry with them information in a form that is translatable by some living cell

(b) Agents that generate such information only after their interaction with the living cell.

The first group is obviously the oncogenic viruses, although theoretically other forms of biologic

organization with similar properties might exist. The viruses vary very much in the amount of

translatable information they may contribute to the cell (Farber and& Farber, 1968). The clearest

picture emerging to date in this area of research appears to the outsider to be with the DNA

viruses, especially polyoma but also SV40. In the case of polyoma, the virus contains only a

relatively small amount of translatable information. With both polyoma and SV40, the viral

DNA becomes incorporated into the cell structure and appears to persist, at least in part, until

neoplastic transformation has been induced. The information which the virus carries with it into

the cell also initiates the synthesis of several proteins, including one localized in the nucleus and

one related to transplantation. The transplantation antigen may reside in the plasma membrane.

(Grimmer., 1983)

1.3.1 INTERACTION WITH CELL CONSTITUENTS

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It is now evident that different types of carcinogens interact with several components of cells

including proteins, RNA, and DNA. Since the original discovery of the firm binding of DAB or

derivatives to liver protein by Miller and Miller in 1947, many oncogenic chemicals have been

found to interact with cell proteins of several different organs or tissues. Where studied in liver

and skin, this interaction has not been found to be random but rather quite specific in that certain

groups of proteins, especially the slow h2 fraction of soluble cytoplasmic proteins, show the

greatest degree of binding with some carcinogens (Farber and & Farber, 1968). However, it

should be pointed out that other protein fractions, including some nuclear proteins, also show

binding but to a lesser degree. The biologic significance of different degrees of binding remains

unknown and, as a consequence, no degree of interaction can be ruled out as insignificant.

Two recent developments in the field of protein-binding seem particularly pertinent and deserve

some special comment.

First, the chemical nature of the bound forms of azo dyes and acetylaminofiuorene has been

clarified to a considerable degree, thanks again to the efforts of the Millers and their coworkers.

The discovery of the interaction of DAB with the S atom of methionine in protein to form a

sulfonium compound in which the S atom is bound to CH3, CHaCHaCH(NH2)-COOH, and to

the azo dye via C2 in the primary benzene ring opens a whole new avenue of study. This finding

has been followed by further studies showing reaction in vitro at a physiologic pH between esters

of N-OH metabolites and some amino acids including methionine. This may be a type reaction

for several different kinds of carcinogens. The further study of these interactions and of the

effects of such alterations on the metabolism and function of proteins offers exciting new

possibilities for understanding the cellular metabolic consequences of the initial impact of

carcinogens upon living tissues. (Barrett & Shelby, 1992)

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The second development is that of Freed and Sorof concerning the possible biologic properties of

one of the h2 proteins of liver. They have found that purified preparations of such fractions have

a reproducible growth-inhibiting effect on cells in vitro. Further analysis of this interesting

finding has shown that the growth inhibitor is probably arginase which acts by destroying the

arginine in the medium. Obviously, the possible role of such a compound in the function of an

intact cell remains to be studied. However, one cannot help but wonder whether this discovery

might not be related to the tumor-inhibiting properties of asparaginase and to the suggested

alterations in arginase in the Shope rabbit papilloma system (Gatto, 2021). In addition to their

obvious interaction with cellular proteins, it is now clear that several carcinogens also interact

with various RNA's and with DNA. In some systems, the reaction with RNA is as strong as that

with protein. With at least one carcinogen, ethionine, the reaction with RNA is 10 to 20 times

that found with total protein. However, when cell proteins are fractionated, a saline-soluble

protein fraction of rat liver nucleus can be obtained which is labeled with L-ethionineethyl-l-14C

to a degree approaching that seen in the tRNA. The tRNA appears to be more heavily labeled

also with AAF and DMN than are some other types of cellular RNA. DNA is also a target for

interaction with several chemical carcinogens . Although the degree of binding of most

compounds to DNA is less than with total RNA, it is nevertheless quantitatively significant. The

one possible exception is ethionine, which effectively labels various RNA's and protein fractions

but which has only an extremely small affinity for DNA. In fact, the level of ethionine

interaction with DNA is so low as to make it difficult to decide with current techniques whether

it occurs at all. (Farber & Farber, 1968)

The existence of the three major targets for chemical carcinogens does not rule out the possible

occurrence of other macromolecular target molecules. In fact, the identification of highly

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reactive chemical derivatives of some of the carcinogens makes it most likely that other types of

cellular constituents such as polysaccharide or lipids may also be altered by Biochemistry of

Carcinogenesis interaction with one or another of the diverse oncogenic chemicals. An intriguing

possibility is the polysaccharide components of the plasma membrane, especially since it is

becoming evident that altered cell membrane function is probably an important property of

neoplastic cells. The increasing evidence for high chemical reactivity of some of the derivatives

of several carcinogens raises a possible doubt concerning the biologic significance of positive or

negative correlations between degrees of binding to or reaction with various cellular constituents

and carcinogenic potency of a particular carcinogen. In the case of those compounds from which

are generated highly reactive products, the degree of interaction with any particular cell

component may be merely a passive reflection of the extent of production of such derivatives

and need not be intimately related to the steps involved in the neo plastic transformation. It may

well be that the selection of some carcinogen-cell-constituent interaction for relevance to cancer

induction may have to depend upon the findings with less potent agents or less potent derivatives

of the most active agents. Such compounds may be more selective in the type and degree of their

interaction with cell components and thus may be useful in deciding which interactions are more

relevant to the induction of neoplasia. (Grimmer., 1983).

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 CHAPTER TWO2

2.1 MECHANISM OF ACTION OF CARCINOGEN

As previously stated, neoplastic development requires the formation of an initiated, mutated cell

and the selective proliferation of the mutated cell to form a neoplasm. Both of these events can

be elicited by carcinogenic agents that are DNA reactive as well as those that are non-DNA

reactive.

2.1.1 DNA-Reactive (Genotoxic) Carcinogens

DNA-reactive agents (previously termed genotoxic carcinogens) initiate cancer by interacting

with and producing DNA damage. DNA-reactive carcinogens can be further subdivided to those

that are active in their parent form (i.e., direct-acting carcinogens – agents that can directly bind

to DNA without being metabolized) and those that require metabolic activation (i.e., indirect-

acting carcinogens – compounds that require metabolism in order to react with DNA).

2.1.1.1 Direct-acting (activation-independent) carcinogens

Several carcinogens exist that do not require metabolic activation or modification to induce

cancer, this and are termed direct-acting or activation-independent carcinogens. These chemicals

function as ultimate carcinogens. Usually existing as highly reactive electrophilic molecules,

direct-acting carcinogens directly interact with and bind to cellular macromolecules, including

DNA. Due to this high reactivity, direct-acting carcinogens frequently result in tumor formation

at the site of chemical exposure. Direct-acting carcinogens include b-propriolactone, epoxides,

imines, alkyl and sulfate esters, halogen derivatives such as mustard gasses, halo ethers

(bis(chloromethyl)ether), nitrosamides, and nitrosoureas (N-methylnitrosourea and N-methyl-N-

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nitro-N-nitrosoguanidine). Direct-acting electrophilic chemicals typically test positive in the

Ames mutagenesis bioassay without additional metabolic activation. The relative potency of

direct-acting carcinogens for inducing cancer depends in part on the relative rates of interaction

between the chemical and DNA, and competing reactions with the chemical and other cellular

nucleophiles. Thus, the relative activity of direct-acting carcinogens will be dependent upon such

competing reactions and also on enzymatic detoxification reactions. Direct-acting carcinogens

are typically carcinogenic at multiple sites and in all species examined (Fox and Scott, 1980; and

Sontag J, 1981).

2.1.1.2 Indirect-acting (activation-dependent) carcinogens

Based on the work of Drs. James and Elizabeth Miller, it has long been established that many

carcinogens are not intrinsically DNA reactive, but require metabolic activation in order to

interact with genomic DNA. The majority of DNA-reactive carcinogens are in a procarcinogenic

form. Procarcinogens are chemically stable and require bioactivation to be capable of interacting

with DNA. Moreover, the While biotransformation can lead to detoxification of a chemical,

bioactivation through P450 can also occur resulting in a DNA reactive and binding form of the

carcinogen. Indirect-acting (activation-dependent) carcinogens, unlike direct-acting, DNA-

reactive carcinogens, usually do not produce cancer at the site of application but are carcinogenic

in tissues that are metabolically able to activate the procarcinogen form to the ultimate DNA-

reactive form. Examples of indirect-acting DNA-reactive chemicals include polycyclic aromatic

hydrocarbons (PAHs) and aflatoxins (Conney, 1982; and Miller and Miller, 1981).

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2.1.2 Cytotoxicity mode of action

Cytotoxicity and the resulting regenerative hyperplasia is a well-documented MOA for many

non-DNA-reactive chemical carcinogens. Chloroform-induced liver and kidney tumors and

melamine-induced bladder tumors are classic examples of chemical carcinogens classified as

functioning via a cytotoxic or cytolethal MOA. Chemicals that function through this mechanism

produce sustained cell death, often related to the metabolism of the chemical, and is

accompanied by persistent regenerative growth to replace damaged cells and tissues. The

enhanced proliferative capacity results in the potential for the acquisition of additional

‘spontaneous’ DNA mutations, and allows mutated cells to accumulate and proliferate. This

process then gives rise to preneoplastic focal lesions which upon further expansion can lead to

tumor formation (Dietrich and Swenberg, 1991; and Larson et al., 1994).

Renal neoplasia induced by d-limonene, 1,4-dichlorobenzene, trimethylpentane, or isophorone

induces renal tumors selectively in the male rat, and illustrates the species, sex, and tissue

specificity often exhibited by non-DNA-reactive carcinogens. In the a2u-globulin mechanism of

action, the species and sex specificity areis related to the ability of these compounds to bind to

a2uglobulin, a protein synthesized only in the male rat at the onset of puberty. a2u-Globulin is

filtered through the glomerulus, and only partially excreted in urine. The reabsorbed fraction

accumulates in the lysosomes of the proximal tubules, where it leads to dysfunction of this

organelle and subsequent release of digestive enzymes and cell necrosis. The loss of cells within

the tubule leads to increased cell proliferation in the proximal tubules, and is responsible for

tumor development selectively observed in the male rat kidney (Dietrich and Swenberg, 1991;

and Melnick et al., 1996).

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2.1.3 Receptor-mediated mode of action

A diverse group of chemicals function to elicit increases in the number and volume of

peroxisomes within cells. Included in this grouping are chemical agents such as herbicides,

chlorinated solvents (e.g., trichloroethylene and perchloroethylene), plasticizers (e.g.,

diethylhexylphthalate and certain other phthalates), lipid-lowering fibrate drugs (e.g.,

ciprofibrate, clofibrate), and natural products. In addition, many of these agents produce liver

enlargement and hepatocellular carcinoma in rats and mice through non-DNA-reactive

mechanisms (Lake, 1995). Two additional tumor types are also associated with exposure to

peroxisome proliferating compounds: Leydig cell tumors in rats and pancreatic acinar-cell

tumors in the rat. The tumor response is species specific, with the rat and the mouse being the

responsive species, whereas primates and the guinea pig proved to be nonresponsive (Bentley et

al., 1993; and Lake, 1995).

The currently accepted MOA for this class of chemicals involves binding or activation of the

nuclear hormone receptor, the peroxisome proliferator-activated receptor alpha (PPARa). Studies

utilizing PPARa null mice have provided evidence supporting a role for PPARa binding as a

required step for the induction of peroxisome proliferation and tumorigenesis in rodents (Corton

et al., 2014 and Klaunig et al., 2003). PPARa plays a central role in lipid metabolism and acts as

a transcription factor to modulate gene expression following ligand activation. This latter effect

arises through the heterodimerization of PPARa and retinoid X receptor a (RXRa), which results

in binding to peroxisome-proliferating response elements (PPREs) and subsequent modulation of

target gene transcription.

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Following this event is theThereafter, the induction of cell proliferation and suppression of

apoptosis takes place (James and Roberts, 1996). Since humans are exposed to a number of these

chemicals, the relevance of this MOA to humans has been evaluated (Corton et al., 2014 and

Klaunig et al., 2003).

2.2 CARBOHYDRATE AND CARCINOGENS

Carbohydrate intake is one aspect of diet that has been hypothesized to modulate cancer risk

depending on the amount and type consumed. Carbohydrates are a broad category of

biomolecules, which, in their monosaccharide forms, function as preferred cellular energy

substrates. Aside from their crude function, carbohydrates exert a comprehensive set of effects at

the cellular, physiological, and ecological levels. Remarkable among these are microbial and

epigenetic modulations as well as endocrine and systemic alterations resulting from their

consumption that may potentially influence cancer risk and progression. Despite in vitro and

animal research providing evidence of mechanisms through which carbohydrates may impact

cancer risk, the epidemiologic evidence linking dietary carbohydrates to cancer development and

progression has remained unclear

2.2.1 Colorectal cancer

An ecological analysis undertaken by Grasburger and his colleagues on observational data

collected across 39 European countries reported weak and moderate positive associations

between refined sugar consumption and CRC incidence in men and women, respectively.

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Giovannucci hypothesized that the synergistic combination of insulin resistance and

consumption of high GL foods waswere responsible for cuing hyperinsulinemia, which can

amplify growth factors and mitogenic response. Giovannucci’s hypothesis also relied on a

number of other concomitant criteria, mainly that of increased fasting plasma glucose, central

obesity, and a paucity of fiber-rich foods being consumed. Epidemiologic studies have,

nonetheless, focused on discerning the relationship between simple sugars and colorectal cancer.

2.2.2 Prostate Cancer (PCa)

Studies examining the relationship between high consumption of simple carbohydrate and the

risk of PCa have been inconsistent. While some studies suggested a positive association between

simple carbohydrate consumption and risk of PCa, others reported null associations. The two

longitudinal studies cited by Makaremetal. In their systematic review come from Giovannucci et

al. and Drake et al. who reported on the Health Professionals Follow-Up and Malmö Diet and

Cancer cohorts, respectively. Notably, Giovannucci et al. found a significantly reduced risk of

advanced PCa associated with higher fructose consumption. In contrast, Drakeetal reported that

the lowest consumption of monosaccharides corresponded with a 31% decreased risk of

symptomatic prostate cancer (i.e., exhibiting lower urinary tract or other malignancy-related

symptoms

2.3 LIPID AND CARCINOGENESIS

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Lipids, together with proteins and nucleic acids, are essential components of biological

membranes and building blocks that constitute cells. In addition, lipids are used in energy storage

and metabolism and have important roles as signaling molecules for many cellular activities. The

regulation of lipid metabolism, such as lipid uptake, synthesis, and hydrolysis, is essential for the

maintenance of cellular homeostasis (R¨ohrigandSchulze, 2016). Cancer cells in tumor

microenvironments, where nutrient availability is consistently changing during tumor

progression, harness lipid metabolism to support their rapid proliferation, survival, migration,

invasion, and metastasis. Glycolipids and phospholipids (which are subcategorized into

phosphoglycerides and sphingolipids), together with cholesterol, represent major components of

biological membranes. Cholesterol is also a substrate for the synthesis of fat-soluble vitamins

and steroid hormones (Luo et al., 2020). As major components of glycolipids and phospholipids,

fatty acids (FAs) can be esterified with a glycerol moiety to form triglycerides, which are

nonpolar lipids synthesized and stored in lipid droplets during high nutrient availability and

hydrolyzed to generate ATP by FA oxidation (FAO, also called β-oxidation) under energy stress

conditions. Aside from energy metabolism and membrane formation, lipids form second

messengers derived from phospholipase-dependent hydrolyzation of membrane lipids and

synthesis from essential FAs, whose availability is largely determined by lipids in the diet (Park

et al., 2012).

Phospholipases (PLC, PLD, and PLA) can generate many bioactive second messengers, such as

diacylglycerol, phosphatidic acid, lysophosphatidic acid, and arachidonic acid. These molecules

trigger the activation of the RAS, phosphoinositide 3 kinases (PI3Ks), protein kinase C, RAC,

RHO, and several other signaling axes that can promote tumorigenesis (Moolenaar and Perrakis,

2011; Park et al., 2012). In addition, sterols, including oxysterol and cholesterol, are critical

22
regulators of sterol regulatory element (SRE)–binding protein (SREBP) activation for

downstream gene expression, and thus their levels affect lipogenesis in cancer. Cholesterol is a

component of lipid rafts for signaling and can also covalently modify Hedgehog and

Smoothened proteins for Hedgehog signaling activation (Porter et al., 1996; Xiao et al., 2017).

2.3.1 Lipid uptake

Fatty Acids uptake: Mammals produce only certain fatty acids (FAs), i.e., those carrying

double bonds to the Δ9 position of the hydrocarbon chain. Other FAs, particularly

polyunsaturated FAs, are essential and obtained from the diet (Nakamura and Nara, 2004). The

known FA protein transporters in the plasma membrane include cluster of differentiation 36

(CD36; also known as FA translocase), the family of FA transport proteins (also collectively

known as SLC27), and plasma membrane FA-binding proteins (FABPs), all of which display

increased gene and protein expression in tumors (Su and Abumrad, 2009). High CD36

expression has been correlated with poor prognosis for patients with breast, ovarian, gastric, and

prostate cancer (Koundouros and Poulogiannis, 2020). Deletion of Cd36 in the prostate of

cancer-susceptible Pten−/− mice or mammary tissues of MMTV-neu mice attenuated increased

FA uptake in cancer and mitigated tumorigenesis (Feng et al., 2019; Watt et al., 2019).

In breast cancer patients, CD36 expression increases following anti-HER2 therapy and correlates

with poor survival. High fat diets induced NF-κB–dependent CD36 expression and elicited O-

GlcN Acylation of CD36 at S468 and T470, which enhanced FA uptake and murine gastric

cancer metastasis (Jiang et al., 2019). Hydrogen sulfide, which is implicated in cancer metastasis,

induces CD36 expression and reduces C333C272 disulfide bond formation in CD36, which

activates the long-chain FA-binding conformation of CD36 to promote FA uptake and accelerate

gastric cancer metastasis (Wang et al., 2019). Palmitic acid induces gastric cancer cell migration

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and invasion through CD36-dependent activation of the protein kinase B (PKB, also known as

AKT)/β-catenin signaling pathway, whereas dietary oleic acid up-regulates CD36 expression and

its expression-dependent activation of the Src-ERK1/2 pathway, which promotes cervical cancer

cell growth (Pan et al., 2019; Yang et al., 2018). Palmitic acid or a high-fat diet can specifically

boost the metastatic potential of metastasis initiating oral cancer cells with high CD36

expression. Blockade of CD36 with neutralizing antibodies inhibits the metastasis of oral cancer

cells in mice (Pascualetal.,2017), implyingarole for dietary lipids and CD36 in tumor metastasis.

The ability of cancer cells to use exogenous lipids for the provision of unsaturated FAs appears

to be dependent on oxygen levels and the type of oncogene expressed, and not all lipids are

exploited equally (Snaebjornsson et al., 2020).

Cholesterol uptake: Dietary cholesterol is absorbed by Niemann–Pick type C1–like 1

(NPC1L1) protein in the membrane of intestinal enterocytes (Altmann et al., 2004), where

cholesterol is esterified by acylCoA: cholesterol acyltransferases (ACATs; also known as sterol

O-acyltransferase) for uptake by the liver (Ko et al., 2020). The liver, the main cholesterol

biosynthesis organ, delivers cholesterol as very-low-density lipoproteins to the blood stream,

where the very-low-density lipoproteins are processed into low density lipoproteins (LDLs) for

uptake by the LDL receptors (LDLRs) on peripheral cells. The cellularly absorbed cholesterol

eventually reaches the ER for sensing, transport, or esterification (Goldstein and Brown, 2009).

LDLR expression was positively correlated with poor prognosis of the patients with small cell

lung cancer (SCLC), breast cancers, and PDAC. LDLR depletion in HER2-overexpressing breast

cancer cells and PDAC cells reduced cholesterol uptake and tumor growth in mice with

hyperlipidemia (Gallagher et al., 2017; Guillaumond et al., 2015; Zhou et al., 2017). In addition,

LDLR expression is transcriptionally up-regulated by epidermal growth factor receptor (EGFR)

24
vIII mutant/PI3K-activated SREBP1 in glioblastoma (Guo et al., 2011). Loss of PTEN and

subsequentPI3K/AKT activation in prostate cancer cells largely enhanced exogenous LDL

uptake required for tumor growth (Yue et al., 2014). These findings underscore that the LDLR

mediated cholesterol uptake plays instrumental roles in the proliferation of some types of cancer

cells.

25
 CHAPTER THREE3

3.1 TREATMENT OF CANCER

The treatment of cancer has undergone evolutionary changes as understanding of the underlying

biological processes has increased. Tumor removal surgeries have been documented in ancient

Egypt, hormone therapy and radiation therapy were developed in the late 19th century.

Chemotherapy, immunotherapy and newer targeted therapies are products of the 20th century.

As new information about the biology of cancer emerges, treatments will be developed and

modified to increase effectiveness, precision, survivability, and quality of life.

3.1.1 SURGERY (Palliative treatment)

In theory, non-hematological cancers can be cured if entirely removed by surgery, but this is not

always possible. When the cancer has metastasized to other sites in the body prior to surgery,

complete surgical excision is usually impossible. In the Halstedian model of cancer progression,

tumors grow locally, then spread to the lymph nodes, then to the rest of the body. This has given

rise to the popularity of local-only treatments such as surgery for small cancers. Even small

localized tumors are increasingly recognized as possessing metastatic potential.

Examples of surgical procedures for cancer include mastectomy for breast cancer, prostatectomy

for prostate cancer, and lung cancer surgery for non-small cell lung cancer. The goal of the

surgery can be either the removal of only the tumor, or the entire organ. A single cancer cell is

invisible to the naked eye but can regrow into a new tumor, a process called recurrence. For this

26
reason, the pathologist will examine the surgical specimen to determine if a margin of healthy

tissue is present, thus decreasing the chance that microscopic cancer cells are left in the patient.

In addition to removal of the primary tumor, surgery is often necessary for staging, e.g.

determining the extent of the disease and whether it has metastasized to regional lymph nodes.

Staging is a major determinant of prognosis and of the need for adjuvant therapy. Occasionally,

surgery is necessary to control symptoms, such as spinal cord compression or bowel obstruction.

This is referred to as palliative treatment.

3.1.2 RADIATION THERAPY

Radiation therapy (also called radiotherapy, X-ray therapy, or irradiation) is the use of ionizing

radiation to kill cancer cells and shrink tumors. Radiation therapy can be administered externally

via external beam radiotherapy (EBRT) or internally via brachy therapy. The effects of radiation

therapy are localised and confined to the region being treated. Radiation therapy injures or

destroys cells in the area being treated (the "target tissue") by damaging their genetic material,

making it impossible for these cells to continue to grow and divide. Although radiation damages

both cancer cells and normal cells, most normal cells can recover from the effects of radiation

and function properly. The goal of radiation therapy is to damage as many cancer cells as

possible, while limiting harm to nearby healthy tissue. Hence, it is given in many fractions,

allowing healthy tissue to recover between fractions.

Radiation therapy may be used to treat almost every type of solid tumor, including cancers of the

brain, breast, cervix, larynx, liver, lung, pancreas, prostate, skin, stomach, uterus, or soft tissue

sarcomas. Radiation is also used to treat leukemia and lymphoma. Radiation dose to each site

27
depends on a number of factors, including the radio sensitivity of each cancer type and whether

there are tissues and organs nearby that may be damaged by radiation. Thus, as with every form

of treatment, radiation therapy is not without its side effects.

Radiation therapy kills cancer cells by damaging their DNA (the molecules inside cells that carry

genetic information and pass it from one generation to the next)

(1).Radiation therapy can either damage DNA directly or create charged particles (free radicals)

within the cells that can in turn damage the DNA.

(2) Radiation therapy can lead to dry mouth from exposure of salivary glands to radiation. The

salivary glands lubricate the mouth with moisture or spit. Post therapy, the salivary glands will

resume functioning but rarely in the same fashion. Dry mouth caused by radiation can be a

lifelong problem.

Radiation might not be a choice of treatment if the tumour was diagnosed on the late stage or is

located on vulnerable places. Moreover, radiation causes significant side effects if used in

children aged 0–14.

3.1.3 CHEMOTHERAPY

Chemotherapy is the treatment of cancer with drugs ("anticancer drugs") that can destroy cancer

cells. In current usage, the term "chemotherapy" usually refers to cytotoxic drugs which affect

rapidly dividing cells in general, in contrast with targeted therapy. Chemotherapy drugs interfere

with cell division in various possible ways, e.g. with the duplication of DNA or the separation of

newly formed chromosomes. Most forms of chemotherapy target all rapidly dividing cells and

are not specific to cancer cells, although some degree of specificity may come from the inability

28
of many cancer cells to repair DNA damage, while normal cells generally can. Hence,

chemotherapy has the potential to harm healthy tissue, especially those tissues that have a high

replacement rate (e.g. intestinal lining). These cells usually repair themselves after

chemotherapy.

Because some drugs work better together than alone, two or more drugs are often given at the

same time. This is called "combination chemotherapy"; most chemotherapy regimens are given

in a combination.

The treatment of some leukaemias and lymphomas requires the use of high-dose chemotherapy,

and total body irradiation (TBI). This treatment ablates the bone marrow, and hence the body's

ability to recover and repopulate the blood. For this reason, bone marrow, or peripheral blood

stem cell harvesting is carried out before the ablative part of the therapy, to enable "rescue" after

the treatment has been given. This is known as autologous stem cell transplantation.

3.1.4 TARGETED THERAPIES

Targeted therapy, which first became available in the late 1990s, has had a significant impact in

the treatment of some types of cancer, and is currently a very active research area. This

constitutes the use of agents specific for the deregulated proteins of cancer cells. Small

molecule targeted therapy drugs are generally inhibitors of enzymatic domains on mutated, over

expressed, or otherwise critical proteins within the cancer cell. Prominent examples are the

tyrosine kinase inhibitors.

Monoclonal antibody therapy is another strategy in which the therapeutic agent is

an antibody which specifically binds to a protein on the surface of the cancer cells. Examples

29
include the anti-HER2/neu antibody trastuzumab (Herceptin) used in breast cancer, and the anti-

CD20 antibody rituximab, used in a variety of B-cell malignancies.

Targeted therapy can also involve small peptides as "homing devices" which can bind to cell

surface receptors or affected extracellular matrix surrounding the tumor. Radionuclides which

are attached to these peptides (e.g. RGDs) eventually kill the cancer cell if the nuclide decays in

the vicinity of the cell. Especially oligo- or multimers of these binding motifs are of great

interest, since this can lead to enhanced tumor specificity and avidity.

Targeted therapies under pre-clinical development as potential cancer treatments

include morpholino splice switching oligonucleotides, which induce ERG exon skipping

in prostate cancer models, multitargeted kinase inhibitors that inhibit the PI3K with other

pathways including MEK and PIM, and inhibitors of NFKB in models of chemotherapy

resistance.

3.1.5 IMMUNOTHERAPY

Cancer immunotherapy refers to a diverse set of therapeutic strategies designed to induce the

patient's own immune system to fight the tumor. Contemporary methods for generating an

immune response against tumours include intravesical BCG immunotherapy for superficial

bladder cancer, and use of interferons and other cytokines to induce an immune response in renal

cell carcinoma and melanoma patients. Cancer vaccines to generate specific immune responses

are the subject of intensive research for a number of tumours, notably malignant

melanoma and renal cell carcinoma. Sipuleucel-T is a vaccine-like strategy in late clinical trials

for prostate cancer in which dendritic cells from the patient are loaded with prostatic acid

phosphatase peptides to induce a specific immune response against prostate-derived cells.

30
Allogeneic hematopoietic stem cell transplantation ("bone marrow transplantation" from a

genetically non-identical donor) can be considered a form of immunotherapy, since the donor's

immune cells will often attack the tumor in a phenomenon known as graft-versus-tumor effect.

For this reason, allogeneic HSCT leads to a higher cure rate than autologous transplantation for

several cancer types, although the side effects are also more severe.

The cell based immunotherapy in which the patients own Natural Killer cells(NK) and Cytotoxic

T-Lymphocytes(CTL) are used has been in practice in Japan since 1990. NK cells and CTLs

primarily kill the cancer cells when they are developed. This treatment is given together with the

other modes of treatment such as surgery, radiotherapy or chemotherapy and called as

Autologous Immune Enhancement Therapy (AIET).

Immune Checkpoint therapy focuses on two "checkpoint" proteins, cytotoxic T-lymphocyte–

associated antigen 4 (CTLA-4) and programmed death 1 (PD-1). Under normal conditions, the

immune system utilizes checkpoint proteins as negative feedback mechanisms to return to

homeostasis once pathogens have been cleared from the body. In tumor microenvironment,

cancer cells can commandeer this physiological regulatory system to "put a brake" on the anti-

cancer immune response and evade immune surveillance

3.1.6 HORMONAL THERAPY

The growth of some cancers can be inhibited by providing or blocking certain hormones.

Common examples of hormone-sensitive tumors include certain types of breast and prostate

cancers. Blocking estrogen or testosterone is often an important additional treatment. In certain

cancers, administration of hormone agonists, such as progestogens may be therapeutically

beneficial.

31
3.1.72 IMPORTANCE OF OXIDATIVE STRESS IN CANCER TREATMENT

Damage caused by oxidative stress is involved in many types of diseases, including neurological

diseases (Alzheimer’s and Parkinson’s), diabetes, atherosclerosis, arthritis, inflammation, and,

most importantly, broader types of cancer including breast cancer (Gonenc et al., 2005; Aldini et

al., 2010; Kruk and Duchnik, 2014). Oxidative stress is an imbalance in the ratio between

oxidants (free radicals) and antioxidants, a condition in which the body’s redox and oxidation

reactions - resuscitation problems arise. Disorders are caused by the increasing of the imbalance

between production and removal of free radicals and reactive species in the body (Chandra et al.,

2000; Tandon et al., 2005; Dayem et al., 2010; Omar et al.,2011).

Many cellular processes, including cell metabolism, signaling pathways, pathways regulating

gene expression, cell proliferation, and apoptosis (programmed cell death), are affected by

oxidative stress (Chandra et al., 2000; Poli et al., 2004; Kim et al., 2013). Increasing the free

radicals changes the structure and functions of the main bimolecular body, including changes in

proteins, lipids, and nucleic acids, and can lead to tissue damage. Products derived from this

injury are used as biomarkers of oxidative stress in the assessment and diagnosis of all cancers.

(Gonenc et al., 2005; Dayem et al., 2010; Sosa et al., 2013).

Previous studies have demonstrated that oxidative stress is associated with carcinogenesis and

the incidence of cancer. During the carcinogenesis process, the level of reactive oxygen species

in cancer cells increases and levels of antioxidants dwindle. ROS in these cells can increase

under the influence of intrinsic or factors, resulting in induction gene mutations and changes in

transcriptional processes as well as changes in signaling pathways and, ultimately, the

occurrence of cancer (Gao et al., 2003; Hwang et al., 2007). Contributory factors in the increased

32
production of ROS in cancer cells can be referred to as cancer-associated fibroblasts (CAFs),

cancer-associated macrophages (CAMs), and hypoxia. CAMs produce ROS via NADPH oxidase

in tumor cells. ROS derived from CAMs in tumor cells causes increased expression of the

hypoxia-inducing factor (HIF-1α) and signaling proteins such as vascular endothelial growth

factor (VEGF), which eventually leads to angiogenesis and tumor progression. CAFs within

CAMs also contribute to increases of ROS in tumor cells, and thus, with the release of matrix

metalloproteinases (MMPs), cytokines induce tumor metastasis and migration, which stimulates

the growth of cancer cells.

In addition, hypoxia through the impairment of complex III (cytochrome b oxidoreductase) of

the mitochondrial respiratory chain and the activity of NADPH oxidase of macrophages play

important roles in aggregate ROS and the intrinsic oxidative stress in tumors. Thus, the hypoxia

participates in the induction of tumor angiogenesis and promotes cancer (Barrera, 2012; Fiaschi

and Chiarugi, 2012; Sosa et al., 2013).

Studies have shown that oxidative stress affects several signaling pathways associated with cell

proliferation (Soliman et al., 2014). Among them the epidermal growth factor receptor signaling

pathway (EGFR) can be mentioned, in which proteins such as the nuclear factor erythroid 2-

related factor2 (Nrf2) and Raf are involved. Furthermore, the mitogen activated protein kinases

(MAPKs), phosphatidyl inositol 3-kinase (PI3K), phospholipase C, and protein kinase C, are

affected by oxidative stress. ROS also alters the expression of the p53 suppressor gene that is key

in apoptosis. Thus, oxidative stress caused by changes in gene expression, cell proliferation,

apoptosis, and angiogenesis plays a significant role in tumor initiation and progression

(Matsuzawa and Ichijo, 2008; Nguyen et al., 2009; Wiemer, 2011; Barrera, 2012).

33
Oxidative Stress and the Treatment and Prevention of Cancer

3.1.7.1. Anticancer drug therapy and oxidative stress: In general, treatment with anticancer

drugs and radiation creates a state of oxidative stress in the body, and active oxygen triggers

apoptosis via p53 and cytochrome release from mitochondria. Anticancer drugs whose main

mechanisms of action involve active oxygen include the anthracyclines (represented by

adriamycin), bleomycin, mitomycin C, and cisplatin. Redox control is also involved in various

issues related to anticancer drug therapy. It is possible that excessive antioxidation mechanisms

take part in a tumor’s acquisition of drug resistance. Thioredoxin and glutathione also play roles

in the resistance to anticancer drugs. An attempt to improve the efficacy of anticancer drugs by

decreasing thioredoxin expression in cisplatin resistant cancer cells has been reported. Secondary

cancer associated with the use of anticancer drugs or radiotherapy is another area of

investigation. A temporary decrease in antioxidants (vitamins C and E, uric acid, etc.) in the

plasma of patients with osteosarcoma or testicular tumor after cisplatin-based chemotherapy has

been reported. Although the main cause is considered to be the consumption of antioxidants to

eliminate the oxidative state, persistent imbalance in the redox state in the body due to anticancer

treatment may also be a cause in cases of secondary cancer associated with anticancer drugs or

radiotherapy. With regard to the side effects of anticancer drugs, if it is possible to ensure that

tumor cells receive more damage than do normal cells, this may be useful for reducing both the

therapeutic dose of anticancer drugs and their side effects.

3.1.8 Preventive and therapeutic efficacy of aAntioxidants: Given the relation between

oxidative stress and cancer, it has been assumed that ingestion of antioxidants such as vitamins E

and C and - carotene is useful in preventing carcinogenesis, and various related investigations

have been implemented. Inhibition of inflammation using antioxidants has also been studied in

34
relation to the risk of carcinogenesis. This approach is expected to become useful for the

prevention of cancer in the long run. However, it is possible that antioxidants may play a role as

prooxidants, as has been suggested for vitamin C. Which antioxidants and the amount to ingest

to obtain a preventive effect remain under investigation. The benefit of antioxidant ingestion

after cancer has also yet to be demonstrated.

35
 CONCLUSION

Carcinogens increase the risk of cancer by changes in cellular metabolism or

damaging DNA directly in cells and it also interfere with biological processes and induce the

uncontrolled malignant division leading to the formation of tumors. Usually,

severe DNA damage leads to programmed cell death, but if the programmed cell death pathway

is damaged, then the cell cannot prevent itself from becoming a cancer cell. Moreover,

Ooxidative stress causes injury to cells, induces gene mutation, and is involved in carcinogenesis

by influencing intracellular signal transduction and transcription factors directly or indirectly via

antioxidants. However, several therapeutic methods for the treatment of cancer was also

identified. Easy, accurate methods of measuring oxidative stress in the human body are

indispensable for investigating the relationship between it and disease and for applying the

results of such research to clinical practice. Methods of measurements also still require

improvement in terms of technology and interpretation of the results. The state of oxidative

stress in carcinogenesis and tumor bearing conditions is an intricate one in which various

substances are involved in complex interactions. Further investigations are expected before

application can be made to the prevention and treatment of cancer in the clinical setting

There are many natural carcinogens. Aflatoxin B1, produced by the fungus Aspergillusflavus is

an example of naturally occurring microbial carcinogen. Some viruses such as hepatitis B and

human papilloma virus, found to cause cancer in humans. Other infectious organisms which

cause cancer in humans include some bacteria (e.g. Helicobacterpylori) and helminths (e.g.

Opisthorchisviverrini and Clonorchissinensis).

36
Dioxins and dioxin-like compounds, benzene, kepone, EDB, and asbestos are considered as

carcinogenic. Industrial smoke and tobacco smoke were sources of carcinogens. Benzopyrene,

tobacco-specific nitrosamines such as nitrosonornicotine, and reactive aldehydes such as

formaldehyde is also a hazardous. Vinyl chloride, from which PVC is manufactured, is a

carcinogen and thus a hazard in PVC production.

37
 REFERENCE

1) Ames, Bruce N; Gold, Lois Swirsky (2000). "Paracelsus to parascience: The

environmental cancer distraction". Mutation Research/Fundamental and Molecular Mechanisms

of Mutagenesis. 447 (1): 3–13. doi:10.1016/S0027-5107(99)00194-3. PMID 10686303.

2) Hatakeyama M., Higashi H. (December 2005). "Helicobacter pylori CagA: a new

paradigm for bacterial carcinogenesis". Cancer Science. 96 (12): 835–43. doi:10.1111/j.1349-

7006.2005.00130.x. PMID 16367902.

3) González C. A., Sala N., Rokkas T. (September 2013). "Gastric cancer: epidemiologic

aspects". Helicobacter. 18 (Supplement 1): 34–8. doi:10.1111/hel.12082. PMID 24011243.

4) Sripa B., Kaewkes S., Sithithaworn P., Mairiang E., Laha T., Smout M., Pairojkul C.,

Bhudhisawasdi V., Tesana S., Thinkamrop B., Bethony J. M., Loukas A., Brindley P. J. (July

2007). "Liver fluke induces cholangiocarcinoma". PLoS Medicine. 4 (7): 1148–1155.

doi:10.1371/journal.pmed.0040201. PMC 1913093. PMID 17622191.

5) Rustagi T, Dasanu CA (June 2012). "Risk factors for gallbladder cancer and

cholangiocarcinoma: similarities, differences and updates". Journal of Gastrointestinal Cancer.

43 (2): 137–47. doi:10.1007/s12029-011-9284-y. PMID 21597894.

6) Report on Carcinogens, Eleventh Edition Archived April 20, 2009, at the Wayback

Machine; U.S. Department of Health and Human Services, Public Health Service, National

Toxicology Program (2011).

38
7) Vert, Michel; Doi, Yoshiharu; Hellwich, Karl-Heinz; Hess, Michael; Hodge, Philip;

Kubisa, Przemyslaw; Rinaudo, Marguerite; Schué, François (2012). "Terminology for biorelated

polymers and applications (IUPAC Recommendations 2012)" (PDF). Pure and Applied

Chemistry. 84 (2): 377–410. doi:10.1351/PAC-REC-10-12-04.

8) Acharya, PVN; The Effect of Ionizing Radiation on the Formation of Age-Correlated

Oligo Deoxyribo Nucleo Phosphoryl Peptides in Mammalian Cells; 10th International Congress

of Gerontology, Jerusalem. Abstract No. 1; January 1975. Work was done while employed by

Dept. of Pathology, University of Wisconsin, Madison.

9) Acharya, PVN; Implications of The Action of Low-Level Ionizing Radiation on the

Inducement of Irreparable DNA Damage Leading to Mammalian Aging and Chemical

Carcinogenesis.; 10th International Congress of Biochemistry, Hamburg, Germany. Abstract No.

01-1-079; July 1976. Work was done while employed by Dept. of Pathology, University of

Wisconsin, Madison.

10) Acharya, PV Narasimh; Irreparable DNA-Damage by Industrial Pollutants in Pre-mature

Aging, Chemical Carcinogenesis, and Cardiac Hypertrophy: Experiments and Theory; 1st

International Meeting of Heads of Clinical Biochemistry Laboratories, Jerusalem, Israel. April

1977. Work conducted at Industrial Safety Institute and Behavioral Cybernetics Laboratory,

University of Wisconsin, Madison.

11) Richter E, Berman T, Ben-Michael E, Laster R, Westin JB (2000). "Cancer in radar

technicians exposed to radiofrequency/microwave radiation: sentinel episodes". International

39
Journal of Occupational and Environmental Health. 6 (3): 187–93.

doi:10.1179/oeh.2000.6.3.187. PMID 10926722.

12) "Harms of Cigarette Smoking and Health Benefits of Quitting". National Cancer Institute.

2017-12-21.

13) Tomar, Rajpal C.; Beaumont and Hsieh (August 2009). "Evidence on the carcinogenicity

of marijuana smoke" (PDF). Reproductive and Cancer Hazard Assessment Branch Office of

Environmental Health Hazard Assessment, California Environmental Protection Agency.

Retrieved 23 June 2012.

14) Abdel-Rahman, O. 2019. Statin treatment and outcomes of metastatic pancreatic cancer:

a pooled analysis of two phase III studies. Clin. Transl. Oncol. 21:810–816

15) Ackerman, D., and M.C. Simon. 2014. Hypoxia, lipids, and cancer: surviving the harsh

tumor microenvironment. Trends Cell Biol. 24:472–478.

16) Ackerman,D.,S.Tumanov,B.Qiu, E.Michalopoulou, M.Spata,A.Azzam,H. Xie, M.C.

Simon, andJ.J. Kamphorst. 2018. Triglycerides Promote Lipid Homeostasis during Hypoxic

Stress by Balancing Fatty Acid Saturation. Cell Rep. 24:2596–2605.e5.

17) Ali,A.,E.Levantini,J.T.Teo,J.Goggi,J.G.Clohessy,C.S.Wu,L.Chen,H.Yang, I. Krishnan,

O. Kocher, et al. 2018. Fatty acid synthase mediates EGFR palmitoylation inEGFR mutated non-

small cell lung cancer. EMBO Mol. Med. 10:e8313.

18) Altmann, S.W., H.R. Davis Jr., L.J. Zhu, X. Yao, L.M. Hoos, G. Tetzloff, S.P. Iyer, M.

Maguire, A. Golovko, M. Zeng, et al. 2004. Niemann-Pick C1 Like 1 protein is critical for

intestinal cholesterol absorption. Science. 303:1201–1204.

40
19) Auciello, F.R., V. Bulusu, C. Oon, J. Tait-Mulder, M. Berry, S. Bhattacharyya,

S.Tumanov,B.L.Allen-Petersen,J.Link,N.D.Kendsersky,etal.2019.A Stromal Lysolipid-

Autotaxin Signaling Axis Promotes Pancreatic Tumor Progression. Cancer Discov. 9:617–627.

1212

20) Aylon, Y., A. Gershoni, R. Rotkopf, I.E. Biton, Z. Porat, A.P. Koh, X. Sun, Y. Lee, M.I.

Fiel, Y. Hoshida, et al. 2016. The LATS2 tumor suppressor inhibits SREBP and suppresses

hepatic cholesterol accumulation. Genes Dev. 30:786–797.

21) Bandyopadhyay,S.,R.Zhan,Y. Wang, S.K.Pai,S.Hirota,S.Hosobe,Y.Takano, K. Saito, E.

Furuta, M. Iiizumi, et al. 2006. Mechanism of apoptosis induced by the inhibition of fatty acid

synthase in breast cancer cells. Cancer Res. 66:5934–5940

22) Bensaad, K.,E.Favaro,C.A.Lewis,B.Peck,S.Lord,J.M.Collins, K.E.Pinnick, S. Wigfield,

F.M. Buffa, J.L. Li, et al. 2014. Fatty acid uptake and lipid storage induced by HIF-1α contribute

to cell growth and survival after hypoxia-reoxygenation. Cell Rep. 9:349–365.

23) Berwick, D.C., I. Hers, K.J. Heesom, S.K. Moule, and J.M. Tavare. 2002. The

identification of ATP-citrate lyase as a protein kinase B (Akt) substrate in primary adipocytes. J.

Biol. Chem. 277:33895–33900. M204681200

24) Bollu,L.R.,J. Ren, A.M. Blessing, R.R. Katreddy, G. Gao, L. Xu, J. Wang, F. Su, and

Z.Weihua. 2014. Involvement of denovo synthesized palmitate and mitochondrial EGFR in EGF

induced mitochondrial fusion of cancer cells. Cell Cycle. 13:2415–2430.

41