New DCA Publication!

TITLE Long-term stabilization of metastatic melanoma with sodium dichloroacetate
AUTHOR(s) Akbar Khan, Doug Andrews, Jill Shainhouse, Anneke C Blackburn
CITATION Khan A, Andrews D, Shainhouse J, Blackburn AC. Long-term stabilization of metastatic melanoma with sodium dichloroacetate. World J Clin Oncol 2017; 8(4): 371-377
URL http://www.wjgnet.com/2218-4333/full/v8/i4/371.htm
DOI http://dx.doi.org/10.5306/wjco.v8.i4.371
OPEN ACCESS This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
CORE TIP Sodium dichloroacetate (DCA) has been studied as a metabolic cancer therapy since 2007. It has been shown that DCA therapy can result in a classic response which is measured by reduction or disappearance of tumours on imaging. However, DCA can also halt cancer cell growth without causing apoptosis (cytostatic effect). This can result in long-term stabilization of metastatic cancer. We present a case of oral DCA therapy resulting in reduction and stabilization of metastatic melanoma in a 32-year-old male for over 4 years, with only minor side effects.
KEY WORDS Dichloroacetate; Cancer; BRAF; Melanoma; Cytostatic
COPYRIGHT © The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
NAME OF JOURNAL World Journal of Clinical Oncology
ISSN 2218-4333
PUBLISHER Baishideng Publishing Group Inc, 7901 Stoneridge Drive, Suite 501, Pleasanton, CA 94588, USA
WEBSITE Http://www.wjgnet.com

CASE REPORT

 

Long-term stabilization of metastatic melanoma with sodium dichloroacetate

 

Akbar Khan, Doug Andrews, Jill Shainhouse, Anneke C Blackburn

 

Akbar Khan, Doug Andrews, Medicor Cancer Centres Inc, Toronto, ON M2N 6N4, Canada

Jill Shainhouse, Insight Naturopathic Clinic, Toronto, ON M4P 1N9, Canada

Anneke C Blackburn, the John Curtin School of Medical Research, the Australian National University, Canberra, ACT 2601, Australia

Author contributions: Khan A treated the patient and wrote most of the case report; Andrews D assisted in development of the natural medication protocol for reduction of DCA side effects, and wrote a portion of the case report; Shainhouse J treated the patient with natural therapy; Blackburn AC interpreted the case report in the context of the literature on in vitro and in vivo DCA research, wrote parts of the introduction and discussion, and reviewed the manuscript overall.

Correspondence to: Akbar Khan, MD, Medical Director, Medicor Cancer Centres Inc, 4576 Yonge St., Suite 301, Toronto, ON M2N 6N4, Canada. akhan@medicorcancer.com

Telephone: +1-416-2270037  Fax: +1-416-2271915

Received: January 30, 2017   Revised: May 5, 2017   Accepted: May 30, 2017

Published online: August 10, 2017

 

Abstract

Sodium dichloroacetate (DCA) has been studied as a metabolic cancer therapy since 2007, based on a pub­lication from Bonnet et al demonstrating that DCA can induce apoptosis (programmed cell death) in human breast, lung and brain cancer cells. Classically, the res­ponse of cancer to a medical therapy in human research is measured by Response Evaluation Criterial for Solid Tumours definitions, which define “response” by the degree of tumour reduction, or tumour disappearance on imaging, however disease stabilization is also a beneficial clinical outcome. It has been shown that DCA can function as a cytostatic agent in vitro and in vivo, without causing apoptosis. A case of a 32-year-old male is presented in which DCA therapy, with no concurrent conventional therapy, resulted in regression and stabilization of re­current metastatic melanoma for over 4 years’ duration, with trivial side effects. This case demonstrates that DCA can be used to reduce disease volume and maintain long-term stability in patients with advanced melanoma.

 

Key words: Dichloroacetate; Cancer; BRAF; Melanoma; Cytostatic

 

Khan A, Andrews D, Shainhouse J, Blackburn AC. Long-term stabilization of metastatic melanoma with sodium dichloroacetate. World J Clin Oncol 2017; 8(4): 371-377  Available from: URL: http://www.wjgnet.com/2218-4333/full/v8/i4/371.htm  DOI: http://dx.doi.org/10.5306/wjco.v8.i4.371

 

Core tip: Sodium dichloroacetate (DCA) has been studied as a metabolic cancer therapy since 2007. It has been shown that DCA therapy can result in a classic response which is measured by reduction or disappearance of tumours on imaging. However, DCA can also halt cancer cell growth without causing apoptosis (cytostatic effect). This can result in long-term stabilization of metastatic cancer. We present a case of oral DCA therapy resulting in reduction and stabilization of metastatic melanoma in a 32-year-old male for over 4 years, with only minor side effects.

 

INTRODUCTION

Sodium dichloroacetate (DCA) caught the attention of the medical community in 2007, when Bonnet et al[1] published the first in vitro and in vivo study illustrating the value of DCA as a metabolic cancer therapy, through its inhibitory action on the mitochondrial enzyme py­ruvate dehydrogenase kinase. Previously, Stacpoole et al[2-4] had published several studies of DCA for the treatment of congenital lactic acidosis in mitochondrial diseases[2-5]. These studies demonstrated that oral DCA is a safe drug for human use. DCA was noted to have an absence of renal, pulmonary, bone marrow and cardiac toxicity[4]. Most DCA side effects were modest, with the most serious one being reversible peripheral neuropathy[6]. Reversible delirium has also been reported[7]. Elevation of liver enzymes (asymptomatic and reversible) has been noted in a small percentage of patients[3]. The prior human research in mitochondrial disorders has enabled the rapid translation of DCA into human use as an off-label cancer therapy. Several reports of clinical trials using DCA as cancer therapy have now been published, confirming its safety profile, and indicating an increasing recognition of the potential usefulness of DCA in the cancer clinic[8-11]. One limitation of these studies involving late stage patients is that they have only reported on treatment for short periods of time.

In Bonnet’s 2007 publication[1], DCA treatment was shown to reduce mitochondrial membrane potential which promoted apoptosis selectively in human cancer cells. Aerobic glycolysis inhibition (the Warburg effect) and mitochondrial potassium ion channel activation were identified as the mechanisms of action of DCA. Further investigations of DCA in vitro have confirmed the anti-cancer activity against a wide range of can­cer types, which have been reviewed recently by Kankotia and Stacpoole[12]. In addition, DCA is also able to enhance apoptosis when combined with other agents[13-15]. Other anticancer actions of DCA have also been suggested, including angiogenesis inhibition[16], alteration of HIF1-a expression[17], alteration of cell pH regulators V-ATPase and MCT1, and other cell survival regulators such as p53 and PUMA[18]. However, many in vitro studies use unreasonably high concentrations of DCA that are not clinically achievable, in an effort to show cytotoxic activity[12]. In other studies, more modest DCA concentrations were used, demonstrating that DCA could be cytostatic. The second report in 2010 of its in vivo anti-cancer activity found DCA alone to be cytostatic in a metastatic model of breast cancer[19], inhibiting proliferation without triggering apoptosis. This suggests a role for DCA as a cancer stabilizer, similar to angiogenesis inhibitors.

In response to the 2007 report of the anti-cancer actions of DCA, Khan began using DCA for the treat­ment of cancer patients with short prognosis or who had stopped responding to conventional cancer therapies. A natural medication protocol was developed in collaboration with a naturopathic physician (Andrews) to address the dose-limiting neurologic toxicity of DCA. This consisted of 3 medicines: Acetyl L-carnitine[20-22], R-alpha lipoic acid[23-25] and benfotiamine[26-28], for neuropathy and encephalopathy prevention. In over 300 advanced stage cancer patients, observational data revealed that DCA therapy benefitted 60%-70% of cases. The neuropathy risk when natural neuro­protective medicines were combined with DCA was approximately 20% using 20-25 mg/kg per day dosing on a 2 wk on/1 wk off cycle (clinic observational data published online at www.medicorcancer.com). Here, a patient case report illustrating both the apoptotic and anti-proliferative effects of chronic DCA treatment over a period of over four years is presented.

 

CASE REPORT

A 32 years old previously healthy fair-skinned male originally noted that a mole on his left calf began to change in 2006. He consulted a doctor and the mole was excised. A pathologic diagnosis of melanoma was made. A sentinel node dissection was carried out, and was negative for metastatic disease. In 2007, the patient noted enlargement of left inguinal lymph nodes, and small melanocytic lesions on the skin of his left leg. He was treated with interferon alpha under a clinical trial at a regional cancer hospital, with reduction of the nodes and resolution of the skin metastases. Interferon was stopped after 9 mo due to side effects.

The patient remained well until 2010, when a new left leg skin metastasis appeared. This was surgically excised. In late 2011, another new cutaneous meta­stasis was identified on the left leg, within the scar from the original melanoma surgery. This was biopsied and a diagnosis of recurrent melanoma was confirmed. He was then treated with wide excision and skin graft.

In March 2012, the patient was diagnosed with a recurrence within the left leg skin graft. This was excised and a new skin graft procedure was performed. Pathology revealed positive margins of the excised metastasis, so a re-excision was performed, again with positive margins. At the same time, needle biopsy of a left inguinal lymph node confirmed the presence of BRAF-positive metastatic melanoma. A Computed tomography (CT) scan performed in Mar 2012 revealed no evidence of distant metastases. The largest left inguinal node was 8mm in diameter, which was reported as “insignificant by size criteria” (Figure 1).

In April 2012, the patient consulted a naturopathic doctor (Shainhouse) and began therapy with the following oral natural anti-cancer agents: Active hexose correlated compound or AHCC (mushroom extract)[29], dandelion root[30], curcumin[31], and astragalus root[32]. Parenteral therapy was also started, which consisted of intravenous vitamin C twice weekly[33] and subcutaneous European mistletoe extract[34]. The patient also changed to a vegan diet.

In May 2012, the patient attended the author’s clinic (Khan) looking to pursue additional non-traditional therapies. DCA therapy was discussed, but the patient decided to give the natural anti-cancer therapies (pre­scribed by Shainhouse) an adequate trial first. CT scan was performed again in May 2012 (after only 1 mo of natural therapy) and indicated mild growth of multiple inguinal and external iliac nodes, with sizes ranging from 10 mm × 11 mm to 14 mm × 15 mm.

In July 2012, CT scan was repeated to assess the patient’s natural anti-cancer therapies. At that time, the left inguinal and external iliac nodes had enlarged again, and ranged in size from 13 mm × 16 mm to 22 mm × 20 mm (Figure 2). PET scan was also performed in preparation for entering a clinical trial in Boston, MA (United States), and confirmed increased glucose uptake in the left inguinal nodes. There was new low intensity (2/10) aching pain in the left inguinal region. Examination revealed a 20 mm non-tender left inguinal lymph node, and two small skin metastases within the left calf skin graft.

The patient was thus diagnosed with disease progression. At that point he decided to initiate DCA therapy. He began oral DCA 500 mg 3 times per day, which was equivalent to 17 mg/kg per day (manufacturer: Tokyo Chemical Industry, United States) in addition to maintaining the other natural therapies. The DCA treatment cycle was 2 wk on and 1 wk off. To minimize the occurrence of DCA side effects, 3 additional natural medications were prescribed: Oral acetyl L-carnitine 500 mg 3 times a day, oral benfotiamine 80 mg twice a day and oral R-alpha lipoic acid 150 mg 3 times a day. These supplements were taken daily (no cycle). Routine baseline blood tests were performed (Table 1). These were all normal, except for low creatinine which was felt to be insignificant.

In November 2012, 4 mo after the addition of DCA to his original natural anti-cancer therapies, the patient was re-assessed. He felt generally well. Two new symptoms were reported to have begun only after initiation of DCA therapy: Slightly reduced sensation of the finger tips and toes, and slightly reduced ability to concentrate during the 2 wk periods in which he was taking DCA. The mild sensory loss was not worsening and was felt to be mild DCA-related neuropathy. Both the numbness and reduced concentration were reported to resolve during the weeks when the patient was off DCA. Blood panel from October 2012 showed no significant changes (Table 1). August 2012 and November 2012 CT scans revealed significant regression of all previously enlarged lymph nodes. The largest node was 10 mm, and there was no evidence of intra-thoracic or intra-abdominal disease, and no bone metastases (Figure 3).

The patient continued to feel well on DCA therapy, and did not notice any new skin metastases or new enlargement of inguinal nodes. He continued to have frequent clinical monitoring with his naturopathic doctor (Shainhouse), and annual follow-up with his medical doctor (Khan). The listed natural anti-cancer therapies (prescribed by Shainhouse) and DCA therapy were maintained into 2016. Blood panel results in June 2016 continued to be normal (Table 1). CT scan was repeated in August 2016, showing no evidence of metastatic melanoma, after a full 4 years of ongoing DCA therapy, combined with natural anti-cancer therapy (Figure 4). By December 2016, the patient reported an increase in work-related stress and a reduction in compliance with his medications. At the time, he noted a new left inguinal mass. Ultrasound imaging was obtained, which revealed a new conglomerate of enlarged lymph nodes measuring 40 mm × 25 mm × 23 mm, with colour Doppler showing blood flow within the mass. This was interpreted as re-growth of melanoma, after approximately four and a half years of continuous DCA therapy. Further workup was performed including a PET/CT scan, which confirmed disease recurrence in 3 left inguinal nodes (SUVmax ranging from 13 to 17.8).

In summary, the patient received conventional therapy for recurrent stage 3 melanoma over a period of 6 years, consisting of primary surgical excision with lymph node dissection, interferon alpha and surgical excisions for recurrent cutaneous metastases on 5 occasions. The patient then received natural anti-cancer therapy alone (prescribed by Shainhouse) for 3 mo with no response, evidenced by steady disease progression on serial CT scans. Finally the patient added oral DCA therapy to the natural anti-cancer therapy, with 3 concurrent neuroprotective medicines (lipoic acid, acetyl L-carnitine and benfotiamine) and no concurrent conventional cancer therapies. The result was a complete radiological remission lasting for over 4 years, followed by recurrence. During the course of DCA therapy, the patient experienced trivial side effects consisting of slight neuropathy and slight reduction of concentration. The patient maintained ECOG level 0 function, and he was able to work full time.

 

DISCUSSION

The use of oral DCA in the metastatic melanoma patient described herein demonstrates tumour shrinkage and long-term disease stability according to clinical status and CT imaging. Disease stability was maintained for over 4 years while taking DCA in the absence of any concurrent conventional therapy, with a survival time since the initial diagnosis of 10 years. According to the National Cancer Institute’s SEER cancer statistics, the survival of this patient who showed no evidence of distant metastases is not remarkable (62.9% 5-year survival rate for melanoma with spread to regional lymph nodes, https://seer.cancer.gov/statfacts/html/melan.html). What is remarkable is that in a situation where involved lymph nodes were clearly enlarging, the addition of oral DCA therapy was efficacious in shrinking the enlarging nodes (Figures 2 and 3), and in achieving a remission lasting over 4 years. It is possible that the natural anti-cancer therapies the patient received synergized with DCA, but it is also clear that these natural therapies alone cannot account for the disease regression. DCA has been reported to have both apoptotic and cytostatic effects[14,17,19,35,36], which is consistent with this patient’s clinical course of regression (apoptotic) and prolonged remission (cytostatic). The recurrence after 4 years coincided with reduced compliance, suggesting that this method of cancer management with DCA requires the metabolic pressure to be maintained continuously. Despite recurrence, the patient remained clinically well and planned to start new immunotherapy medications. It remains to be seen if a change in therapy can once again achieve disease regression or stability.

In addition to the maintenance of remission for over 4 years, this case illustrates that DCA can be well-tolerated in a cancer patient for a prolonged time period, as compared to all published DCA cancer clinical trials. Notably, this patient was able to tolerate 17 mg/kg per day in a regime of 2 wk on/1 wk off for 4 years with minimal side effects. This is similar to our previous case report of chronic DCA usage in colon cancer[37], where the patient was able to tolerate 16 mg/kg per day (but not 25 mg/kg per day) in the same regime, but contrasts with the clinical trials for DCA, which recommend a lower dose of 10-12.5 mg/kg per day given continuously[9,11]. The 1 wk break or the neuroprotective supplements may both contribute to the ability of the patients in the case reports to tolerate the higher dose. Genetic polymorphisms in GSTZ1, the liver enzyme that metabolises DCA, may also contribute to the dose of DCA that can be tolerated[9,38]. Variable drug levels have been reported in the trials, but not all of them have considered this pharmacogenetic aspect of DCA therapy[9,11], and further studies are needed to clarify if this is a significant contributor to DCA tolerance. As of this writing, a DCA multiple myeloma human trial is ongoing, which is examining both GSTZ1 genotypes and drug levels to contribute to our understanding of these issues (Australia New Zealand Clinical Trials Register #ACTRN12615000226505, http://www.anzctr.org.au).

This case report shows that chronic DCA therapy can be used without reducing quality of life, as compared to conventional melanoma therapies such as interferon. To determine the optimal protocol for maximum tolerable acute or chronic treatment with DCA, human trials are needed. But more importantly, it still remains to be clarified what dose is required for on-target effects that will be efficacious against cancer. This information is necessary before investing in larger, long term studies on patient outcomes. DCA deserves further investigation in clinical trials as a non-toxic cancer therapy due to its modest cost and low toxicity, and deserves consideration as an off-label cancer therapy.

 

ACKNOWLEDGMENTS

The authors wish to thank Dr. Humaira Khan for her assistance, and also the patient for his support and consent to publish his case.

 

COMMENTS

Case characteristics

The 32-year-old male patient presented with a pigmented lesion on his leg.

 

Clinical diagnosis

The patient was diagnosed with a melanoma.

 

Laboratory diagnosis

Melanoma confirmed by excisional biopsy.

 

Imaging diagnosis

Enlarged inguinal node confirmed to be involved with melanoma (needle biopsy).

 

Pathological diagnosis

Melanoma, BRAF positive.

 

Treatment

Excision of primary lesion with skin graft, sentinel node dissection, multiple excisions of recurrent cutaneous metastases. Traditional therapy stopped and natural anti-cancer therapies started (AHCC, dandelion root, curcumin, astragalus root, i.v. vitamin C, s.c. European mistletoe). Progression after 3 mo, dichloroacetate (DCA) added. Regression and remission following addition of DCA lasting for over 4 years.

 

Related reports

Computed tomography scan reports demonstrate the course of the disease and response to therapies.

 

Term explanation

DCA: Dichloroacetate sodium; RECIST: Response Evaluation Criteria for Solid Tumours; ECOG: Eastern Cooperative Oncology Group.

 

Experiences and lessons

DCA can act as a pro-apoptotic and cytostatic drug, and can thus achieve regression as well as long-term stabilization of metastatic cancer without serious side effects, as illustrated by this melanoma case.

 

Peer-review

Dr. Khan described a 32-year-old man received DCA therapy, with other medications from natural therapists and maintained in a stabilization state (metastatic melanoma) for over 4 years. It is an interesting case.

 

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FIGURE LEGENDS

Figure 1  Computed tomography scan from March 2012 prior to natural therapies and prior to dichloroacetate therapy. Largest node measured 8 mm in diameter.

Figure 2  Computed tomography scan from July 2012 after 3 mo of natural therapy alone, just prior to the start of dichloroacetate therapy. Largest node measured 22 mm × 20 mm.

Figure 3  Computed tomography scan from November 2012 after 4 mo of dichloroacetate therapy. Largest node measured 10 mm.

Figure 4  Computed tomography scan after 4 years of dichloroacetate therapy without any concurrent conventional cancer therapies. Scan demonstrates absence of cancer re-growth. All nodes measure less than 10 mm.

 

FOOTNOTES

Informed consent statement: The patient described in this manuscript has given consent to publish his case anonymously.

Conflict-of-interest statement: One of the authors (Khan) administers dichloroacetate therapy for cancer patients through Medicor Cancer Centres at a cost, and without profit. The clinic is owned by a family member of this author. The other authors have nothing to disclose.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Manuscript source: Invited manuscript

Peer-review started: February 12, 2017

First decision: March 28, 2017

Article in press: May 31, 2017

P- Reviewer: Su CC    S- Editor: Ji FF    L- Editor: A    E- Editor: Lu YJ 

 

 

 

 

 

 

 

 

 

 

 

 

CASE REPORT

 

Long-term stabilization of metastatic melanoma with sodium dichloroacetate

 

Akbar Khan, Doug Andrews, Jill Shainhouse, Anneke C Blackburn

 

Akbar Khan, Doug Andrews, Medicor Cancer Centres Inc, Toronto, ON M2N 6N4, Canada

Jill Shainhouse, Insight Naturopathic Clinic, Toronto, ON M4P 1N9, Canada

Anneke C Blackburn, the John Curtin School of Medical Research, the Australian National University, Canberra, ACT 2601, Australia

Author contributions: Khan A treated the patient and wrote most of the case report; Andrews D assisted in development of the natural medication protocol for reduction of DCA side effects, and wrote a portion of the case report; Shainhouse J treated the patient with natural therapy; Blackburn AC interpreted the case report in the context of the literature on in vitro and in vivo DCA research, wrote parts of the introduction and discussion, and reviewed the manuscript overall.

Correspondence to: Akbar Khan, MD, Medical Director, Medicor Cancer Centres Inc, 4576 Yonge St., Suite 301, Toronto, ON M2N 6N4, Canada. akhan@medicorcancer.com

Telephone: +1-416-2270037  Fax: +1-416-2271915

Received: January 30, 2017   Revised: May 5, 2017   Accepted: May 30, 2017

Published online: August 10, 2017

 

Abstract

Sodium dichloroacetate (DCA) has been studied as a metabolic cancer therapy since 2007, based on a pub­lication from Bonnet et al demonstrating that DCA can induce apoptosis (programmed cell death) in human breast, lung and brain cancer cells. Classically, the res­ponse of cancer to a medical therapy in human research is measured by Response Evaluation Criterial for Solid Tumours definitions, which define “response” by the degree of tumour reduction, or tumour disappearance on imaging, however disease stabilization is also a beneficial clinical outcome. It has been shown that DCA can function as a cytostatic agent in vitro and in vivo, without causing apoptosis. A case of a 32-year-old male is presented in which DCA therapy, with no concurrent conventional therapy, resulted in regression and stabilization of re­current metastatic melanoma for over 4 years’ duration, with trivial side effects. This case demonstrates that DCA can be used to reduce disease volume and maintain long-term stability in patients with advanced melanoma.

 

Key words: Dichloroacetate; Cancer; BRAF; Melanoma; Cytostatic

 

Khan A, Andrews D, Shainhouse J, Blackburn AC. Long-term stabilization of metastatic melanoma with sodium dichloroacetate. World J Clin Oncol 2017; 8(4): 371-377  Available from: URL: http://www.wjgnet.com/2218-4333/full/v8/i4/371.htm  DOI: http://dx.doi.org/10.5306/wjco.v8.i4.371

 

Core tip: Sodium dichloroacetate (DCA) has been studied as a metabolic cancer therapy since 2007. It has been shown that DCA therapy can result in a classic response which is measured by reduction or disappearance of tumours on imaging. However, DCA can also halt cancer cell growth without causing apoptosis (cytostatic effect). This can result in long-term stabilization of metastatic cancer. We present a case of oral DCA therapy resulting in reduction and stabilization of metastatic melanoma in a 32-year-old male for over 4 years, with only minor side effects.

 

INTRODUCTION

Sodium dichloroacetate (DCA) caught the attention of the medical community in 2007, when Bonnet et al[1] published the first in vitro and in vivo study illustrating the value of DCA as a metabolic cancer therapy, through its inhibitory action on the mitochondrial enzyme py­ruvate dehydrogenase kinase. Previously, Stacpoole et al[2-4] had published several studies of DCA for the treatment of congenital lactic acidosis in mitochondrial diseases[2-5]. These studies demonstrated that oral DCA is a safe drug for human use. DCA was noted to have an absence of renal, pulmonary, bone marrow and cardiac toxicity[4]. Most DCA side effects were modest, with the most serious one being reversible peripheral neuropathy[6]. Reversible delirium has also been reported[7]. Elevation of liver enzymes (asymptomatic and reversible) has been noted in a small percentage of patients[3]. The prior human research in mitochondrial disorders has enabled the rapid translation of DCA into human use as an off-label cancer therapy. Several reports of clinical trials using DCA as cancer therapy have now been published, confirming its safety profile, and indicating an increasing recognition of the potential usefulness of DCA in the cancer clinic[8-11]. One limitation of these studies involving late stage patients is that they have only reported on treatment for short periods of time.

In Bonnet’s 2007 publication[1], DCA treatment was shown to reduce mitochondrial membrane potential which promoted apoptosis selectively in human cancer cells. Aerobic glycolysis inhibition (the Warburg effect) and mitochondrial potassium ion channel activation were identified as the mechanisms of action of DCA. Further investigations of DCA in vitro have confirmed the anti-cancer activity against a wide range of can­cer types, which have been reviewed recently by Kankotia and Stacpoole[12]. In addition, DCA is also able to enhance apoptosis when combined with other agents[13-15]. Other anticancer actions of DCA have also been suggested, including angiogenesis inhibition[16], alteration of HIF1-a expression[17], alteration of cell pH regulators V-ATPase and MCT1, and other cell survival regulators such as p53 and PUMA[18]. However, many in vitro studies use unreasonably high concentrations of DCA that are not clinically achievable, in an effort to show cytotoxic activity[12]. In other studies, more modest DCA concentrations were used, demonstrating that DCA could be cytostatic. The second report in 2010 of its in vivo anti-cancer activity found DCA alone to be cytostatic in a metastatic model of breast cancer[19], inhibiting proliferation without triggering apoptosis. This suggests a role for DCA as a cancer stabilizer, similar to angiogenesis inhibitors.

In response to the 2007 report of the anti-cancer actions of DCA, Khan began using DCA for the treat­ment of cancer patients with short prognosis or who had stopped responding to conventional cancer therapies. A natural medication protocol was developed in collaboration with a naturopathic physician (Andrews) to address the dose-limiting neurologic toxicity of DCA. This consisted of 3 medicines: Acetyl L-carnitine[20-22], R-alpha lipoic acid[23-25] and benfotiamine[26-28], for neuropathy and encephalopathy prevention. In over 300 advanced stage cancer patients, observational data revealed that DCA therapy benefitted 60%-70% of cases. The neuropathy risk when natural neuro­protective medicines were combined with DCA was approximately 20% using 20-25 mg/kg per day dosing on a 2 wk on/1 wk off cycle (clinic observational data published online at www.medicorcancer.com). Here, a patient case report illustrating both the apoptotic and anti-proliferative effects of chronic DCA treatment over a period of over four years is presented.

 

CASE REPORT

A 32 years old previously healthy fair-skinned male originally noted that a mole on his left calf began to change in 2006. He consulted a doctor and the mole was excised. A pathologic diagnosis of melanoma was made. A sentinel node dissection was carried out, and was negative for metastatic disease. In 2007, the patient noted enlargement of left inguinal lymph nodes, and small melanocytic lesions on the skin of his left leg. He was treated with interferon alpha under a clinical trial at a regional cancer hospital, with reduction of the nodes and resolution of the skin metastases. Interferon was stopped after 9 mo due to side effects.

The patient remained well until 2010, when a new left leg skin metastasis appeared. This was surgically excised. In late 2011, another new cutaneous meta­stasis was identified on the left leg, within the scar from the original melanoma surgery. This was biopsied and a diagnosis of recurrent melanoma was confirmed. He was then treated with wide excision and skin graft.

In March 2012, the patient was diagnosed with a recurrence within the left leg skin graft. This was excised and a new skin graft procedure was performed. Pathology revealed positive margins of the excised metastasis, so a re-excision was performed, again with positive margins. At the same time, needle biopsy of a left inguinal lymph node confirmed the presence of BRAF-positive metastatic melanoma. A Computed tomography (CT) scan performed in Mar 2012 revealed no evidence of distant metastases. The largest left inguinal node was 8mm in diameter, which was reported as “insignificant by size criteria” (Figure 1).

In April 2012, the patient consulted a naturopathic doctor (Shainhouse) and began therapy with the following oral natural anti-cancer agents: Active hexose correlated compound or AHCC (mushroom extract)[29], dandelion root[30], curcumin[31], and astragalus root[32]. Parenteral therapy was also started, which consisted of intravenous vitamin C twice weekly[33] and subcutaneous European mistletoe extract[34]. The patient also changed to a vegan diet.

In May 2012, the patient attended the author’s clinic (Khan) looking to pursue additional non-traditional therapies. DCA therapy was discussed, but the patient decided to give the natural anti-cancer therapies (pre­scribed by Shainhouse) an adequate trial first. CT scan was performed again in May 2012 (after only 1 mo of natural therapy) and indicated mild growth of multiple inguinal and external iliac nodes, with sizes ranging from 10 mm × 11 mm to 14 mm × 15 mm.

In July 2012, CT scan was repeated to assess the patient’s natural anti-cancer therapies. At that time, the left inguinal and external iliac nodes had enlarged again, and ranged in size from 13 mm × 16 mm to 22 mm × 20 mm (Figure 2). PET scan was also performed in preparation for entering a clinical trial in Boston, MA (United States), and confirmed increased glucose uptake in the left inguinal nodes. There was new low intensity (2/10) aching pain in the left inguinal region. Examination revealed a 20 mm non-tender left inguinal lymph node, and two small skin metastases within the left calf skin graft.

The patient was thus diagnosed with disease progression. At that point he decided to initiate DCA therapy. He began oral DCA 500 mg 3 times per day, which was equivalent to 17 mg/kg per day (manufacturer: Tokyo Chemical Industry, United States) in addition to maintaining the other natural therapies. The DCA treatment cycle was 2 wk on and 1 wk off. To minimize the occurrence of DCA side effects, 3 additional natural medications were prescribed: Oral acetyl L-carnitine 500 mg 3 times a day, oral benfotiamine 80 mg twice a day and oral R-alpha lipoic acid 150 mg 3 times a day. These supplements were taken daily (no cycle). Routine baseline blood tests were performed (Table 1). These were all normal, except for low creatinine which was felt to be insignificant.

In November 2012, 4 mo after the addition of DCA to his original natural anti-cancer therapies, the patient was re-assessed. He felt generally well. Two new symptoms were reported to have begun only after initiation of DCA therapy: Slightly reduced sensation of the finger tips and toes, and slightly reduced ability to concentrate during the 2 wk periods in which he was taking DCA. The mild sensory loss was not worsening and was felt to be mild DCA-related neuropathy. Both the numbness and reduced concentration were reported to resolve during the weeks when the patient was off DCA. Blood panel from October 2012 showed no significant changes (Table 1). August 2012 and November 2012 CT scans revealed significant regression of all previously enlarged lymph nodes. The largest node was 10 mm, and there was no evidence of intra-thoracic or intra-abdominal disease, and no bone metastases (Figure 3).

The patient continued to feel well on DCA therapy, and did not notice any new skin metastases or new enlargement of inguinal nodes. He continued to have frequent clinical monitoring with his naturopathic doctor (Shainhouse), and annual follow-up with his medical doctor (Khan). The listed natural anti-cancer therapies (prescribed by Shainhouse) and DCA therapy were maintained into 2016. Blood panel results in June 2016 continued to be normal (Table 1). CT scan was repeated in August 2016, showing no evidence of metastatic melanoma, after a full 4 years of ongoing DCA therapy, combined with natural anti-cancer therapy (Figure 4). By December 2016, the patient reported an increase in work-related stress and a reduction in compliance with his medications. At the time, he noted a new left inguinal mass. Ultrasound imaging was obtained, which revealed a new conglomerate of enlarged lymph nodes measuring 40 mm × 25 mm × 23 mm, with colour Doppler showing blood flow within the mass. This was interpreted as re-growth of melanoma, after approximately four and a half years of continuous DCA therapy. Further workup was performed including a PET/CT scan, which confirmed disease recurrence in 3 left inguinal nodes (SUVmax ranging from 13 to 17.8).

In summary, the patient received conventional therapy for recurrent stage 3 melanoma over a period of 6 years, consisting of primary surgical excision with lymph node dissection, interferon alpha and surgical excisions for recurrent cutaneous metastases on 5 occasions. The patient then received natural anti-cancer therapy alone (prescribed by Shainhouse) for 3 mo with no response, evidenced by steady disease progression on serial CT scans. Finally the patient added oral DCA therapy to the natural anti-cancer therapy, with 3 concurrent neuroprotective medicines (lipoic acid, acetyl L-carnitine and benfotiamine) and no concurrent conventional cancer therapies. The result was a complete radiological remission lasting for over 4 years, followed by recurrence. During the course of DCA therapy, the patient experienced trivial side effects consisting of slight neuropathy and slight reduction of concentration. The patient maintained ECOG level 0 function, and he was able to work full time.

 

DISCUSSION

The use of oral DCA in the metastatic melanoma patient described herein demonstrates tumour shrinkage and long-term disease stability according to clinical status and CT imaging. Disease stability was maintained for over 4 years while taking DCA in the absence of any concurrent conventional therapy, with a survival time since the initial diagnosis of 10 years. According to the National Cancer Institute’s SEER cancer statistics, the survival of this patient who showed no evidence of distant metastases is not remarkable (62.9% 5-year survival rate for melanoma with spread to regional lymph nodes, https://seer.cancer.gov/statfacts/html/melan.html). What is remarkable is that in a situation where involved lymph nodes were clearly enlarging, the addition of oral DCA therapy was efficacious in shrinking the enlarging nodes (Figures 2 and 3), and in achieving a remission lasting over 4 years. It is possible that the natural anti-cancer therapies the patient received synergized with DCA, but it is also clear that these natural therapies alone cannot account for the disease regression. DCA has been reported to have both apoptotic and cytostatic effects[14,17,19,35,36], which is consistent with this patient’s clinical course of regression (apoptotic) and prolonged remission (cytostatic). The recurrence after 4 years coincided with reduced compliance, suggesting that this method of cancer management with DCA requires the metabolic pressure to be maintained continuously. Despite recurrence, the patient remained clinically well and planned to start new immunotherapy medications. It remains to be seen if a change in therapy can once again achieve disease regression or stability.

In addition to the maintenance of remission for over 4 years, this case illustrates that DCA can be well-tolerated in a cancer patient for a prolonged time period, as compared to all published DCA cancer clinical trials. Notably, this patient was able to tolerate 17 mg/kg per day in a regime of 2 wk on/1 wk off for 4 years with minimal side effects. This is similar to our previous case report of chronic DCA usage in colon cancer[37], where the patient was able to tolerate 16 mg/kg per day (but not 25 mg/kg per day) in the same regime, but contrasts with the clinical trials for DCA, which recommend a lower dose of 10-12.5 mg/kg per day given continuously[9,11]. The 1 wk break or the neuroprotective supplements may both contribute to the ability of the patients in the case reports to tolerate the higher dose. Genetic polymorphisms in GSTZ1, the liver enzyme that metabolises DCA, may also contribute to the dose of DCA that can be tolerated[9,38]. Variable drug levels have been reported in the trials, but not all of them have considered this pharmacogenetic aspect of DCA therapy[9,11], and further studies are needed to clarify if this is a significant contributor to DCA tolerance. As of this writing, a DCA multiple myeloma human trial is ongoing, which is examining both GSTZ1 genotypes and drug levels to contribute to our understanding of these issues (Australia New Zealand Clinical Trials Register #ACTRN12615000226505, http://www.anzctr.org.au).

This case report shows that chronic DCA therapy can be used without reducing quality of life, as compared to conventional melanoma therapies such as interferon. To determine the optimal protocol for maximum tolerable acute or chronic treatment with DCA, human trials are needed. But more importantly, it still remains to be clarified what dose is required for on-target effects that will be efficacious against cancer. This information is necessary before investing in larger, long term studies on patient outcomes. DCA deserves further investigation in clinical trials as a non-toxic cancer therapy due to its modest cost and low toxicity, and deserves consideration as an off-label cancer therapy.

 

ACKNOWLEDGMENTS

The authors wish to thank Dr. Humaira Khan for her assistance, and also the patient for his support and consent to publish his case.

 

COMMENTS

Case characteristics

The 32-year-old male patient presented with a pigmented lesion on his leg.

 

Clinical diagnosis

The patient was diagnosed with a melanoma.

 

Laboratory diagnosis

Melanoma confirmed by excisional biopsy.

 

Imaging diagnosis

Enlarged inguinal node confirmed to be involved with melanoma (needle biopsy).

 

Pathological diagnosis

Melanoma, BRAF positive.

 

Treatment

Excision of primary lesion with skin graft, sentinel node dissection, multiple excisions of recurrent cutaneous metastases. Traditional therapy stopped and natural anti-cancer therapies started (AHCC, dandelion root, curcumin, astragalus root, i.v. vitamin C, s.c. European mistletoe). Progression after 3 mo, dichloroacetate (DCA) added. Regression and remission following addition of DCA lasting for over 4 years.

 

Related reports

Computed tomography scan reports demonstrate the course of the disease and response to therapies.

 

Term explanation

DCA: Dichloroacetate sodium; RECIST: Response Evaluation Criteria for Solid Tumours; ECOG: Eastern Cooperative Oncology Group.

 

Experiences and lessons

DCA can act as a pro-apoptotic and cytostatic drug, and can thus achieve regression as well as long-term stabilization of metastatic cancer without serious side effects, as illustrated by this melanoma case.

 

Peer-review

Dr. Khan described a 32-year-old man received DCA therapy, with other medications from natural therapists and maintained in a stabilization state (metastatic melanoma) for over 4 years. It is an interesting case.

 

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FIGURE LEGENDS

Figure 1  Computed tomography scan from March 2012 prior to natural therapies and prior to dichloroacetate therapy. Largest node measured 8 mm in diameter.

Figure 2  Computed tomography scan from July 2012 after 3 mo of natural therapy alone, just prior to the start of dichloroacetate therapy. Largest node measured 22 mm × 20 mm.

Figure 3  Computed tomography scan from November 2012 after 4 mo of dichloroacetate therapy. Largest node measured 10 mm.

Figure 4  Computed tomography scan after 4 years of dichloroacetate therapy without any concurrent conventional cancer therapies. Scan demonstrates absence of cancer re-growth. All nodes measure less than 10 mm.

 

FOOTNOTES

Informed consent statement: The patient described in this manuscript has given consent to publish his case anonymously.

Conflict-of-interest statement: One of the authors (Khan) administers dichloroacetate therapy for cancer patients through Medicor Cancer Centres at a cost, and without profit. The clinic is owned by a family member of this author. The other authors have nothing to disclose.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Manuscript source: Invited manuscript

Peer-review started: February 12, 2017

First decision: March 28, 2017

Article in press: May 31, 2017

P- Reviewer: Su CC    S- Editor: Ji FF    L- Editor: A    E- Editor: Lu YJ 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Proof that the cancer industry doesn’t want a cure – even if it’s a pharmaceutical

Tuesday, January 31, 2012 by: PF Louis

http://www.naturalnews.com/034823_cancer_industry_patent_protection_drugs.html

(NaturalNews) A safe and effective cure for cancer has been discovered with a drug that was once used for unusual metabolic problems. Yet, the cancer industry shows no interest with following up on dichloroacetate (DCA) research from University of Alberta in Edmonton, Canada, reported in 2007. That’s because DCA is no longer patented. (1)

That research also confirmed cancer as a metabolic malfunction, not a weird mutation of cells often explained away as a genetic issue. But the medical mafia doesn’t want you to hear about it. But it confirms what most alternative cancer therapists already know.

Since Nixon declared the “war on cancer” in the 1970s, the cancer industry has succeeded with raising money for researching very expensive chemo substances at $50,000 to $100,000 per round or more for toxic therapies that rarely work. (2)

Chemo drugs usually lead to demanding more business with drugs to ease terrible side effects (http://www.naturalnews.com/034761_cancer_drugs_toxicity_Voraxaze.html). Meanwhile, more are getting cancer and more are dying from it, mostly because of the toxic treatments.

Explaining DCA research results

Evangelos Michelakis and the Alberta University research team tested DCA on human cancer cells outside the body and in cancerous mice with profound success. DCA was once used for unusual metabolic disorders. The worst side effects, which rarely occur, include some numbness and an affected gait.

The mice were fed DCA in water, and in weeks they had remarkable tumor shrinkage. This indicates DCA can be taken orally. DCA works by restoring the cells’ mitochondria. Michelakis and his team had discovered that the mitochondria in cancer cells are not permanently damaged and irreparable. This is what mainstream medicine thinks.

With mitochondria malfunctioning, cancer cells use glucose fermentation for survival energy. This fermentation occurs when glycolysis (glucose conversion) occurs in an anaerobic cellular environment, which can be created by benign tumor masses, toxins, and low pH levels.

DCA restores mitochondria in cells to make them function properly. Another function of normal mitochondria is signaling apoptosis, or cellular self destruction. Normal cells die and become replaced constantly. But with cancer cells, the apoptosis signal is nullified, making cancer cells “immortal.” (3)

The Alberta University researchers also realized that glycolysis fermentation in cancer cells produces lactic acid. The lactic acid breaks down the collagen holding those cells together in a tumor. This allows cancer cells to easily break away from a tumor shrinking with mainstream therapies.

The researchers reasoned this is why cancer metastasizes or spreads to different parts of the body or reappears after remission from chemo.

Tragic hypocrisy

Alternative cancer therapies have little or no problem with metastatic cancer or even cancer reoccurring after remission. Most alternative cancers simply cure cancers completely.

DCA offers the cancer industry an opportunity to come up with a pharmaceutical cure that is much cheaper and safer than their current standard of care. Yet the cancer industry is ignoring this opportunity. Instead, DCA is a homeless orphan begging for research funds to avoid legal issues with off label use on cancer. (4)

Alternative cancer practitioners have always simply tried out and when they succeeded shared them with others who cared more about healing than money and power.

The medical mafia has created a matrix that demands big bucks to make big bucks for sick care instead of curing. Everyone in on the scam makes out financially. The cancer industry accuses alternative cancer therapists of quackery and taking advantage of the desperately ill for financial gain. Accusing others of your motives and crimes is called projection.

The medical/pharmaceutical complex is crony capitalism that doesn’t want a cure for cancer from anywhere.

Sources for this article include:

(1) http://www.newscientist.com/article/dn10971

(2) http://www.sawilsons.com/gonzalez2.htm

(3) http://www.cell.com/cancer-cell/retrieve/pii/S1535610806003722

(4) http://www.dca.med.ualberta.ca/Home/Donations/

Chemotherapies that target angiogenesis can increase metastasis threefold- Cancer Cell Journal

Study finds that tumor cells can prevent cancer spread

January 17, 2012 in Cancer Cell Journal

http://medicalxpress.com/news/2012-01-tumor-cells-cancer.html

A new study finds that a group of little-explored cells in the tumor microenvironment likely serve as important gatekeepers against cancer progression and metastasis. Published in the January 17 issue of Cancer Cell, these findings suggest that anti-angiogenic therapies – which shrink cancer by cutting off tumors’ blood supply – may inadvertently be making tumors more aggressive and likely to spread.

One approach to treating cancer targets angiogenesis, or blood vessel growth. In this new investigation, senior author Raghu Kalluri, MD, PhD, Chief of the Division of Matrix Biology at Beth Israel Deaconess Medical Center (BIDMC) and Professor of Medicine at Harvard Medical School (HMS), wanted to find out if targeting a specific cell type, the pericyte, could inhibit tumor growth in the same way that other antiangiogenic drugs do. Pericytes are an important part of tissue vasculature, covering blood vessels and supporting their growth. Kalluri and his colleagues began by creating mice genetically engineered to support drug-induced depletion of pericytes in growing tumors. They then deleted pericytes in implanted mouse breast cancer tumors, decreasing pericyte numbers by 60 percent. Compared with wild-type controls, they saw a 30 percent decrease in tumor volumes over 25 days. However, contrary to conventional clinical wisdom, the investigators found that the number of secondary lung tumors in the engineered mice had increased threefold compared to the control mice, indicating that the tumors had metastasized. “If you just looked at tumor growth, the results were good,” says Kalluri. “But when you looked at the whole picture, inhibiting tumor vessels was not controlling cancer progression. The cancer was, in fact, spreading.” To understand the mechanism behind this increased metastasis, Kalluri and his team examined the tumor’s microenvironment to find out what changes were taking place at the molecular level. They found a fivefold percentage increase in hypoxic areas in tumors lacking pericytes. “This suggested to us that without supportive pericytes, the vasculature inside the tumor was becoming weak and leaky—even more so than it already is inside most tumors—and this was reducing the flow of oxygen to the tumor,” explains Kalluri. “Cancer cells respond to hypoxia by launching genetic survival programs,” he adds. To that end, the investigators found evidence of epithelial-to-mesenchymal transition (EMT), a change that makes the cells more mobile, so they can travel through those leaky vessels to new locations, and makes them behave more like stem cells, so they are better able to survive. Experiments that demonstrated fivefold increases in protein markers of EMT showed that the cells had undergone the change. The team also found a fivefold increase in activation of Met, a receptor molecule that promotes cell migration and growth.

Importantly, the team found that these molecular changes occurred inside the smaller, pericyte-depleted tumors that had increased incidences of secondary tumors in the lungs in the mouse models. “This suggested that smaller tumors are shedding more cancer cells into the blood and causing more metastasis,” says Kalluri. “We showed that a big tumor with good pericyte coverage is less metastatic than a smaller tumor of the same type with less pericyte coverage.” Because cancer therapies such as Imatinib, Sunitinib and others have been shown to decrease pericytes in tumors, the researchers’ next step was to perform the same experiments in mice with primary tumors, only this time, using Imatinib and Sunitinib rather than genetic programs to decrease pericyte numbers. And while both Imatinib and Sunitinib caused a 70 percent pericyte depletion, the end results, stayed the same: metastasis increased threefold. “We showed that a big tumor with good pericyte coverage is less metastatic than a smaller tumor of the same type with less pericyte coverage,” says Kalluri, who corroborated these findings in multiple types of cancer by repeating these same experiments with implanted renal cell carcinoma and melanoma tumors. Additional experiments showed that combining pericyte-depleting drugs with the Met-inhibiting drug helped suppress EMT and metastasis. Finally, to determine if the findings were relevant to patients, the scientists examined 130 breast cancer tumor samples of varying cancer stages and tumor sizes and compared pericyte levels with prognosis. They found that samples with low numbers of pericytes in tumor vasculature and high levels of Met expression correlated with the most deeply invasive cancers, distant metastasis and 5- and 10- year survival rates lower than 20 percent. “These results are quite provocative and will influence clinical programs designed to target tumor angiogenesis,” says Ronald A. DePinho, president of the University of Texas MD Anderson Cancer Center. “These impressive studies will inform and refine potential therapeutic approaches for many cancers.” Meanwhile, for Kalluri, the work suggests that certain assumptions about cancer must be revisited. “We must go back and audit the tumor and find out which cells play a protective role versus which cells promote growth and aggression,” says Kalluri. “Not everything is black and white. There are some cells inside a tumor that are actually good in certain contexts.” Provided by Beth Israel Deaconess Medical Center

Read more at: http://medicalxpress.com/news/2012-01-tumor-cells-cancer.html#jCp

Surgery – Biopsies Cause Metastasis – New Study finds

PROOF THAT CANCER SURGERY INCREASES MORTALITY

Walter Last

It is generally accepted in cancer research that the vast majority of patients or about 90% die from metastases or secondary tumours, and only a small minority from a primary tumour. Therefore it should be of great concern to therapists as well as patients that already more than 30 years ago it was conclusively shown that cancer surgery is the main cause of metastasis (Krokowski, see below). However, this research was completely ignored by the profession, it was just too awful to contemplate, and patients never got to know about it (1).

Since then more and more disturbing data and reviews have been published, the latest one is a comprehensive review by an international team of leading cancer researchers with the conclusion obvious from the title: Surgery Triggers Outgrowth of Latent Distant Disease in Breast Cancer: An Inconvenient Truth? (2).

Because of the undisputed status of the members of this team, their conclusions can no longer be ignored by the medical profession and cause much consternation, especially as the review is an open access publication. I expect that efforts are being made to prevent this information from becoming widespread public knowledge.

The review also found that future organ metastasis is independent of the size of the primary tumour and its apparent malignancy or the involvement of any lymph glands. Metastasis seems to depend mainly on the degree of stress for the tumour and the patient, growth stimulation due to the wound-healing mechanism initiated by surgery as well as on the quality of the immune system.

Furthermore, as the following examples show, surgery is not the only medical procedure that increases metastasis. In recent years there has been a steady stream of research showing that basically all medical interventions can trigger metastasis while a growing number of natural remedies and methods tend to inhibit metastasis.

Recent research findings

While most cancer research is funded by drug companies with the aim of increasing their profits, there are now also a growing number of independent studies that show the negative side of conventional cancer therapy. Here is a small selection of interesting research findings.

Conflict of Interest in Cancer Research: This analysis shows why it is so difficult to get to the truth in medical research. Conflicts of interest exist in a considerable number of cancer research articles published in medical journals, and there is a high degree of financial connections between researchers and pharmaceutical companies. This produces biased results with a more favourable outcome for investigated drugs and technologies (3).

Experts want to stop screening: Screening for breast and prostate cancer has not brought a decline in deaths from these diseases. Instead screening programs lead to tumour over-detection and over-treatment (4).

Morphine stimulates cancer and shortens life: Morphine has been used in cancer treatment for two centuries. Now research shows that it stimulates the growth and spread of cancer cells and shortens the survival time of patients (5).

Diagnostic X-rays cause cancer: It has been estimated that diagnostic X-rays over a lifetime cause up to 3.2% additional cancers in a population. Germany ranks among the countries with the highest X-ray cancer rates while with 0.6% the U.K. and Poland have the lowest lifetime risk, in Australia it is 1.3% (6).

Radiation therapy damages bones: The scientific world has been shaken by a report that a single therapeutic dose of radiation can cause appreciable bone loss. Years later osteoporosis, bone necrosis or bone cancer may develop (7).

More radiation danger: Exposure to ionizing radiation is known to result in genetic damage that can make cells cancerous. Now a new study has revealed that radiation can alter the environment surrounding cells so that future cells are more likely to become cancerous (8).

Chemotherapy promotes metastasis: Taxol, a chemotherapy drug, causes cancer cell micro-tentacles to grow longer and tumour cells to reattach faster. If treated with taxol before surgery to shrink the primary tumour, levels of circulating tumour cells go up 1,000 to 10,000 fold, potentially increasing metastasis (9).

Tamoxifen increases aggressive tumours: Tamoxifen use for breast cancer patients decreases their risk of developing a more common and less dangerous type of second breast cancer but has a more than four-fold increased risk of causing a more aggressive and deadly tumour (10).

Biopsies cause metastases: Biopsies may actively encourage the spread of metastases. Needle biopsies caused a 50% increase of metastatic spread to nearby lymph glands of breast tumours as compared to lumpectomies (11).

Stress promotes cancer: Stress hormones protect cancer cells from self destruction, promote the spread and growth of tumours directly as well as indirectly by weakening the immune system and encouraging new blood vessel growth. Patient stress  was associated with faster disease progression (12).

Stress kills: Stress hormones are released in high amounts with fear and during surgery. They greatly impair the immune system and promote the spread of metastases. Blocking stress hormones increased long-term post-operative cancer survival rates in animal models by 200-300 percent (13).

Breast cancer metastasis after hormone replacement therapy: Previously it had been shown that hormone replacement therapy increases the risk of breast cancer. Now a new study has found that it also increases the chance of the cancer metastasizing, or spreading to the lymph nodes (14).

Sharp drop in breast cancer rates: In recent years breast cancer rates dropped sharply due to a corresponding sharp drop in the use of hormone replacement therapy (15).

Ernst KrokowskiErnst H. Krokowski, M.D., Ph.D. (1926 – 1985) was a German Professor of Radio­logy. His research provided the first convincing proof that cancer surgery triggers metastasis. While many of his articles on different subjects are still on public record, his research on the relationship between surgery and metastases is difficult to find, even in German. His only paper on this subject in English is not listed in PubMed, and the journal in which it was published does no longer exist (16). Because of the obvious importance of this research I have now made this article available on my website (1). Also a related lecture in German can still be downloaded (17).

The Summary of his article reads: ‘It can no longer be doubted that under certain conditions diagnostic or surgical procedures can result in metastases. Analysis of metastatic growth rates has shown that from 30 percent (in hypernephroma) to 90 percent (in sarcoma and seminoma) of the diagnosed metastases were provoked by such procedures. This has been established by numerous animal experiments and clinical observations, and necessitates a change in the currently held concept of cancer therapy. The previ­ously applied and proven treatments by surgery and radiation must be preceded by a metastasis prophylaxis. Three different ways to achieve such a prophylaxis are proposed.’

With radiological imaging he measured the growth rates of 2,893 metastatic tumours in 568 patients with different cancers. From these he derived the following conclusions:

 

<!–[if !supportLists]–> 1.     <!–[endif]–> Metastases arise only from primary tumours or from their local recurrences; they disseminate at one time or only in a few shoves.

 

<!–[if !supportLists]–> 2.     <!–[endif]–> Lymph node metastases behave biologically differ­ently from organ metastases [lymph node metastases are relatively harmless, organ metastases are very dangerous].

 

<!–[if !supportLists]–> 3.     <!–[endif]–> The more than 3,000 growth curves (including exper­imental data from animals) can be described by a growth formula. The growth curves of a very large number of meta­stases, from 30 to 90 percent depending on the type of tumour, can be traced back to the time of the first treatment.

 

Here are some key observations from his article:

 

<!–[if !supportLists]–> §  <!–[endif]–> Inflated success rates [of cancer surgery] are the result of either selective composition of the groups of patients studied or of correspondingly adapted, i.e., corrected, statistics.

 

<!–[if !supportLists]–> §  <!–[endif]–> Cures related to the same stage and tumour size have not improved in the last 20 to 25 years [more recent findings state that the cure rate has not significantly increased since the 1970’s, which means that overall there was no significant improvement since the 1950’s].

 

<!–[if !supportLists]–> §  <!–[endif]–> Untreated postmenopausal women with breast cancer live longer than medically treated patients.

 

<!–[if !supportLists]–> §  <!–[endif]–> Metasta­ses occur sooner in fast-growing tumours than in slow-growing tumours. This suggests that these metastases begin their development at the same time as the first treatment.

 

<!–[if !supportLists]–> §  <!–[endif]–> Present cancer surgery may be regarded as a second Semmelweis phenomenon! (Dr Semmelweis campaigned for surgeons to wash and disinfect  their hands to stop them killing women during childbirth).

 

<!–[if !supportLists]–> §  <!–[endif]–> Manipulation of a tumour, such as severe palpation and pressure [mammography!], biopsy or surgery, results in a sudden increase of tumour cells released into the blood with a higher probability of metastasis.

 

<!–[if !supportLists]–> §  <!–[endif]–> The connection between surgery and formation of metastases was particularly impressive in single observed cases: in a patient with a sarcoma, formation of metastases occurred after surgery of the primary tumour and each time after four further surgeries of locally recurrent tumours.

 

<!–[if !supportLists]–> §  <!–[endif]–> It has long been taught in medicine that a melanoma should not be injured since lesions would cause an almost explosion-like growth of metastases.

 

<!–[if !supportLists]–> §  <!–[endif]–> Not only disturbance of a tumour but also unrelated surgery at a different location can trigger metastasis.

 

<!–[if !supportLists]–> §  <!–[endif]–> The larger a tumour becomes the slower its growth, and some observations suggest that it eventually stops growing.

 

<!–[if !supportLists]–> §  <!–[endif]–> Radiation and chemotherapy of the tumour before and after surgery were both unsuccessful.

 

<!–[if !supportLists]–> §  <!–[endif]–> The chance to decisively improve the cure quota occurs only once during the course of cancer, namely at the time of the first treatment.

 

An Inconvenient Truth?

 

The following review cites a steady stream of studies showing that it is better for patients to leave tumours alone. But that is not in the interest of the cancer industry for which invasive treatment is the financial life-blood. There were always new drugs and new ways to combine chemotherapy and radiotherapy with surgery, and claims that now a way has been found to prolong the lives of  patients. With new methods of early detection and small, precancerous, non-invasive and dormant tumours classified as cancer—tumours that would not have become malignant if left alone—some statistics indeed showed improved cure rates. This has now changed with a comprehensive review by this international team of leading cancer researchers.

Michael Retsky, Romano Demicheli, William Hrushesky, Michael Baum and Isaac Gukas

Review:Surgery Triggers Outgrowth of Latent Distant Disease in Breast Cancer: An Inconvenient Truth?

Cancers 2010, 2(2), 305-337; doi:10.3390/cancers2020305

Received: 9 March 2010; in revised form: 25 March 2010 / Accepted: 26 March 2010 / Published: 30 March 2010

Here is the Abstract of Surgery Triggers Outgrowth of Latent Distant Disease in Breast Cancer: An Inconvenient Truth? (2):

‘We review our work over the past 14 years that began when we were first confronted with bimodal relapse patterns in two breast cancer databases from different countries. These data were unexplainable with the accepted continuous tumour growth paradigm. To explain these data, we proposed that metastatic breast cancer growth commonly includes periods of temporary dormancy at both the single cell phase and the avascular micrometastasis phase. We also suggested that surgery to remove the primary tumour often terminates dormancy resulting in accelerated relapses. These iatrogenic events are apparently very common in that over half of all metastatic relapses progress in that manner. Assuming this is true, there should be ample and clear evidence in clinical data. We review here the breast cancer paradigm from a variety of historical, clinical, and scientific perspectives and consider how dormancy and surgery-driven escape from dormancy would be observed and what this would mean. Dormancy can be identified in these diverse data but most conspicuous is the sudden synchronized escape from dormancy following primary surgery. On the basis of our findings, we suggest a new paradigm for early stage breast cancer. We also suggest a new treatment that is meant to stabilize and preserve dormancy rather than attempt to kill all cancer cells as is the present strategy.’

http://www.mdpi.com/journal/cancers/special_issues/induced_angiogenesis

The bimodal relapse patterns referred to in this abstract mean that there are two time peaks when metastases appear after surgery for the primary tumour. The first peak is after 18 months, then follows a dip at 50 months and a broad peak at 60 months with a long tail extending for 15 to 20  years. About 50 to 80% of all relapses are in the first peak. Patients with large tumours relapse mainly in the first peak while with smaller tumours relapses are equal in both peaks.

 

There is also a structure in the first peak. Relapses in the first 10 months are due to micro-metastases that pre-exist with the primary tumour and that are stimulated to grow. This mode is most common for premenopausal patients with positive lymph nodes, over 20% of whom relapse. The rest of the first peak is due to single cells that are initially dormant but are induced to divide as a result of surgery. The second peak is then due to single cancer cells that have been seeded during surgery and are subsequently gradually developing into metastases.

 

This dynamic also accounts for the persistent excess mortality of premenopausal women in the third year of long-term mammography screening trials: metastases appear after 10 months and the time between relapse and death in breast cancer is approximately 2 years, which then results in death about 3 years after screening. I remember a young and apparently healthy patient who just had her breast removed after a mammogram showed a tiny tumour. She was confident that she had been saved because it had been caught so early, but 3 years later she was dead.

 

Other interesting evidence in this paper is from a Danish report: forensic autopsies show that 39% of women aged 40–49 have hidden and dormant breast cancer, while the lifetime risk of clinical breast cancer in Denmark is only 8%. This means that only about 20% of positive mammograms are for real and would have progressed to a clinical stage. The rest are either completely harmless and boost the medical cure rate, or in others subsequent surgery does trigger metastases and these women eventually die due to their treatment.

 

Here are some more highlights from this article:

 

<!–[if !supportLists]–> §  <!–[endif]–> Getting women screened with mammography is a major goal of some organizations so this information (about possible harm) is withheld as its release will be contrary to achieving their goal.

 

<!–[if !supportLists]–> §  <!–[endif]–> During most of the 20th century radical mastectomy was the accepted therapy. Unfortunately, only 23% of patients survived 10 years. The natural response to this failure was even more radical surgery.

 

<!–[if !supportLists]–> §  <!–[endif]–> The next step by medical oncologists was similar to that by surgeons: if a little doesn‘t work then try a lot! Needless to say the high dose chemotherapy with bone marrow rescue was a failure and the least said about this sorry episode in the history of breast cancer the better.

 

<!–[if !supportLists]–> §  <!–[endif]–> Pathological and autopsy studies have suggested that most of the occult tumours in breast (and prostate cancers) may never reach clinical significance.

 

<!–[if !supportLists]–> §  <!–[endif]–> Cancer cells and micro-metastases remain in a state of dormancy until some signal, perhaps the act of surgery or other adverse life event (emotional shock according to Dr Hamer) stimulates them into fast growth. The act of wounding the patient creates a favorable environment for the sudden transfer of a micro-metastasis from a latent to an active phase.

 

<!–[if !supportLists]–> §  <!–[endif]–> A large primary tumour inhibits the development and growth of any distant metastases! Removal of the primary results in the establishment and rapid growth of large numbers of latent metastases, the majority of which would have remained dormant or would have disappeared if the primary tumour had not been removed. The growth-stimulating postoperative effects on pre-existing latent metastases are due to removal of the primary tumour.

 

<!–[if !supportLists]–> §  <!–[endif]–> Other cancers also need to be carefully examined. There are data showing similar activity especially in melanoma and osteosarcoma.

References

 

<!–[if !supportLists]–> 1)     <!–[endif]–> http://www.health-science-spirit.com/Krokowski.pdf

 

<!–[if !supportLists]–> 2)     <!–[endif]–> http://www.mdpi.com/2072-6694/2/2/305/pdf, 30 March 2010

 

<!–[if !supportLists]–> 3)     <!–[endif]–> http://www.eurekalert.org/pub_releases/2009-05/acs-rfc050609.php, 11 May 2009

 

<!–[if !supportLists]–> 4)     <!–[endif]–> http://esciencenews.com/articles/2010/03/24/study.questions.whether.screening.really.cuts.breast.cancer.deaths, 24 March 2010, http://www.sciencedaily.com/releases/2009/10/091020181301.htm, 22 October 2009, and http://scienceblog.com/35676/implementing-comparative-effectiveness-research-lessons-from-the-mammography-screening-controversy/ 22 June 2010

 

<!–[if !supportLists]–> 5)     <!–[endif]–> http://www.sciencedaily.com/releases/2009/11/091118143209.htm, 18 November 2009

 

<!–[if !supportLists]–> 6)     <!–[endif]–> http://www.abc.net.au/science/news/stories/s1034306.htm, 30 January 2004

 

<!–[if !supportLists]–> 7)     <!–[endif]–> http://www.cancerdecisions.org/102906_page.html, 29 October 2006

 

<!–[if !supportLists]–> 8)     <!–[endif]–> http://www.physorg.com/news192978184.htm, 13 May 2010

 

<!–[if !supportLists]–> 9)     <!–[endif]–> http://www.sciencedaily.com/releases/2010/03/100312133712.htm, 15 March 2010

 

<!–[if !supportLists]–> 10)  <!–[endif]–> http://www.medicalnewstoday.com/articles/161850.php, 26 August 2009

 

<!–[if !supportLists]–> 11)  <!–[endif]–> http://articles.mercola.com/sites/articles/archive/2005/04/16/needle-biopsy.aspx, 16 April 2005

 

<!–[if !supportLists]–> 12)   <!–[endif]–> http://www.scientificamerican.com/article.cfm?id=does-stress-feed-cancer, 13 April 2010

 

<!–[if !supportLists]–> 13)   <!–[endif]–> http://scienceblog.com/15572/stress-fear-increase-cancer-recurrence-risk-study-says/, 27 February 2008

 

<!–[if !supportLists]–> 14)  <!–[endif]–> http://www.medicalnewstoday.com/articles/188001.php, 07 May 2010

 

<!–[if !supportLists]–> 15)  <!–[endif]–> http://breast-cancer-research.com/content/12/1/R4, 8 January 2010

 

<!–[if !supportLists]–> 16)  <!–[endif]–> Krokowski, E.H.: Is the Current Treatment of Cancer Self-Limiting in the Extent of its Success? J Int Acad Preventive Medicine, 6 (1) 23 – 39, 1979

 

<!–[if !supportLists]–> 17)  <!–[endif]–> http://www.windstosser.ch/museum/manuskript/allgem_u_historisch/05_7.html –  Krokowski, E,H.: Verändertes Konzept der Krebsbehandlung. Lecture at the ‘Kongress der DEUTSCHEN AKADEMIE FÜR MEDIZINISCHE FORTBILDUNG 1978 in Kassel’

 

<!–[if !supportLists]–> 18)  <!–[endif]–> http://www.cancerdecisions.com/031509_page.html, 15 March 2009

 

<!–[if !supportLists]–> 19)  <!–[endif]–> http://www.medicalnewstoday.com/articles/23042.php, 19 April 2005

 

<!–[if !supportLists]–> 20)  <!–[endif]–> http://www.sanfordburnham.org/default.asp?contentID=785, 15 September 2009

 

<!–[if !supportLists]–> 21)  <!–[endif]–> http://www.curenaturalicancro.com/pdf/bicarbonate-increases-tumour-ph-and-inhibits-metastases.pdf, 10 March 2009

 

<!–[if !supportLists]–> 22)  <!–[endif]–> http://www.sciencedaily.com/releases/2010/03/100309182449.htm, 10 March 2010

 

<!–[if !supportLists]–> 23)  <!–[endif]–> http://scienceblog.com/10094/ginkgo-biloba-extract-more-than-just-for-memory/,24 February 2006

 

<!–[if !supportLists]–> 24)  <!–[endif]–> http://www.medicalnewstoday.com/articles/167261.php, 14 October 2009

 

<!–[if !supportLists]–> 25)  <!–[endif]–> http://www.scientificamerican.com/article.cfm?id=environment-as-cause-for-cancer, 6 May 2010

 

<!–[if !supportLists]–> 26)  <!–[endif]–> http://www.newscientist.com/article/dn18799-rats-on-junk-food-pass-cancer-down-the-generations.html, 20 April 2010

 

<!–[if !supportLists]–> 27)  <!–[endif]–> http://www.medicinenet.com/script/main/art.asp?articlekey=104326, 4 August 2009

 

<!–[if !supportLists]–> 28)  <!–[endif]–> http://cancerres.aacrjournals.org/cgi/content/full/67/3/847, 1 February 2007, and also http://www.sciencedaily.com/releases/2010/05/100509144652.htm, 9 May 2010

 

<!–[if !supportLists]–> 29)  <!–[endif]–> http://scienceblog.com/20646/autoantibodies-may-be-created-in-response-to-bacterial-dna/, 27 April 2009

 

<!–[if !supportLists]–> 30)  <!–[endif]–> http://www.sciencedaily.com/releases/2009/06/090611160658.htm, 11 June 2009

 

<!–[if !supportLists]–> 31)  <!–[endif]–> http://foodforbreastcancer.com/news/fasting-protects-normal-cells-and-sensitizes-cancer-cells-to-chemotherapy, 6 May 2010

 

<!–[if !supportLists]–> 32)  <!–[endif]–> Last, Walter: The Holistic Solution to Overcoming Cancer. NEXUS 2008; 16(1); also at http://www.health-science-spirit.com/cancersolution.htm

 

<!–[if !supportLists]–> 33)  <!–[endif]–> http://www.wired.com/wiredscience/2009/05/cancercompromise/

 

<!–[if !supportLists]–> 34)  <!–[endif]–> Websites: http://www.health-science-spirit.com/, www.heal-yourself.com.au or www.healing-yourself.com. Books: Overcoming Cancer http://www.the-heal-yourself-series.com/OvercomingCancer.html, and Heal Yourself the Natural Way http://www.the-heal-yourself-series.com/Heal_Yourself_The_Natural_Way.html

 

http://www.health-science-spirit.com/cancersurgery.htm

Dichloroacetate reduces sympathetic nerve responses to static exercise

Dichloroacetate reduces sympathetic nerve responses to static exercise

  1. 1.  S. Ettinger,
  2. 2.  K. Gray,
  3. 3.  S. Whisler, and
  4. 4.  L. Sinoway

+ Author Affiliations

1.   1Milton S. Hershey Medical Center, Division of Cardiology, PennsylvaniaState University, Hershey 17033.

Abstract

Lactic acid is thought to be a stimulant of muscle metaboreceptors. The goal of the present study was to determine if inhibition of lactic acid production by dichloroacetate (DCA) would attenuate muscle sympathetic nerve activity (MSNA) during static forearm exercise. DCA increases pyruvate dehydrogenase levels. Thus, for a given amount of pyruvate produced, less lactic acid is formed. Seven subjects performed static forearm exercise at 20% maximal voluntary contraction until fatigue followed by posthandgrip circulatory arrest (PHG-CA) (trial.1). Subjects then received DCA (35 mg/kg) and repeated the exercise protocol (trial 2). We observed an attenuated rise in forearm venous lactate and MSNA. The trial 2 MSNA value during PHG-CA was 51 +/- 11% less than the value during trial 1 (P less than 0.01). In seven control subjects, two bouts of static forearm exercise were performed with an intervening saline infusion. This intervention had no effect on lactate or MSNA responses to exercise. We conclude that DCA attenuates lactate responses to static exercise, and this is associated with a blunted MSNA response.

 

The Prime Cause and Prevention of Cancer Otto Warburg

Otto Warburg

The Prime Cause and Prevention of Cancer

(Revised Lindau Lecture)

By OTTO WARBURG

(Director, Max Planck Institute for Cell Physiology, Berlin-Dahlem, Germany) English Edition by DEAN BURK*), National Cancer Institute, Bethesda, Maryland*)

Note by DEAN BURK: Adapted from a lecture originally delivered by O. Warburg at the 1966 annual meeting of Nobelists at Lindau, Germany. O. Warburg won the Nobel Prize in Medicine in 1931 for his discovery of the oxygen-transferring enzyme of cell respiration, and was voted a second Nobel Prize in 1944 for his discovery of the active groups of the hydrogen transferring enzymes. Many universities, like Harvard, Oxford, Heidelberg have offered him honorary degrees. He is a Foreign member of the Royal Society of London, a Knight of the Order of Merit founded by Frederick the Great, and was awarded the Great Cross with Star and Shoulder ribbon of the Bundesrepublik. His main interests are Chemistry and Physics of Life. In both fields no scientist has been more successful.

There are prime and secondary causes of diseases. For example, the prime cause of the plague is the plague bacillus, but secondary causes of the plague are filth, rats, and the fleas that transfer the plague bacillus from rats to man. By a prime cause of a disease I mean one that is found in every case of the disease.

Cancer, above all other diseases, has countless secondary causes. But, even for cancer, there is only one prime cause. Summarized in a few words, the prime cause of cancer is the replacement of the respiration of oxygen in normal body cells by a fermentation of sugar. All normal body cells meet their energy needs by respiration of oxygen, whereas cancer cells meet their energy needs in great part by fermentation. All normal body cells are thus obligate aerobes, whereas all cancer cells are partial anaerobes. From the standpoint of the physics and chemistry of life this difference between normal and cancer cells is so great that one can scarcely picture a greater difference. Oxygen gas, the donor of energy in plants and animals is dethroned in the cancer cells and replaced by an energy yielding reaction of the lowest living forms, namely, a fermentation of glucose.

The key to the cancer problem is accordingly the energetics of life, which has been the field of work of the Dahlem institute since its initiation by the Rockefeller Foundation about 1930. In Dahlem the oxygen transferring and hydrogen transferring enzymes were discovered and chemically isolated. In Dahlem the fermentation of cancer cells was discovered decades ago; but only in recent years has it been demonstrated that cancer cells can actually grow in the body almost with only the energy of fermentation. Only today can one submit, with respect to cancer, all the experiments demanded by PASTEUR and KOCH as proof of the prime causes of a disease. If it is true that the replacement of oxygen-respiration by fermentation is the prime cause of cancer, then all cancer cells without exception must ferment, and no normal growing cell ought to exist that ferments in the body.

An especially simple and convincing experiment performed by the [US] Americans MALMGREN and FLANEGAN confirms the view. If one injects tetanus spores, which can germinate only at very low oxygen pressures, into the blood of healthy mice, the mice do not sicken with tetanus, because the spores find no place in the normal body where the oxygen pressure is sufficiently low. Likewise, pregnant mice do not sicken when injected with the tetanus spores, because also in the growing embryo no region exists where the oxygen pressure is sufficiently low to permit spore germination. However, if one injects tetanus spores into the blood of tumor-bearing mice, the mice sicken with tetanus, because the oxygen pressure in the tumors can be so low that the spores can germinate. These experiments demonstrate in a unique way the anaerobiosis of cancer cells and the non-anaerobiosis of normal cells, in particular the non-anaerobiosis of growing embryos.

The Fermentation of Morris Hepatomas

A second type of experimentation demonstrates a quantitative connection between fermentation of tumors and growth rate of tumors.

If one injects rats with cancer-inducing substances of different activities, one can create, as HAROLD MORRIS of the National Cancer Institute in Bethesda has found, liver cancers (hepatomas) of very different degrees of malignancy. Thus, one strain of tumor may double its mass in three days, another strain may require 30 days. Recently DEAN BURK and MARK WOODS 3), also of the National Cancer Institute, measured the in vitro rates of anaerobic fermentation in different lines of these hepatomas, and obtained a curve (Fig. 1) that shows a quantitative relationship between fermentation and growth rate, and therefore between fermentation and malignancy, in these various tumor strains. The fermentation increases with the malignancy, and indeed the fermentation increases even faster than the malignancy.

Special interest attaches to the fermentation of the most slowly growing hepatomas, because several investigators in the United States believed that they had found *) that such tumors had no fermentation; that is that anaerobiosis cannot be the prime cause of cancer.

*) For example see C. H. BÖHRINGER SON, Ingelheim am Rhein, the factory Work-Journal “Das Medizinische Prisma” , Vol. 13, 1963. Here a lecture of VAN POTTER (Madison, Wisconsin) is reprinted where owing to the slow-growing Morris-tumors anaerobiosis as prime cause of cancer is rejected and the lack of “intracellular feeding back” is claimed to be the real cause of cancer.

Fig. 1. Velocity of growth and fermentation of the Morris-Hepatomas, according to DEAN BURK and MARK WOODS

DEAN BURK and MARK WOODS saw immediately from their curves that in the region of the zero point the rate of fermentation was so small that it could no longer be measured by the usual gross methodology employed by the aforementioned workers, whereas in the same region the smallest growth rate was always easily measurable. BURK and WOODS saw, in other words, that in the region of the zero pint of their curves the growth test was more sensitive than the usual fermentation test. With refined and adequate methods for measuring fermentation of sugar (glucose) they found, what any physical chemist after a glance at the curve would realize, that even the most slow-growing Morris hepatomas fermented sugar.

The results of DEAN BURK and MARK WOODS were confirmed and extended by other workers with independent methods. PIETRO GULLINO, also in Bethesda, developed a perfusion method whereby a Morris hepatoma growing in the living animal could be perfused for long periods of time, even weeks, by means of a single artery and single vein, and the blood entering and leaving any given tumor could be analyzed. GULLINO found with this method that the slow-growing Morris hepatomas always produced fermentation lactic acid during their growth. This was in contrast to liver, where, as known since the days of CLAUDE BERNARD, lactic acid is not produced but consumed by liver; the difference between liver and Morris tumors in vivo is thus infinite (+ vs. -). GULLINO further found that tumors grow in vivo with diminished oxygen consumption. In summary, GULLINO’s findings indicate that the slow-growing Morris hepatomas are partial anaerobes. SILVIO FIALA, a biochemist at the University of Southern California, found that not only did the slow-growing hepatomas produce lactic acid, but also that the number of their oxygen-respiring grana was reduced.

The slow-growing Morris hepatomas are therefore far removed from having refuted the anaerobiosis of tumors. On the contrary, they are the best proof of this distinctive characteristic. For forty years cancer investigators have searched for a cancer that did not ferment. When finally a non-fermenting tumor appeared to have been found in the slow-growing Morris tumors, it was shown to be a methodological error.

Transformation of Embryonic Metabolism into Cancer Metabolism

A third type of experiment, from the institute in Dahlem with coworkers GAWEHN, GEISSLER and LORENZ, is likewise highly pertinent. Having established that anaerobiosis is that property of cancer cells that distinguishes them from all normal body cells, we attacked the question, namely, how normal body cells may become transformed into anaerobes 6)7)8).

If one puts embryonic mouse cells into a suitable culture medium saturated with physiological oxygen pressures, they will grow outside the mouse body, in vitro, and indeed as pure aerobes, with a pure oxygen respiration, without a trace of fermentation. However, if during the growth one provides and oxygen pressure so reduced that the oxygen respiration is partially inhibited, the purely aerobic metabolism of the mouse embryonic cells is quantitatively altered within 48 hours, in the course of two cell divisions, into the metabolism characteristic of fermenting cancer cells. Fig. 2 illustrates the very simple experimental procedure involved.

If one then brings such cells, in which during their growth under reduced oxygen pressure a cancer cell metabolism has been produced, back under the original high oxygen pressure, and allows the cell to grow further, the cancer metabolism remains. The transformation of embryonic cell metabolism into cancer cell metabolism can thus be irreversible, and important result, since the origin of cancer cells from normal body cells is an irreversible process. It is equally important that these body cells whose metabolism has thus been transformed into cancer metabolism now continue to grow in vitro as facultative anaerobes. The duration of our experiments is still too limited to have yielded results of tests of inoculation of such cells back into mice, but according to all previous indications such cells will later grow as anaerobes upon transplantation into animals.

In any case, these experiments belong to the most important experiments in the field of cancer investigation since the discovery of the fermentation of tumors. For cancer metabolism, heretofore, measured so many thousand of times, has now been induced artificially in body cells by the simplest conceivable experimental procedure, and with this artificially induced cancer metabolism the body cells divide and grow as anaerobes in vitro*).

*) The experiments were at once repeated, when they were published, of course without acknowledgment. See for example Th. Goodfriend, D. M. Sokol and N. O. Kaplan, J. molecular Biol. 15, 18, 1966.

In recent months we have further developed our experimental arrangements so that we can measure manometrically the oxygen respiration and fermentation of the growing mouse embryonic cells during the metabolic transformation. Fig. 3 shows the experimental arrangement. We find by such experiments that 35 percent inhibition of oxygen respiration already suffices to bring about such a transformation during cell growth**). Oxygen pressures that inhibit respiration 35 percent can occur at the end of blood capillaries in living animals, so that the possibility arises that cancer may result when too low oxygen pressures occur during cell growth in animal bodies.

**) These experiments show, like the curve of Dean Burk and Mark Woods in Fig. 1, that it is more correct to designate tumor cells as “partial anaerobes” rather than “facultative anaerobes”. A body cell is transformed into a tumor cell if only a part of the respiration is replaced by fermentation.

 

Fig. 2. Method to transform embryonic metabolism into cancer metabolism by

decreasing the oxygen pressure (Weniger O2 = Less O2, Viel O2 = Much O2)

The induction of cancers by solid materials injected into animals is a further experimental indication of this possibility. If one implants discs of solid substances under the skin of rats, the discs will soon be surrounded by capsules of living tissue that will be nourished with blood vessels from the hypodermis. Sarcomas very frequently develop in these capsules. It is immaterial whether the solid discs are chemically plastics, gold, or ivory, etc. What produces the cancer is not the chemical nature of the solid discs, but the special kind of blood nourishment supplied to the tissue encapsulating the discs. This blood provision varies with the site and in adequacy within a given animal, and induces cancer from the low oxygen pressure in the encapsulating disc.

Fig. 3. Method to measure manometrically respiration and fermentation during

the transformation of embryonic into cancer metabolism*)

(Luft = Air)

*) The vessels are not shaken, because shaking inhibits growth. Therefore, the oxygen pressure in the liquid phase at the bottom of the vessels is much lower than in the gasphase. For example, when the oxygen pressure in the gas phase was 2000 mm H2O it was at the bottom of the vessels 130 mm H2O. (O. Warburg, A. Geissler and S. Lorenz, Zeitschr. für Naturforschung 20b, 1070, 1965.)

Thermodynamics

If a lowered oxygen pressure during cell growth may cause cancer, or, more generally, if any inhibition of respiration during growth may cause cancer, then a next problem is to show why reduced respiration induces cancer. Since we already know that with a lowering of respiration fermentation results, we can re-express our question: Why does cancer result if oxygen-respiration is replaced by fermentation?

The early history of life on our planet indicates that life existed on earth before the earth’s atmosphere contained free oxygen gas. The living cells must therefore have been fermenting cells then, and, as fossils show, they were undifferentiated single cells. Only when free oxygen appeared in the atmosphere – some billion years ago – did the higher development of life set in, to produce the plant and animal kingdoms from the fermenting, undifferentiated single cells. What the philosophers of life have called “Evolution créatrice” has been and is therefore the work of oxygen.

The reverse process, the dedifferentiation of life, takes place today in greatest amount before our eyes in cancer development, which is another expression for dedifferentiation. To be sure, cancer development takes place even in the presence of free oxygen gas in the atmosphere, but this oxygen may not penetrate in sufficient quantity into the growing body cells, or the respiratory apo-enzymes of the growing body cells may not be saturated with the active groups. In any case, during the cancer development the oxygen-respiration always falls, fermentation appears, and the highly differentiated cells are transformed to fermenting anaerobes, which have lost all their body functions and retain only the now useless property of growth. Thus, when respiration disappears, life does not disappear, but the meaning of life disappears, and what remains are growing machines that destroy the body in which they grow.

But why oxygen differentiates and why lack of oxygen dedifferentiates? Nobody would dispute that the development of plants and animals and man from unicellular anaerobes is the most improbable process of all processes in the world. Thus there is no doubt, that EINSTEIN descended from a unicellular fermenting organism – to illustrate the miracle, molecular O2 achieved. But according to the thermodynamics of Boltzmann, improbable processes require work to take place.

It requires work to produce temperature differences in a uniformly temperatured gas; whereas the equalization of such temperature differences is a spontaneous process that does not require work. It is the oxygen-respiration that provides in life this work, and dedifferentiation begins at once when respiration is inhibited in any way. In the language of thermodynamics, differentiation represents a forced steady state, whereas dedifferentiation – that is, cancer – is the true equilibrium state. Or, illustrated by a picture: the differentiated body cell is like a ball on an inclined plane, which, would roll down except for the work of oxygen-respiration always preventing this. If oxygen respiration is inhibited, the ball rolls down the plane to the level of dedifferentiation.

But why respiratory energy and not fermentation energy can differentiate, whereas in general, for example in growth, respiratory energy and fermentation energy are equivalent? Obviously, there would be no cancer if there were not this discrimination of fermentation energy, that is, if fermentation like respiration could differentiate. Then, when respiration is replaced by fermentation, fermentation would take over differentiation, and a high state of differentiation would be maintained even in the fermenting body cells.

Chemistry

Physics cannot explain why the two kinds of energy are not equivalent in differentiation; but chemistry may explain it. Biochemists know that both respiration energy and fermentation energy do their work as phosphate energy, but the ways of phosphorylation are different. If one applies this knowledge to carcinogenesis, it seems that only oxidative phosphorylation but not fermentative phosphorylation can differentiate, a result, that may in future explain the mechanism of differentiation.

Yet Biochemistry can explain already today why fermentation arises, when respiration decreases. Figure 4 shows that the pathways of respiration and fermentation are common as far as pyruvic acid. Then the pathways diverge. The endproducts of fermentation is reached by one single reaction, the reduction of pyruvic acid by dihydro-nicotinamide to lactic acid. On the other hand, the endproducts of the oxidation of pyruvic acid, H2O and CO2, are only reached after many additional reactions. Therefore, when cells are harmed, it is probable that first respiration is harmed.

In this way the frequency of cancer is explained by reasons of probability.

Figure 4

To sum up:

Impairment of respiration is [more] frequent than impairment of fermentation because respiration is more complicated than fermentation.

The impaired respiration can be easily replaced by fermentation, because both processes have a common catalyst, the nicotinamide.

The consequence of the replacement of respiration by fermentation is mostly glycolysis, with death of the cells by lack of energy. Only if the energy of fermentation is equivalent to the lost energy of respiration, is the consequence anaerobiosis. Glycolysis means death by fermentation, anaerobiosis means life by fermentation.

Cancer arises, because respiration, but not fermentation, can maintain and create the high differentiation of body cells.

To conclude the discussion on the prime cause of cancer, the virus-theory of cancer may be mentioned. It is the most cherished topic of the philosophers of cancer. If it were true, it would be possible to prevent and cure cancer by the methods of virology; and all carcinogens could be eaten or smoked freely without any danger, if only contact with the cancer virus would be avoided.

It is true that some virus-caused cancerb) occur in animals, but no one sure human virus-cancer has been observed so far, whereas innumerable substances cause cancer without viruses in animals and man. Thus viruses do not meet the demands of Pasteur, that is must be possible to trace the prime cause in every case of the disease. Therefore science classifies viruses as remote causes of cancer, leading to anaerobiosis, the prime cause that meets the demands of Pasteur.

b) The chicken Rous sarcoma, which is labeled today as a virus tumor, ferments glucose and lives as a partial anaerobe like all tumors. O. WARBURG, Bioch. Zeitschrift 160, 307, 1925; F. WIND, Klinische Wochenschrift, Nr. 30, 1926.

Many may remember how anaerobiosis as prime cause of cancer was recently disputed emphatically, when one single cancer – the slow Morris hepatomas – was believed (wrongly) to lack in fermentation. In contrast the virus theory is adhered to although all cancers of man are lacking in virus-origin. This means the surrender of the principles of Pasteur and the relapse into bygone times of medicine.

Applications

Of what use is it to know the prime cause of cancer? Here is an example. In Scandinavian countries there occurs a cancer of throat and esophagus whose precursor is the so-called Plummer-Vinson syndrome. This syndrome can be healed when one adds to the diet the active groups of respiratory enzymes, for example: iron salts, riboflavin, nicotinamide, and pantothenic acid. When one can heal the precursor of a cancer, one can prevent this cancer. According to ERNEST WYNDER 3) of the Sloan-Kettering Institute for Cancer Research in New York, the time has come when one can exterminate this kind of cancer with the help of the active groups of the respiratory enzymes.

It is of interest in this connection that with the help of one of these active groups of the respiratory enzymes, namely nicotinamide, tuberculosis can be healed quite as well as with streptomycin, but without the side effects of the latter c). Since the sulfonamides and antibiotics, this discovery made in 1945 is the most important event in the field of chemotherapy generally, and encourages, in association with the experiences in Scandinavia, efforts to prevent cancer by dietary addition of large amounts of the active groups of the respiratory enzymes. Since there can scarcely be overdosage, such experiments can do no harm.

c) V. CHORINE: C. R. sci. Paris, 220, 150 (1945). – H. FUST and A. STUDER, Schweizerische Z. für allgemeine Pathologie, Band 14; Fasc 5 (1951).

I would like to go further and propose always making dietary additions of large amounts of the active groups of the respiratory enzymes after successful operations when there is danger from metastatic growths. One could indeed never succeed in redifferentiating the dedifferentiated cancer cells, since during the short duration of human life the probability of such a back-differentiation is zero. But one might increase the respiration of growing metastases, and thereby inhibit their fermentation, and – on the basis of the curve of DEAN BURK and MARK WOODS obtained with the Morris hepatomas – thereby inhibit the growth of metastases to such an extent that they might become as harmless as the so-called “sleeping” cancer cells in the prostates of elderly men.

A Second Example of Application

The physicist MANFRED VON ARDENNE has recently attacked the problem of the therapy of cancer. ARDENNE discovered that cancer cells owing to their fermentation, are more acid – inside and on their surface – than normal cells and hence are more sensitive to high temperatures. On this basis, he and his medical colleagues have treated cancer patients, after surgical removal of the primary tumors, by raising the body temperature of the patients to about 109º Fahrenheit for an hour, in the hope that the metastases will then be killed or their growth so slowed up as to become harmless. It is not yet decided whether this idea can be described as a practical success. But the provisional work of ARDENNE is already of great significance in a field where hopes of conventional chemotherapy have been dimmed but might be brightened by combination with extreme or moderate hyperthermy.

A third application. According to an estimate by K. H. Bauer of the Cancer Institute in Heidelberg, at least one million of the now living twenty five million male inhabitants of West Germany will die of cancer of the respiratory tract; still more will die from other cancer. When one considers that cancer is a permanent menace, one realizes that cancer has become one of the most dangerous menaces in the history of medicine.

Many experts agree that one could prevent about 80% of all cancers in man, if one could keep away the known carcinogens from the normal body cells. This prevention of cancer might involve no expenses, and especially would require little further research to bring about cancer prevention in up to 80 percent *).

*) Since this estimate was published, some thought 80% even too low. Yet prevention remained taboo and early diagnosis was the only consolation that was offered.

Why then does it happen that in spite of all this so little is done towards the prevention of cancer? The answer has always been that one does not know what cancer or the prime cause of cancer [might] be, and that one cannot prevent something that is not known.

But nobody today can say that one does not know what cancer and its prime cause [may] be. On the contrary, there is no disease whose prime cause is better known, so that today ignorance is no longer an excuse that one cannot do more about prevention. That prevention of cancer will come there is no doubt, for man wishes to survive. But how long prevention will be avoided depends on how long the prophets of agnosticism will succeed in inhibiting the application of scientific knowledge in the cancer field. In the meantime, millions of men must die of cancer unnecessarily.

The Prime Cause and Prevention of Cancer

with two prefaces on prevention

 

Revised lecture at the meeting of the Nobel Laureates on June 30, 1966 at Lindau, Lake Constance, Germany by Otto Warburg, Director, Max Planck-Institute for Cell Physiology, Berlin-Dahlem

English Edition by Dean Burk, National Cancer Institute, Bethesda, Maryland, USA

The Second Revised Edition

Published by Konrad Triltsch, Würzburg, Germany, 1969

Otto Warburg 1883-1970

Preface to the Second Revised German Edition of the Lindau Lecture

(The way to prevention of cancer)

Since the Lindau lecture of June 1966 many physicians have examined – not unsuccessfully – the practical consequences of the anaerobiosis of cancer cells. The more who participate in these examinations, the sooner will we know what can be achieved. It is a unique aspect of these examinations that they can be carried out on human patients, on the largest scale, without risk; whereas experiments on animals have been misleading many times. The cure of human cancer will be the resultant of biochemistry of cancer and of biochemistry of man.

A list of selected active groups of respiratory enzymes will soon be published, to which we recently added cytohemin and d-amino-Levulinic acid, the precursor of oxygen-transferring hemins. In the meantime commercial vitamin preparations may be used that contain, besides other substances, many active groups of the respiratory enzymes. Most of these may be added to the food. Cytohemin and vitamin B 12 may be given subcutaneously. (A synonym of “active group” is “prosthetic” group of an enzyme.)

There exists no alternative today to the prevention of cancer as proposed at Lindau. It is the way that attacks the prime cause of cancer most directly and that is experimentally most developed. Indeed millions of experiments in man, through the effectiveness of some vitamins, have shown, that cell respiration is impaired if the active groups of the respiratory enzymes are removed from the food; and that cell respiration is repaired at once, if these groups are added again to the food. No way can be imagined that is scientifically better founded to prevent and cure a disease, the prime cause of which is an impaired respiration. Neither genetic codes of anaerobiosis nor cancer viruses are alternatives today, because no such codes and no such viruses in man have been discovered so far; but anaerobiosis has been discovered.8

What can be achieved by the active groups, when tumors have already developed? The answer is doubtful, because tumors live in the body almost anaerobically, that is under conditions that the active groups cannot act.

On the other hand, because young metastases live in the body almost aerobically, inhibition by the active groups should be possible. Therefore we propose first to remove all compact tumors, which are the anaerobic foci of the metastasis. Then the active group should be added to the food, in the greatest possible amount, for many years, even for ever. This is a promising task. If it succeeds, then cancer will be a harmless disease.

Moreover, we discovered recentlya) in experiments with growing cancer cells in vitro that very low concentrations of some selected active groups inhibit fermentation and the growth of cancer cells completely, in the course of a few days. From these experiments it may be concluded that de-differentiated cells die if one tries to normalize their metabolism. It is a result that is unexpected and that encourages the task of inhibiting the growth of metastases with active enzyme groups.

As emphasized, it is the first precondition of the proposed treatment that all growing body cells be saturated with oxygen. It is a second precondition that exogenous carcinogens be kept away, at least during the treatment. All carcinogens impair respiration directly or indirectly by deranging capillary circulation, a statement that is proved by the fact that no cancer cell exists, the respiration of which is not impaired. Of course, respiration cannot be repaired if it is impaired at the same time by carcinogens.

It has been asked after the Lindau lecture why the repair of respiration by the active groups of the enzymes was proposed as late as 1966, although the fermentation of the cancer cell was discovered as early as 1923. Why was so much time lost?

He who asked this questions ignored that in 1923 the chemical mechanism of enzyme action was still a secret of living nature alone.1 The first active group of an enzyme, “Iron, the Oxygen-Transferring Part of the Respiratory Enzyme” was discovered in 19242. There followed in two decades the discoveries of the O2-transferring metalloproteins, the flavoproteins and the pyridinproteins, a period that was concluded by the “Heavy Metals as Prosthetic Groups of Enzymes”3 and by the “Hydrogen Transferring Enzymes”4 in 1947 to 1949.

Moreover, during the first decades after 1923 glycolysis and anaerobiosis were constantly confused, so that nobody knew what was specific for tumors. The three famous and decisive discoveries of DEAN BURK and colleagues5 of the National Cancer Institute at Bethesda were of the years 1941, 1956 and 1964: first, that the metabolism of the regenerating liver, which grows more rapidly than most tumors, is not cancer metabolism, but perfect aerobic embryonic metabolism; second, that cancer cells, descended in vitro from one single normal cell, were in vivo the more malignant, the higher the fermentation rate; third, that in vivo growing hepatomas, produced in vivo by different carcinogens, were in vivo the more malignant, the higher the fermentation rate. Furthermore, the very unexpected and fundamental fact, that tissue culture is carcinogenic and that a too low oxygen pressure is the intrinsic cause were discovered6-8 in the years 1927 to 1966. Anaerobiosis of cancer cells was an established fact only since 1960 when methods were developed7 to measure the oxygen pressure inside of tumors in the living body.

This abridged history shows that even the greatest genius would not have been able to propose in 1923, what was proposed at Lindau in 1966. As unknown as the prime cause of cancer was in 1923 was the possibility to prevent it.

Life without oxygen in a living world that has been created by oxygen9 was so unexpected that it would have been too much to ask that anaerobiosis of cancer cells should be accepted at once by all scientists. But most of the resistance disappeared when at Lindau it was explained that on the basis of anaerobiosis there is now a real chance to get rid of this terrible disease, if man is willing to submit to experiments and facts. It is true that more than 40 years were necessary to learn how to do it. But 40 years is a short time in the history of science.10

Wiesenhof über Idar-Oberstein, August 1967

OTTO WARBURG

Two years after the Lindau lecture LINUS PAULING (Science Vol. 160, Page 265, 1968) proposed to control mental diseases by adding to the food the active groups of respiratory enzymes. But here the experimental basis was lacking. No mental disease is known so far, the prime cause of which is an impairment of the respiration of brain cells.

Preface to the First Edition

(Prevention of endogenous cancer)

Most experts agree that nearly 80% of cancers could be prevented, if all contact with the known exogenous carcinogens could be avoided. But how can the remaining 20%, the endogenous or so-called spontaneous cancers, be prevented?

Because no cancer cell exists, the respiration of which is intact1, it cannot be disputed that cancer could be prevented if the respiration of the body cells would be kept intact.

Today we know two methods to influence cell respiration.1 The first is to decrease the oxygen pressure in growing cells. If it is so much decreased that the oxygen transferring enzymes are no longer saturated with oxygen, respiration can decrease irreversibly and normal cells can be transformed into facultative anaerobes.

The second method to influence cell respiration in vivo is to add the active groups of the respiratory enzymes to the food of man. Lack of these groups impairs cell respiration and abundance of these groups repairs impaired cell respiration – a statement that is proved by the fact that these groups are necessary vitamins for man.2

To prevent cancer it is therefore proposed first to keep the speed of the blood stream so high that the venous blood still contains sufficient oxygen; second, to keep high the concentration of hemoglobin in the blood; third to add always to the food, even of healthy people, the active groups of the respiratory enzymes; and to increase the doses of these groups, if a precancerous state3 has already developed. If at the same time exogenous carcinogens are excluded rigorously, then most cancers may be prevented today.

These proposals are in no way utopian. On the contrary, they may be realized by everybody, everywhere, at any hour. Unlike the prevention of many other diseases the prevention of cancer requires no government help, and no extra money.

Wiesenhof, August 1966

 

Literature to Preface of Second Edition:

1. WILLSTAETTER, WIELAND and EULER, Lectures on enzymes at the centenary of the Gesellschaft Deutscher Naturforscher. Berichte der Deutschen Chemischen Gesellschaft, 55, 3583, 1922. The 3 lectures of the 3 chemists show that in the year 1922 the action of all enzymes was still a mystery. No active group of any enzyme was known.

2. OTTO WARBURG, Biochem. Zeitschrift, 152, 479, 1924.

3. OTTO WARBURG, Heavy Metals as prosthetic groups of enzymes, Clarendon Press, Oxford, 1949.

4. OTTO WARBURG, Wasserstoffübertragende Fermente, Verlag Werner Sänger, Berlin, 1948.

5. DEAN BURK, 1941. On the specificity of glycolysis in malignant liver tumors as compared with homologous adult or growing liver tissues. In Symposium of Respiratory Enzymes, Univ. of Wisconsin Press. pp. 235-245,1942. DEAN BURK, Science 123,314,1956. Woods, M. W., Sandford, K. K., Burk, D., and Earle, W. R. J. National Cancer Institute 23, 1079-1088, 1959. DEAN BURK, Burk, D., Woods, M. and Hunter, J. On the Significance of Glucolysis for Cancer Growth, with Special Reference to Morris Rat Hepatomas. Journ. National Cancer Institute 38, 839-863, 1967.

6. O. WARBURG und F. KUBOWITZ, Bioch. Z. 189, 242, 1927; H. GOLDBLATT und G. CAMERON, J. Exper. Med. 97, 525, 1953.

7. O. WARBURG, 17. Mosbacher Kolloquium, April 1966. Verlag Springer, Heidelberg, 1966.

8. O. WARBURG, K. GAWEHN, A. W. GEISSLER, D. KAYSER and S. LORENZ, Klinische Wochenschrift 43, 289, 1965.

9. O. WARBURG, Oxygen, The Creator of Differentiation, Biochemical Energetics, Academic Press, New York, 1966.

10. O. WARBURG, New Methods of Cell Physiology, Georg Thieme, Stuttgart, and Interscience Publishers, New York, 1962.

 

Literature to Preface of First Edition:

 

1. OTTO WARBURG, A. W. GEISSLER, and S. LORENZ: Über die letzte Ursache und die entfernten Ursachen des Krebses. 17. Mosbacher Kolloquium, April 1966. Verlag Springer, Heidelberg 1966.

2. Any book on vitamins, such as Th. Bersin. Biochemie der Vitamine. Akad. Verlags.-Ges. Frankfurt 1966.

3. ERNEST L. WYNDER, SVEN HULTBERG, FOLKE JACOBSSON, and IRWIN J. BROSS, Environmental Factors in Cancer. Cancer, Vol. 10, 470, 2057.

Find this article on: Ozone Services http://www.ozoneservices.com/ozoneser/c&n/contact.htm  

 

“My overall assessment is that the national cancer programme must be judged a qualified failure.” – Dr. John Bailer

Twenty years on the staff of the National Cancer Institute and editor of its journal.  Recipient in July 1990 of the prestigious MacArthur Fellowship, one of the few scientists so chosen says:

“My overall assessment is that the national cancer programme must be judged a qualified failure.”
(Speaking at the Annual Meeting of the American Association for the Advancement of Science in May 1985.)

  • “I am no longer convinced that there are wonderful cancer cures out there waiting to be found.  I do not think that we should base public policy on an assumption that if we just try hard enough, we will find them.”
  • “If we are to effectively prevent cancer, we will have to change our lives.  We’ll have to change our diets and certainly change our smoking habits.  We’re going to have to clean up our environment, change industrial processes, and do any number of things that will be difficult, expensive time-consuming and intrusive.”
  • “We have poured vast amounts of money into the search for cancer cures over a very long period of time.  We’ve brought some of the world’s best research minds to bear on these problems.  We’ve given it our best shot.  It’s time to admit it hasn’t worked and start down another track.”
  • “There was a trial in Sweden for which a report was published several years ago.  In it there was a table that showed that women under fifty who had had mammograms actually had more deaths from breast cancer than a matched control group.”
  • “A change at the National Cancer Institute of the kind I am describing… would mean a massive disruption in ideas, in momentum, in the research community, and IN THE BUSINESSES THAT SUPPORT THAT RESEARCH COMMUNITY.”
    (Author‘s emphasis.)

These were Dr Bailer’s answers to questions put by Neal D. Barnard, M.D. of the Physicians Committee for Responsible Medicine, U.S.A. and published in PCRM Update, September/October 1990.  (Kindly supplied to the Author by K. and M. Ungar, U.S.A.)

 

Dichloroacetate induces apoptosis and cell-cycle arrest in colorectal cancer cells

Dichloroacetate induces apoptosis and cell-cycle arrest in colorectal cancer cells

B M Madhok1, S Yeluri1, S L Perry1, T A Hughes2 and D G Jayne1

  1. 1Section of Translational Anaesthesia & Surgery, University of Leeds, Level 7 Clinical Sciences Building, St. James’s University Hospital, Leeds, UK
  2. 2Leeds Institute of Molecular Medicine, University of Leeds, St. James’s University Hospital, Leeds, UK

Correspondence: Dr BM Madhok, E-mail: umbm@leeds.ac.uk

Revised 23 March 2010; Accepted 26 April 2010; Published online 18 May 2010. Top of page

Link: http://www.nature.com/bjc/journal/v102/n12/full/6605701a.html

 

Background:

Cancer cells are highly dependent on glycolysis. Our aim was to determine if switching metabolism from glycolysis towards mitochondrial respiration would reduce growth preferentially in colorectal cancer cells over normal cells, and to examine the underlying mechanisms.

Methods:

Representative colorectal cancer and non-cancerous cell lines were treated with dichloroacetate (DCA), an inhibitor of pyruvate dehydrogenase kinase.

Results:

Dichloroacetate (20 mM) did not reduce growth of non-cancerous cells but caused significant decrease in cancer cell proliferation (P=0.009), which was associated with apoptosis and G2 phase cell-cycle arrest. The largest apoptotic effect was evident in metastatic LoVo cells, in which DCA induced up to a ten-fold increase in apoptotic cell counts after 48 h. The most striking G2 arrest was evident in well-differentiated HT29 cells, in which DCA caused an eight-fold increase in cells in G2 phase after 48 h. Dichloroacetate reduced lactate levels in growth media and induced dephosphorylation of E1α subunit of pyruvate dehydrogenase complex in all cell lines, but the intrinsic mitochondrial membrane potential was reduced in only cancer cells (P=0.04).

Conclusions:

Pyruvate dehydrogenase kinase inhibition attenuates glycolysis and facilitates mitochondrial oxidative phosphorylation, leading to reduced growth of colorectal cancer cells but not of non-cancerous cells.

Keywords:

dichloroacetate; colorectal cancer; pyruvate dehydrogenase; pyruvate dehydrogenase kinase

Colorectal cancer is the third most common cancer in the world and the fourth leading cause of cancer-related death (Shike et al, 1990). In 2007 colorectal cancer accounted for 17.1 deaths per 100 000 persons in the United Kingdom (UK Bowel Cancer Statistics, 2009). Despite recent advances, the prognosis of patients with advanced and metastatic colorectal cancer remains poor. Targeting tumour metabolism for cancer therapy is a rapidly developing area (Pan and Mak, 2007). Early observations concerning the metabolic differences between cancer and normal cells were made by Otto Warburg, who showed that cancer cells are inherently dependent on glycolysis for production of chemical energy (Warburg, 1956). There is now mounting evidence that this increased glycolysis results from the influence of multiple molecular pathways, including adaptive responses to the hypoxic tumour microenvironment, oncogenic signalling, and mitochondrial dysfunction (Gatenby and Gillies, 2004; Gillies and Gatenby, 2007; Wu et al, 2007). The glycolytic phenotype offers growth advantages to cancer cells by resisting apoptosis, and facilitating tumour spread and metastasis (Yeluri et al, 2009).

A key regulator of cellular metabolism is pyruvate dehydrogenase (PDH). Pyruvate dehydrogenase converts pyruvate, produced from glycolysis, to acetyl-CoA, which is oxidised in the tricarboxylic acid cycle within mitochondria. Pyruvate dehydrogenase activity is tightly regulated by inhibitory phosphorylation by pyruvate dehydrogenase kinase (PDK). Phosphorylation occurs on the E1α sub-unit of PDH (PDHE1α) at three sites: Ser232, Ser293, and Ser300 (Rardin et al, 2009). Dichloroacetate (DCA) is an inhibitor of all the four isoenzymes of PDK(1–4) (Stacpoole, 1989), and has recently been shown to reduce growth of lung, endometrial, and breast cancer cell lines (Bonnet et al, 2007; Wong et al, 2008; Sun et al, 2009). It has been reported to reduce growth of these cancer cells mainly by reducing inhibitory phosphorylation of PDH, thereby promoting mitochondrial oxidative phosphorylation and inducing apoptosis through mitochondrial, NFAT-Kv 1.5, and p53 upregulated modulator of apoptosis (PUMA)-mediated pathways.

Colorectal cancer cells have been found to undergo increased glycolysis (Bi et al, 2006), and the tumour microenvironment has been found to be hypoxic and acidotic, mainly due to poorly developed blood supply (Dewhirst et al, 1989; Milosevic et al, 2004). We have previously shown that this is especially true for the more aggressive phenotype (Thorn et al, 2009), and expression of the important markers of hypoxia is increased in colorectal cancer especially at the invasive margin (Rajaganeshan et al, 2008, 2009). The purpose of this study was to investigate the effects of DCA on the growth of colorectal cancer cells in an attempt to examine PDK inhibition as a novel therapeutic strategy against colorectal cancer.

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Materials and methods

Cell cultures

All cell lines were purchased from American Type Culture Collection (Manassas, VA, USA) or European Collection of Cell Cultures (Salisbury, Wiltshire, UK): HB2 (breast epithelial cells of non-cancer origin), 293 (epithelial cells from human embryo kidney), HT29 (well-differentiated primary colorectal adenocarcinoma), SW480 (poorly differentiated primary colorectal adenocarcinoma), and LoVo (metastatic left supraclavicular lymph node from colorectal adenocarcinoma). 293 and HB2 cells were maintained in DMEM medium, HT29 and SW480 in RPMI 1640 medium, and LoVo in F12 medium (all from Invitrogen, Carlsbad, CA, USA), supplemented with 10% fetal calf serum, in a 37°C, 5% CO2 humidified incubator. For experiments under hypoxic conditions, we incubated cells in a humidified, hypoxic incubator (1% O2, 5% CO2, 94% N2, 37°C). Sodium dichloroacetate (Specials Lab, Prudhoe, UK) was donated by the Pharmacy Department at St. James’s University Hospital, Leeds, UK.

MTT assays

Cells (1 × 104) per well were seeded in 96-well tissue culture plates. After overnight incubation, we replaced media with fresh media containing increasing doses of DCA (0, 10, 15, 20, 30, 50, and 100 mM). After 24 and 48 h of incubation, we performed MTT assay by replacing the media with 50 μl of 1 mg ml−1 MTT solution and the plates were incubated in the dark for 3 h. MTT solution was then removed and the dark blue formazan precipitates were dissolved in 100 μl of propan-1-ol. Optical density was measured using microplate reader (Opsys MR; Dynex Technologies Ltd, Worthing, West Sussex, UK) at 570 nm.

Annexin V and 7-AAD assays

Cells were seeded in 25 cm2 tissue culture flasks and incubated overnight in standard conditions. Media was replaced with fresh media containing a range of doses of DCA (0, 10, 20, and 50 mM). Flow cytometric analysis was performed after 24 and 48 h of incubation. Cells were washed twice with cold PBS and resuspended in 1 × binding buffer (BD Bioscience, Franklin Lakes, NJ, USA) at 5 × 106 cells per ml. 100 μl of solution (5 × 105 cells) was transferred to 5 ml culture tubes. These cells were stained with 5 μl annexin V-FITC and 10 μl 7-AAD (BD Bioscience), gently vortexed, and incubated at ambient temperature for 15 min in dark. Following this 400 μl 1 × binding buffer was added to each tube and analysed within an hour on LSR II flow cytometer (BD Bioscience).

Propidium iodide assays

Cells were propagated as mentioned for the apoptosis assay. Dichloroacetate (50 mM) was used and compared to vehicle control. After harvesting, we resuspended cells in 350 μl of PBS at a concentration of 0.5–1.0 × 106 cells per ml. 100 μl of 0.25 mg ml−1 propidium iodide (PI)/5% Triton (Sigma, St Louis, MO, USA) was added to the cell suspension. 50 μl of 1 mg ml−1 ribonuclease A (Sigma) was then added. Sample tubes were thoroughly vortexed and incubated for 10 min in the dark at room temperature. Flow cytometry was performed on LSR II flow cytometer (BD Bioscience) and data were analysed using FlowJo software (FlowJo, Ashland, OR, USA).

Lactate measurements

Lactate measurements in growth media were performed by the chemical pathology department at the General Infirmary, Leeds Teaching Hospitals NHS Trust. Cells were incubated in 25 cm2 flasks overnight in normoxia. Media was replaced next day with a range of doses of DCA (0, 10, 20, and 50 mM). After 48 h of incubation, we collected 2 ml of media in fluoride tubes and transferred immediately to the chemical pathology laboratory. The tubes were maintained on ice during the transfer. Lactate levels were measured using an automated analyser (Advia 1200 Chemistry system; Siemens Healthcare Diagnostics, Camberley, Surrey, UK).

TMRM assays

Cells were treated with DCA as described for the apoptosis assay. After 24 and 48 h of incubation, we washed cells in PBS, and suspended 1 × 106 cells per ml in Hank’s buffered salt solution with 50 nM tetramethylrhodamine methyl ester (TMRM) (Invitrogen). 100 μl of the cell suspension (1 × 105 cells per well) was transferred to opaque 96-well plates, incubated for 30 min, and fluorescence was measured at 530/620 nm at 37°C using a plate reader (Mithras LB 40; Berthold Technologies, Bad, Wildbad, Germany).

Western blotting

Cells were treated with DCA as described above. After 8 h of treatment, we extracted proteins from cells in Laemmli buffer (2% SDS, 10% glycerol, 0.7% 2-mercaptoethanol, 0.05% bromophenol blue, and 0.5 M Tris-HCl). Lysates were resolved by electrophoresis on NuPAGE Novex 12% Bis-Tris gels (Invitrogen) in MOPS-SDS running buffer (Invitrogen). Proteins were transferred to a polyvinylidene fluoride membrane (GE Healthcare, Chalford St Giles, Bucks, UK). The membrane was blocked for 1 h at ambient temperature in 5% skimmed milk in TBS-T (Tris-buffered saline with 0.1% Tween). The membrane was then probed with primary antibodies in 1% skimmed milk in TBS-T for 90 min, washed in TBS-T, and then probed with the appropriate horseradish peroxidase (HRP)-conjugated secondary antibody for 60 min. Primary antibodies rabbit polyclonal phosphodetect anti-PDH-E1α (pSer293), 1 : 500 (AP1062; EMD Chemicals, Darmstadt, Germany), and mouse monoclonal anti-PDHE1α, 1 : 500 (459400; Invitrogen). Secondary antibodies anti-rabbit or anti-mouse HRP conjugates, 1 : 1000 (Dako, Glostrup, Denmark). Proteins were visualised with Supersignal West Pico or Femto chemiluminescent substrate (Pierce Biotechnology, Rockford, IL, USA) and the Chemidoc XRS system (Bio-Rad, Hercules, CA, USA). β-Actin was used as a loading control.

Statistical analyses

Flow cytometry data were acquired using specific software, BD FACSDiva 6.0 and FlowJo software. Statistical analyses were performed using SPSS for Windows (SPSS version 15.0, Chicago, IL, USA). Differences between DCA-treated and vehicle control groups were assessed using the Mann–Whitney U-test and the 95% confidence intervals of the difference in means between the two groups. A P-value of less than 0.05 was considered to be statistically significant. Data are represented as mean from at least three independent experiments and error bars represent standard deviation of mean.

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Results

DCA reduces cancer cell proliferation and the effect is similar in normoxia and hypoxia

First, we wished to determine if treatment with DCA inhibited cellular proliferation and whether there would be a differential response in cancer and non-cancerous cells in normoxic and hypoxic conditions. With respect to hypoxia, our hypothesis was that influence of DCA would be particularly potent with oxygen levels that are insufficient to support additional oxidative phosphorylation. All cell lines (HB2, 293, HT29, SW480, and LoVo) were treated with a range of doses of DCA for 24–48 h in normoxic and hypoxic conditions. Relative cell numbers were assessed using MTT assays.

Treatment with increasing doses of DCA reduced cellular proliferation in a dose-dependent manner (Figure 1A-D). Contrary to our expectation, the profiles of reduced cell growth were similar in hypoxia and normoxia. At 24 and 48 h, up to 20 mM DCA did not affect the growth of cultures of the non-cancerous cells, HB2 and 293. However, 20 mM DCA significantly reduced growth of cultures of all three colorectal cancer cell lines (P0.009). The effect of DCA was greater on the poorly differentiated SW480 cells and the metastatic LoVo cells than the well-differentiated HT29 cells. The growth of cultures of LoVo cells treated with 20 mM DCA was reduced by up to 40% compared to cells treated with vehicle control. Because there was relatively little difference in the reduction of growth of cultures treated with DCA in hypoxic and normoxic conditions, further experiments were performed only in normoxia.

Figure 1.

 

Dichloroacetate (20 mM) did not significantly reduce growth of cultures of the non-cancerous 293 and HB2 cells but caused a significant reduction in growth of cultures of all the colorectal cancer cells (*P0.009). Cells were treated with various doses of DCA or vehicle control in normoxia (A and C) or hypoxia (B and D), and the relative number of viable cells was assessed at 24 h (A and B) and 48 h (C and D) using MTT assay. Data are expressed as percentage of control (0 mM dose) (* – significant difference relative to control – white bar (0 mM)).

Full figure and legend (149K)

 

DCA promotes apoptosis in cancer cells sparing non-cancerous cells

Next, we wished to investigate whether the reduced growth of cultures on treatment with DCA was associated with induction of apoptosis. Cells were treated with range of doses of DCA (0, 10, 20, and 50 mM) for 24 and 48 h, and the proportion of cells undergoing apoptosis was assessed by detecting membrane phosphatidylserine with annexin V-FITC. Cells were stained with annexin V-FITC and vital dye 7-AAD, and analysed using flow cytometry. There was a dose-dependent induction of apoptosis in the cancer cell lines after 24 and 48 h of treatment, with little, if any, apoptosis induced in the non-cancerous cells (Figure 2A and B). The greatest effect was observed in the metastatic LoVo cells; 50 mM DCA caused a ten-fold increase in the proportion of apoptotic cells after 48 h, whereas there was a seven- and five-fold increase in HT29 and SW480 cells, respectively. Increase in the mean percentage of total apoptotic cells with 50 mM DCA was: 2.8 (95% CI: 2–3) in HT29 cells, 3.5 (95% CI: 2–5) in SW480 cells, and 21 (95% CI: 8–34) in LoVo cells. There was minimal apoptosis induced in the 293 cells even with 50 mM DCA, 0.2 (95% CI: −0.2 to 0.6). In HB2 cells, there was a nonsignificant decrease in the percentage of apoptotic cells on treatment with 50 mM DCA, −0.9 (95% CI: −2.2 to 0.4).

Figure 2.

 

Dichloroacetate induced a dose-dependent increase in percentage of the apoptotic population in the cancer cells with minimal apoptosis in the non-cancerous cells. Cells were treated with doses of DCA for 24 h (A) and 48 h (B), stained with annexin V-FITC and 7-AAD, and analysed with flow cytometry. Data points represent the mean (±s.d.) of three independent experiments for 0 and 50 mM DCA (* – significant difference relative to control).

Full figure and legend (71K)

 

DCA induces G2 phase arrest in colorectal cancer cells but has no effect on cell-cycle profile of non-cancerous 293 cells

We also wished to examine whether the reduction in growth of cultures on treatment with DCA was associated with induction of growth arrest. Cells were treated with 50 mM DCA for 24 or 48 h, and cell-cycle profiles were analysed using flow cytometric assessment of DNA content after PI staining. Dichloroacetate treatment caused changes in the cell-cycle profiles of all the cancer cells but did not affect the non-cancerous cells. The changes in cell-cycle profile were detectable after 24 h of treatment, and were persistent at 48 h (Figure 3A and B).

Figure 3.

 

Dichloroacetate induced G2 phase arrest in colorectal cancer cells with no effect on cell-cycle profiles of non-cancerous cells; 293 and HB2. Cells were treated with 50 mM DCA or vehicle control for 24 h (A) and 48 h (B), stained with PI, and analysed with flow cytometry. For analyses of statistical significances, we compared mean proportion of cells in each phase of cell cycle (G1, S, and G2) in DCA-treated cells to mean proportion of cells in the respective phases in untreated cells (* – significant difference relative to control).

Full figure and legend (87K)

 

After 48 h of treatment with 50 mM DCA, there was an eight-fold increase in the cells in G2 phase in HT29 and SW480 cells, and three-fold increase in LoVo cells. Increase in the mean percentage of all cancer cells in G2 phase was: 21 (95% CI: 13–30) for HT29, 19 (95% CI: 13–24) for SW480 cells, and 14 (95% CI: 10–21) for LoVo cells; whereas there was no difference in the 293 cells, 1 (95% CI: −4 to 7), and HB2 cells, −0.3 (95% CI: −9 to 9). There was a corresponding decrease in cells in G0/G1 phase in all cancer cell lines. Intriguingly, in HT29 cells there was a small decrease, but in SW480 and LoVo cells there was a significant increase in the proportion of cells considered to be in the S phase (see Discussion section). The cell-cycle profile of 293 and HB2 cells changed minimally on treatment with DCA.

DCA reduces extracellular lactate levels in growth media

To establish whether the changes in growth and apoptosis induced by DCA correlated with reduced glycolysis, we measured lactate levels in growth media. Lactic acid is the end product of glycolysis. If DCA were inducing mitochondrial oxidative phosphorylation, pyruvate would be decarboxylated to acetyl-CoA and not reduced to lactate, hence lactate levels in the growth media would decrease. Lactate levels in growth media of all cell lines were measured after 48 h of treatment with a range of doses of DCA (Figure 4). Lactate levels were determined with an auto-analyser that is used routinely for biochemical measurement of lactate levels; the assays are based on a colorimetric reaction catalysed by lactate oxidase. Treatment with DCA reduced extracellular lactate levels in growth media in a dose-dependent manner in all the cancer and non-cancerous cell lines.

Figure 4.

 

Dichloroacetate reduced lactate levels in growth media in a dose-dependent manner in both cancer and non-cancerous cells. Cells were treated with range of doses of DCA for 48 h, and extracellular lactate levels were measured in the growth media using an auto-analyser. Results are expressed as relative of control.

Full figure and legend (65K)

 

DCA depolarises the intrinsic mitochondrial membrane in colorectal cancer cells but not in non-cancerous cells

To verify if the induction of apoptosis in cancer cells on treatment with DCA was associated with promotion of mitochondrial oxidative phosphorylation, we measured the intrinsic mitochondrial membrane potential (ΔΨm). Escalation of mitochondrial respiration would reactivate the electron transport chain and reduce the hyperpolarised ΔΨm in cancer cells. Cells were treated with doses of DCA for 24 and 48 h and stained with the dye TMRM, which allows fluorescent measurement of ΔΨm.

As with previous experiments, the effect of DCA was apparent after 24 h of treatment and persisted at 48 h (Figure 5A and B). Dichloroacetate treatment reduced the hyperpolarised ΔΨm in all the cancer cells in a dose-dependent manner. Dichloroacetate did not have any effect on ΔΨm of the non-cancerous HB2 cells, whereas, surprisingly the ΔΨm of the non-cancerous 293 cells increased in a dose-dependent manner. At 24 h of treatment, 50 mM DCA significantly reduced ΔΨm in all cancer cells; however, in LoVo cells there was a significant reduction even with 20 mM DCA (Figure 5A, P=0.02). In the non-cancerous 293 cells, there was a trend towards increase in ΔΨm on DCA treatment, although this was not statistically significant (P=0.08). At 48 h of treatment, there was significant reduction of ΔΨm in all cancer cells and increase in the 293 cells, with 20–50 mM DCA (Figure 5B, P0.04).

Figure 5.

 

Dichloroacetate treatment reduced the intrinsic mitochondrial membrane potential (ΔΨm) in all cancer cells, increased ΔΨm in non-cancerous 293 cells, and had no effect on ΔΨm in non-cancerous HB2 cells. Cells were treated with doses of DCA for 24 h (A) and 48 h (B), stained with TMRM, and fluorescence was measured at 530/620 nm at 37°C (* – significant difference relative to control).

Full figure and legend (112K)

 

DCA treatment leads to dephosphorylation of the PDHE1α sub-unit

DCA is thought to inhibit all four isoenzymes of PDK, and hence reduce phosphorylation of the PDHE1α sub-unit, leading to, in turn, activation of the PDH complex. To verify if the dephosphorylation of PDHE1α was occurring with DCA treatment in the cell lines used, we used western blot analyses on lysates of DCA-treated and untreated cells. In all cell lines, treatment with 20 mM DCA for 8 h caused a dramatic reduction in signal for phosphorylation at the pSer293 site, but no change was detected in the levels of total PDHE1α (Figure 6). Phospho-specific antibodies for the other two phosphorylation sites, Ser232 and Ser300, are not yet commercially available.

Figure 6.

 

Dichloroacetate treatment reduced phosphorylation of PDHE1α at pSer293 site with no effect on the levels of total PDHE1α in all the cell lines investigated. Whole-cell lysates were prepared after treating cells with 20 mM DCA for 8 h and from untreated cells, and western blot analyses were performed.

Full figure and legend (70K)

 

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Discussion

Differential effects of DCA on growth of cancer and non-cancerous cells

We have shown that DCA induces a dose-dependent reduction in growth of in vitro cultures of colorectal cancer cells and non-cancerous cells. However, the cancer cells were more sensitive to DCA, with a dose of 20 mM causing a significant inhibition of cancer cell growth, but having little effect on the non-cancerous cells. We have shown that the components of this differential effect are the following: a potent induction of apoptosis and cell-cycle arrest in cancer cells, but not in the non-cancerous cells.

These conclusions support a simple model of differential sensitivity to DCA. However, some data require further discussion. First, 50 mM DCA reduced growth of cultures of the non-cancerous 293 and HB2 cells, yet no increase in apoptotic cells or change in cell-cycle profile of these cells was observed. A possible explanation for these findings could be that this dose of DCA led to a slower transit of these non-cancerous cells through all stages of the cell cycle, without changing the relative proportions within each stage. Second, our results indicate that DCA induced G2 arrest in colorectal cancer cells. This is in contrast to previous studies, which have shown G1 arrest or no change on cell-cycle profile with DCA treatment (Cao et al, 2008; Wong et al, 2008). Wong et al (2008) showed increased expression of PUMA in all the endometrial cancer cell lines that had an apoptotic response to DCA, and concluded that this p53 activation led to G1 arrest. However, colorectal cancer cells in our study arrested in G2 phase on treatment with DCA, and we did not find any induction of p53 by DCA in our colorectal cancer cell lines (data not shown). Intriguingly, Cao et al (2008) found that the combination of DCA and radiotherapy arrested prostate cancer cells in G2 phase, although DCA on its own did not affect cell-cycle profile. Third, in SW480 and LoVo cells, DCA treatment resulted in an increase in the proportion of cells considered to be in the S phase. This suggests an increase in proliferation as well as induction of apoptosis. A similar finding was reported by Wong et al (2008) in one of several endometrial cancer cells tested. An alternative explanation is that a proportion of the cells observed to be in ‘S phase’ after DCA treatment of the cancer cell lines actually represent apoptotic cells in the ‘sub-G2’ region, as has been reported previously in lymphoma cells (Klucar and Al-Rubeai, 1997).

Changes in cellular metabolism with DCA treatment

DCA appeared to suppress lactic acid production from pyruvate in both cancer and non-cancerous cells. In addition, treatment with DCA led to dephosphorylation of PDHE1α, and hence activation of PDH in all the cell lines investigated. Hence, the basis of DCA’s differential effect on cancer and non-cancerous cells may reside in its influence on mitochondrial function. Treatment with DCA reduced the high ΔΨm of all cancer cells but not of the non-cancerous cells. This suggests that DCA, by inhibiting PDK and hence activating PDH, promotes mitochondrial respiration that leads to depolarisation of the intrinsic mitochondrial membrane, and induces apoptosis by the proximal mitochondrial pathway as described in the previous studies (Bonnet et al, 2007; Cao et al, 2008; Wong et al, 2008). Induction of apoptosis and changes in mitochondrial function were most pronounced in the highly invasive and metastatic LoVo cells than the less invasive HT29 and SW480 cells. This could have clinical implications for the treatment of metastatic colorectal cancer, as it is usually the highly invasive metastatic cancers that are most resistant to conventional chemotherapy, and which may be most sensitive to PDK inhibition. In support of this, a recent study reported that the colorectal tumours resistant to 5-fluorouracil are more likely to have upregulated glycolysis, and hence more amenable to therapy targeting cancer metabolism (Shin et al, 2009). In this regard, our results contrast the findings of Wong et al (2008), who found highly invasive endometrial cancer cells to be most resistant to DCA treatment.

PDK inhibition as cancer therapy against colorectal cancer

We found doses of 20–50 mM DCA gave differential responses between cancer and non-cancerous cells. Thus, potential therapeutic DCA doses would be between 20 and 50 mM. In addition, a recent study reported that the IC50 of DCA for breast cancer cells to be between 20 and 30 mM (Ko and Allalunis-Turner, 2009). This is in contrast to previous studies that have reported DCA to reduce proliferation and induce apoptosis in cancer cells with doses as low as 0.5–10 mM (Bonnet et al, 2007; Wong et al, 2008; Sun et al, 2009). Dichloroacetate has been found to be relatively safe in humans when used for treatment of lactic acidosis (Stacpoole et al, 2003). The main side effects with up to 100 mg kg−1 DCA are on the nervous system and the liver, causing mild sedation or drowsiness, reversible peripheral neuropathy, and mild asymptomatic elevation of serum transaminases reflecting hepatocellular damage (Stacpoole et al, 1998). In addition, recent studies reported that DCA effectively reduced tumour growth in clinically achievable doses both in vitro and in vivo (Bonnet et al, 2007; Sun et al, 2009). It was suggested that DCA could rapidly translate to early-phase cancer clinical trials (Michelakis et al, 2008). However, the dose of DCA required to inhibit growth of colorectal cancer cells in our study is unlikely to be achieved clinically without causing significant side effects. The dose of DCA required to achieve the equivalent plasma concentrations in vivo would be about five to ten times than that used in clinical trials against lactic acidosis. It appears that the colorectal cancer cells used in our study are more resistant to DCA than lung, endometrial, and breast cancer cells. Intriguingly, Sun et al (2009) in their study on breast cancer cells found that DCA inhibited proliferation of cancer cells, but did not induce apoptosis or cell death. These results were markedly different to the effects of DCA observed on lung (Bonnet et al, 2007), endometrial (Wong et al, 2008), and colorectal cancer cells in our study. Thus, although DCA inhibits growth of a variety of cancer cells, the effect and the underlying mechanisms seem to be cell-type dependent. A likely explanation for these differential effects could be the difference in expression of the PDK isoenzymes in the cancer cells examined. Dichloroacetate is a non-specific inhibitor of PDK (Whitehouse and Randle, 1973), and has a different Ki for each of the four PDK isoenzymes (Bowker-Kinley et al, 1998). In addition, the four PDK isoenzymes are known to be differentially expressed in various tissues. Thus, there is a need to develop inhibitors to the individual PDK isoenzymes that should allow cancer cell-type-specific metabolic manipulation.

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Response to: Unapproved cancer therapy DCA makes some tumours worse (ANNE McILROY)

The Globe and Mail reports that DCA has been shown ineffective in colorectal cancer and even worse, it has been shown to protect certain cancerous cells.

http://www.theglobeandmail.com/life/health/unapproved-cancer-therapy-dca-makes-some-tumours-worse/article1806516/

The article made it to the Associated Press as well:

http://www.rdmag.com/News/FeedsAP/2010/11/life-sciences-unapproved-cancer-therapy-dca-makes-some-tumours-w/

The state of science reporting is truly depressing and distressing to say the least.  The lack of scientific literacy makes room for such errant reporting.  The article is filled with conjecture and supposition with very little reference to the actual article.

Very few people have actually read the journal post, and fewer still can understand it.  Just the same, here it is:

http://www.martincwiner.com/wp-content/uploads/2010/11/DCAColorectalTumorHypoxia.pdf

The article says that under hypoxic conditions (low oxygen) conditions that DCA is proven to be ineffective.

No kidding.

DCA is a drug that restores mitochondrial function.  The mitochondria are responsible for cell aptopsis (cell suicide) in cancer.  When they are restored to normal function, they are able to recognize that the cell is in an errant state and kill the cell.  Mitochondria rely on oxygen to work.  The mechanism by which they produce energy for a cell is called none other than oxidative phosphorylation (ie, it requires oxygen).

At the core of a dense tumour there is almost no oxygen at all.  Indeed, it’s unlikely DCA could even be delivered to the core of a deeply dense tumour where there is insufficient blood vessel perfusion.  If DCA was administered to cells where there was no oxygen available, it would be equivalent to fixing an engine but still being out of gas — the engine still wouldn’t turn over.

The ‘protective’ effect DCA supposedly offers hypoxic cancer cells could be explained by restored mitochondrial function which is able to provide cellular energy with the little oxygen available, whereas the mitochondria aren’t functioning well enough to effect aptopsis.  By continued analogy, DCA might fix the engine enough to allow it to turn over with the pint of gas in the tank, but the engine would stall before being able to arrive at the destination: aptopsis.

What the researchers fail to ask is: what is occurring at the surface of the tumour where there is sufficient oxygen?  Is it possible that DCA is able to reach the cells on the surface and effect aptopsis there?  If so, then DCA could work it’s way in slowly from the outside in… it a far gentler and safer way than most common anti-cancer treatments.

In fact, many common cancer treatments kill cancers too rapidly causing a rapid decline in overall health of the patient opening the patient to further cancers or eventual worsening of tumour in question.

Dr. Brenda Coomber et al out at the University of Guelph have managed only to underscore the vital need for a full clinical trial of DCA to answer the questions posed here an in other places as to the efficacy and safety of DCA in broad spectrum use against many forms of cancer.

If journalists who aren’t versed in science would like to publish articles about said subject, might I suggest they direct their attention to the fact that DCA is not likely to receive funds to make its way through a full clinical trial.  Regrettably DCA is as common as table salt and is not patentable.  Journalists need to focus on why profit trumps caring in medical research.

More From www.martincwiner.com

 

‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured

‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured

  1. 1.  David C. Classen1,*,
  2. 2.  Roger Resar2,
  3. 3.  Frances Griffin3,
  4. 4.  Frank Federico4,
  5. 5.  Terri Frankel5,
  6. 6.  Nancy Kimmel6,
  7. 7.  John C. Whittington7,
  8. 8.  Allan Frankel8,
  9. 9.  Andrew Seger9 and

10.Brent C. James10

+ Author Affiliations

1.   1David C. Classen (dclassen@csc.com) is an associate professor of medicine at the University of Utah, in Salt Lake City.
2.   2Roger Resar is a senior fellow at the Institute for Healthcare Improvement, in Cambridge, Massachusetts.
3.   3Frances Griffin is a faculty member at the Institute for Healthcare Improvement.
4.   4Frank Federico is an executive director at the Institute for Healthcare Improvement.
5.   5Terri Frankel is a director at the Institute for Healthcare Improvement.
6.   6Nancy Kimmel is director of quality and safety at the Missouri Baptist Medical Center, in St. Louis.
7.   7John C. Whittington is a senior fellow at the Institute for Healthcare Improvement.
8.   8Allan Frankel is an associate professor at Brigham and Women’s Hospital, in Boston, Massachusetts.
9.   9Andrew Seger is an assistant professor at Brigham and Women’s Hospital.
10.  10Brent C. James is chief quality officer at Intermountain Healthcare, in Salt Lake City, Utah.
  1. *Corresponding author

Abstract

Identification and measurement of adverse medical events is central to patient safety, forming a foundation for accountability, prioritizing problems to work on, generating ideas for safer care, and testing which interventions work. We compared three methods to detect adverse events in hospitalized patients, using the same patient sample set from three leading hospitals. We found that the adverse event detection methods commonly used to track patient safety in the United States today—voluntary reporting and the Agency for Healthcare Research and Quality’s Patient Safety Indicators—fared very poorly compared to other methods and missed 90 percent of the adverse events. The Institute for Healthcare Improvement’s Global Trigger Tool found at least ten times more confirmed, serious events than these other methods. Overall, adverse events occurred in one-third of hospital admissions. Reliance on voluntary reporting and the Patient Safety Indicators could produce misleading conclusions about the current safety of care in the US health care system and misdirect efforts to improve patient safety.