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In the past, there were different concerns in
regards to the association of statins with high prevalence of cancer and
increased cancer-associated death; now, there are lot of evidences supporting
the cytotoxic, cytostatic and anti-cancer efficacy this drug. Statins are
confirmed competitive inhibitors of hydroxy-methylglutaryl (HMG)-CoA reductase
enzyme, therefore regularly prescribed as cholesterol-lowering agents. Of
recent, dysregulation of lipid metabolism has been confirmed as one of the
hallmarks cancer cells. As a result, statins drugs have gained much attention
towards its potential as therapeutic agents in cancer. Here, we discuss and
summarize several observations on the anti- tumorigenic and angiogenic effect
of the known mevalonate pathway inhibitor that is the statins drugs.
Keywords: Statins, Mevalonate, Cancer, HMG-CoA
reductase, Hyperlipidemia
INTRODUCTION
Cancer is a complicated disease
that ravages millions of people globally. The major available therapies are
cytotoxic, while most cancers are incurable. Some clinical result trials
recorded the probable effect of statins drug in cancer showing that statins can
either increase or decrease the risk of carcinogenesis.
Ever since their endorsement in 1987 as an
agent for hyperlipidemia reduction to prevent and manage cardiovascular
diseases; statins, recognized cholesterol-lowering agents, is now one of the most
commonly approved drugs globally, owing to their confirmed efficiency and good
safety. Statins exert its main effect via the endogenous mevalonate pathway by
binding and inhibiting the rate limiting enzyme that is HMG-CoA reductase
enzyme in cholesterol and isoprenoids biosynthesis (Figure 1) [1]. The
reversible inhibition, dose-dependent and competitive effects on 3-HMG-CoA
reductase leads to the blocking of the 3-hydroxy-3-methylglutaryl CoA
conversion to mevalonate, thereby inhibiting all other downstream intermediates
and products such as isoprenoid and cholesterol metabolites.
With a significant pharmacological profile
showed by Stains and accumulated data of their multiple effects apart from the
know cholesterol-lowering for example neuroprotective effects,
anti-inflammatory, anti-proliferative, encouraged research into their
usefulness in a wide range of diseases including cancer.
EFFECT OF STATINS IN TUMORIGENESIS
Vital cellular metabolic adjustments were
observed as a result of cell’s high energy demands. These adjustments are known
as the Warburg effect, which is a distinctive phenotypical feature of a cancer
cell [3]. The mevalonate pathway for cholesterol biosynthesis and protein
prenylation has been involved in several aspect of carcinogenesis. The
oncoproteins such as the Ras protein family that is Ras and Rho-GTPase depends
on post-translational and isoprenylation for their anchoring to the membrane
and other activities as they are involved in a high fraction of human cancers
incidence [4]. As a result, transformed malignant cells are highly dependent on
the isoprenoid pathway for the synthesis of lipid moieties important for
membrane integrity, cell proliferation, cell signaling and cell cycle
progression [5-7]. Thus, with non-steroidal isoprenoid molecules as
geranylgeranyl pyrophosphate (GGPP) and farnesyl pyrophosphate (FPP) production
inhibition, and therefore of oncoproteins prenylation, leads to their activity
inhibition.
The likely mechanisms that result in
increased lipid synthesis in tumor cells might be:
(1) Availability of precursors for example
acetyl-CoA, derived from hyper-activation of the glycolytic pathway [8]
(2) Loss of HMG-CoA reductase feedback
control or
(3) Increase in expression and function
HMG-CoA reductase.
Hence,
cancer progression (for example in breast and liver) is promoted by the
uncontrolled expression of HMG-CoA reductase collaborating with the Ras
oncogene hypothesizing the role of HMGCR enzyme as a metabolic oncogene [8].
Surprisingly, breast cancer cells with mutant p53 have promoted mevalonate
pathway activity. However, the system in which p53 mutant relates with sterol
gene promoters through the sterol regulatory element binding protein (SREBP)
transcription factors, may specifically be sensitive to inhibition by statins,
this may reverse the malignant phenotype by inhibiting cancer cell invasive
growth and survival (Freed-Pastor et al. [9].
Other enzymes in the mevalonate pathway have
been shown to partake in tumor progression and resistance to chemotherapy [10],
for example, farnesyl diphosphate synthetase (FDPS), this enzyme catalyzes the
formation of GPP and FPP which are key isoprenoid intermediates, utilized as
substrates for protein prenylation.
Certainly, an increased farnesyl diphosphate
synthetase (FDPS) expression and activity in human colon cancer has been
established and has been shown to be involved in the pathology of some tumors
[11]. Furthermore, the mevalonate pathway has been implicated in multidrug resistance
(MDR), affecting the P-glycoprotein (P-gp) activity through hyper-activation of
farnesyl diphosphate synthetase. The P-gp, a plasma membrane transporter plays
a significant role in multi-drug resistance (MDR) by enhancing the efflux of
several drugs even chemotherapeutics.
Inhibition of farnesyl diphosphate synthetase
(FDPS) effect by zoledronic acid which is a strong amino-biphosphonate,
arrested Rho A and Ras activity preventing hypoxia inducible factor-1alpha
(HIF-1α)-driven P-glycoprotein expression and returning the sensitivity of
cancer cells to chemotherapy [12]. In lieu of these, increasing clinical and
experimental data propose a novel promising therapeutic approach depending on
the inhibition of enzymes associated with the mevalonate pathway, as statins
drugs, a likely candidate in cancer treatment strategies hinder tumor growth
[13].
Statins mevalonate-dependent targets Rho A and
C proteins, are involved in cancer cell proliferation and more significantly in
invasion and migration [14]. It has been confirmed that statins inhibit
migration, chemotaxis, and adhesion of acute lymphoblastic leukemia cell lines
through specific GTPases suppression [15]. Of note, statins could exhibit
cytotoxic and anti-proliferative activity via the inhibition of HMG-CoA
reductase and also against the natural killer cells. Similar to all
lymphocytes, natural killer cell malignancies can increase leukemia [16]. The
treatment with a particular statin drug (simvastatin) was able to inhibit the
migration, proliferation and invasion of murine melanoma cells and shrink the
tumor mass in mice (Figure 2) [17].
IMMUNO-MODULATORY EFFECT OF STATINS IN CANCER
Recently, there has been interplay between
tumor cell and its microenvironment majorly the immune cells and the balance
among these determines the development and inhibition of cancer cell.
Furthermore, its contribution to tumor development and progression, activation
of the isoprenoid pathway can represent an essential adaptive host response to
stress, thus activating the anti-cancer immunity mechanism. Although the
isoprenoid pathway is common and vital to cell survival, the
mevalonate-deficient cells cannot be formed by selection induced mechanisms.
Hence, making cells with modified isoprenoid pathway detection an optimal
system for assessing the metabolic integrity of cells susceptible to
modification, either during neoplastic conversion or during infection [19].
Recently, a study was conducted for the first
time on the potential of an endogenous isoprenoid derivative of mevalonate
pathway that is N-6-isopentenyladenosine (iPA) to selectively enlarge and
directly target the human Natural Killer cells (NKC) [20]. Also, it was
reported that the pharmacological agents, amino-bisphosphonates that causes
accumulation of the phosphorylated metabolites inhibiting farnesyl diphosphate
synthetase enhancing in vivo and in vitro cancer cells to T
cells, leading to a reduction in cancer development [21]. Similarly, inhibition
of bisphosphonates, protein prenylation can also initiate caspase-1-dependent
activation of the natural killer cells; together with T cells exert anti-tumor
immune response [22]. For some years now, this huge therapeutic potential point
to bisphosphonates (BPs) has the most promising method in inhibiting the
mevalonate pathway in cancer cells to attain a protective anti-cancer response.
Meanwhile statins drugs to which significant immuno-adjuvant characteristics
have been ascribed shows a related positive mechanism. Effects of statins on
the anti-tumor cell intrinsic barrier are well known, comprising of protein
prenylation inhibition through decrease of downstream isoprenoid metabolites
needed for essential cellular mechanisms [23] (Figure 3).
ANTI-METASTATIC PROPERTIES
It is
worth of note that approximately 1% of cellular proteins are geranylgeranylated
including the Rho proteins family, N-Ras, and K-Ras. Ras and Ras-homologous
(Rho) Guanosine-5-triphosphate-ases (GTPases) are recognized as regulatory
proteins, in which prenylation is vital for their normal intracellular function
and localization. These proteins play a crucial role in several signal
transduction pathways related to cell death, tumor progression and cell
proliferation [28]. Statins have also been shown to exert anti-metastatic
effects and geranyl geranylation is crucial to this mechanism. Many researches
have connected the anti-invasive effect of statins (cerivastatin) therapy with
RhoA delocalization from the cell membrane, leading to disorientation of actin
fibres and removal of focal adhesion sites. Furthermore, inhibition of RhoA
results in deactivation of nuclear factor kappa-light-chain-enhancer of
activated B cells (NF-κB), leading to low expression of proteases involved in
cell migration (urokinase and metalloproteinase 9) [29]. In particular,
cerivastatin affects cell signaling pathways related with invasiveness and the
metastatic attributes of extremely invasive cancer cells.
Statins could promote apoptosis by
inhibiting GPP needed for ultimate Rho mediated cell proliferation. Statins can
also up-regulate the pro-apoptotic proteins for example, Bim and Bax and down
regulate anti-apoptotic proteins for example Bcl-2. Also, statins activate
caspases involved in cell death. Thus, showing many possible mechanisms for
apoptosis [30] (Figure 4).
Statins consistently reduce the progression of liver fibrosis,
mostly due to their ability to alleviate portal hypertension, immunomodulatory
effect, and also enhances transcription factors with vasoprotective effects in
the liver and inhibit stellate cells, hence possibly further decreasing fibrosis
[31]. However, the zeal concerning statins potentials has been mitigated by
fears about their safety profile in cirrhotic individuals due to their risk of
dose-dependent hepatic injury [32].
In breast cancer, most of clinical evidence supports a
protective potential of statins on reducing recurrence of breast cancer. The
benefits of statins on reducing the recurrence of breast cancer appears shows
strong effect in younger individuals, proposing a longitudinal effect of statin
therapy. Another research established a 36% reduction in the risk of breast
cancer recurrence in individuals on lipophilic statins therapy.
ANTI-ANGIOGENIC
EFFECT OF STATINS
The
mevalonate pathway metabolites dolichol through the inhibition of
isoprenylation has been shown to have a stimulatory effect on DNA synthesis and
regulate cell growth [33]. This action is significant in cancer cells, as there
is an increase in G protein activity in many cancer types including,
pancreatic, kidney, bladder, colorectal,
Cancer
cells need new vasculature (angiogenesis) to provide nutrients and oxygen as
the mass increases; without enough supply, the tumor development can be
hindered. Therefore, via angiogenesis inhibition, statins exert its anti-cancer
effect. Hence, cancer promotes hypoxia to stimulate mediators for angiogenesis
[36]. It inhibits formation of new blood vessels by inhibiting endothelial cell
proliferation, stopping extracellular matrix adhesion and by decreasing the
pro-angiogenic factors such as vascular endothelial growth factor (VEGF).
Caveolin, a protein involved in the low expression and activity of endothelial
nitric oxide synthase (eNOS) is essential for the inhibition of angiogenesis
[37]. Hence, endothelial cell with low level caveolin might be more sensitive
to the angiogenic effect of statins. Together with its angiogenic effect,
statins may also exhibit anti-metastasis by inhibiting metastasis mechanisms
such as cell adhesion, extravasation, breaking down of extracellular matrix
(ECM), migration and also invasion of other tissues by decreasing endothelial
adhesion molecules for example matrix metalloproteinase-9 and E-selectin [38].
CONCLUSION
Even though the potential anti-cancer effect showed by statins in preclinical models of several cancer types, only or in combination with other chemotherapeutic drugs, via the prevention of migration, invasion, induction of apoptosis and proliferation their actual efficacy in the clinical setting is not yet confirmed. Nevertheless, the likelihood to increase statins doses in cancer patients is narrow by the higher risk of side effects such as rhabdomyolysis and myalgia. A probable solution is to find appropriate favorable combinations of statins and standard chemotherapeutic agents or drugs, capable of having synergistic effects and therefore permit the use of lower effective doses both of the cytotoxic drug and statin, significantly decreasing side effects and promoting the quality of life of the patient.
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