Tobacco Smoke and Cancer Prevention Strategies by Silvio De Flora

1. GE ATHE NUEN NAE SE UM Fumo di sigaretta e tumori. Strategie di prevenzione Silvio De Flora Dipartimento di Scienze della Salute Università degli Studi di Genova GdL SItI Prevenzione Tumori / Screening Oncologici

2. MAINSTREAM SMOKE ENVIRONMENTAL CIGARETTE SMOKE (ECS) SIDESTREAM SMOKE

3. CIGARETTE SMOKE AND CANCER Evidence for a causal association with the following cancers Respiratory system Nasal cavity and paranasal sinuses Naso-, oro-, and hypopharynx Larynx Lung (90%) Digestive system Oral cavity Oesophagus Stomach Colon-rectum Liver Pancreas Urinary tract Kidney pelvis Bladder Ureter Reproductive tract Ovary Uterine cervix Haematopoietic system Myeloid leukemia IARC Vol. 83, 2004; IARC Vol. 100 E, 2012

4. TOTAL TUMORS 30% LUNG TUMORS 85-90% AERODIGESTIVE TRACT TUMORS 50–70% synergism with alcohol CARDIOVASCULAR DISEASES 30% synergism with other risk factors COPD 75% DEATHS ATTRIBUTABLE TO TOBACCO SMOKE Italy 90,000 deaths / year EU 650,000 deaths / year USA 430,000 deaths / year

6. 100 90 80 70 60 50 40 30 20 10 0 100 90 80 70 60 50 40 30 20 10 0 1950 1960 1970 1980 1990 2000 1930 1940 1950 1960 1970 1980 1990 2000 1930 1940 Lungand stomachcancers in Italy MALES FEMALES CRUDE DATA Deaths per 100,000 AGE-STANDARDIZED DATA Year

7. STOP Exposure dose GROWTH OF THE NEOPLASTIC MASS CARCINOGENESIS PROCESS Pharmacologic dose C H E M O P R E V E N T I O N Cell divisions No. of cells Weight (g) Cellular dose TOXICOKINETIKS AND METABOLISM 0 -9 10 10 0 Target dose DNA DAMAGE AND REPAIR 1 -8 10 10 Molecular dose 5 INITIATION 2 -7 10 10 (days - weeks) PRIMARY PREVENTION -6 3 10 10 10 PROMOTION 4 -5 10 10 (years - decades) 15 5 -4 10 10 -3 6 10 20 10 7 -2 10 10 25 BENIGN TUMOR 8 -1 10 10 PROGRESSION (~ 1 year) SECONDARY 9 0 10 10 30 PREVENTION CANCER 10 1 10 10 THERAPY - REHABILITATION INVASION 35 METASTASIS 11 2 10 10 TERTIARY PREVENTION 3 12 10 10 40 NEOPLASTIC MASS S. De Flora et al., Mutat. Res. 480-481, 9-22, 2001

8. 0.35 11.06 1.95 CONTROLS (STANDARD DIET) URETHANE (STANDARD DIET) URETHANE (DIET WITH NAC 0.2%) PREVENTION OF LUNG TUMORS IN MICE NUMBER OF TUMORS/MOUSE S. De Flora et al., Cancer Lett. 32, 235-241,1986

9. PASSIVE SMOKING IN MUTANT MICE P53 S. De Flora et al. Molecular alterations and lung tumors in P53 mutant mice exposed to cigarette smoke. Cancer Res. 63, 793–800, 2003 A. Izzotti et al. Gene expression in the lung of P53 mutant mice exposed to cigarette smoke. Cancer Res.64, 8566–72, 2004 Fhit F. D’Agostini et al. Early loss of Fhit in the respiratory tract of rodents exposed to environmental smoke. Cancer Res. 66, 3936–41, 2006 S. De Flora et al. Molecular alterations induced by cigarette smoke in mice heterozygous for Fhit. Cancer Res.67, 1001–6, 2007 R. Balansky et al. Influence of Fhit on benzo(a)pyrene induced tumors and alopecia in mice. PNAS 103, 7823–8, 2006

10. GENOMIC CHANGES IN MOUSE LUNG AT BIRTH A. Izzotti et al., Mutat. Res. (Rev. Genetic Toxicol.), 544, 441-449, 2003 Lung of newborn mice / fetuses 8-oxo-dGuo DNA adducts Expression of 746 genes 5.0 UNTREATED PREGNANT MICE 1.9 P < 0.001 P < 0.05 0.9 NAC–TREATED PREGNANT MICE 2.0 NS NS

11. Birth 7.5 months CHEMOPREVENTION STUDIES IN SWISS H MICE EXPOSEDTO MCS Chemopreventive agents MCS Carcinoma in situ Hyperplasia of alveolar epithelium Papillary hyperplasia of bronchial epithelium Adenoma 4 months Weaning Tumors Systemic genotoxicity Small cell carcinoma Adenocarcinomatous and small cell areas Adenosquamous carcinoma Low differentiated carcinoma

12. DIETARY AND PHARMACOLOGICAL AGENTS THAT HAVE BEEN TESTED FOR THE ABILITY TO INTERFERE IN CIGARETTE SMOKE CARCINOGENESIS (S. De Flora et al., Trends Pharmacol. Sci. 37, 120-142, 2016) Anticancer drugs Bexarotene Lapatinib Vorinostat Anti- inflammatory drugs Antidiabetic drugs Budesonide Aspirin Celecoxib Licofelone Naproxen Metformin Pioglitazone Natural agents Phenethyl Isothiocyanate Myo-inositol N-Acetylcysteine Ascorbic acid Blackberry Strawberry

13. EARLY BIOLOGICAL DAMAGE BIOLOGICALLY EFFECTIVE Metabolic alterations DOSE DNA damage and repair EXPOSURE MARKERS Cytogenetic effects Protein adducts DNA adducts Activation of oncogenes 8-oxo-dG Deletion or mutation of oncosuppressor genes Effects on proliferation, Mutagenicity differentiation, apoptosis, etc. of escreta Multigene expression microRNA profiles Proteomic profiles DISEASES DECODING THE BLACK BOX YEARS - DECADES RISK FACTORS DAYS - WEEKS Metabolites In excreta

14. THE ICEBERG OF CHRONIC DEGENERATIVE DISEASES DIAGNOSIS CARDIOVASCULAR DISEASES THERAPY COPD CANCER EPIDEMIOLOGY PREVENTION RISK FACTORS AND PROTECTIVE FACTORS

15. EXPRESSION OF 4858 GENES IN RAT LUNG A. Izzotti et al., Mutat. Res. 591, 212–223, 2005 EFFICACY SAFETY SMOKE-FREE RATS SMOKE-EXPOSED RATS SHAM NAC OPZ OPZ + NAC 5,6-BF PEITC I3C PEITC + I3C ECS OPZ NAC 5,6-BF OPZ + NAC I3C PEITC + I3C PEITC

16. 0 . 6 0 . 5 ECS + PEITC + I3C 0 . 4 ECS + OPZ + NAC ECS + PEITC 0 . 3 ECS + NAC 0 . 2 ECS + I3C ECS + OPZ 0 . 1 ECS ECS + BF 0 SHAM BF NAC NAC + OPZ - 0 . 1 PEITC - 0 . 2 OPZ PEITC + I3C - 0 . 4 - 0 . 3 - 0 . 2 - 0 . 1 0 0 . 1 0 . 2 0 . 3 0 . 4 0 . 5 0 . 6 0 . 7 0 . 8 EFFECT OF ENVIRONMENTAL CIGARETTE SMOKE AND CHEMOPREVENTIVES ON miRNA EXPRESSION IN RAT LUNG PCA component 2 PCA component 1 A. Izzotti et al, Cancer Prev. Res. 3, 62–72, 2010

17. ** ** Slow Null PHARMACOGENOMICS / NUTRIGENOMICS OF CHEMOPREVENTIVE AGENTS 2.4 before NAC 2.0 6 months after NAC 1.6 MN (‰) 1.2 * 0.8 0.4 0 + Fast All subjects NAT2 GSTM1