Cáncer y vitamina D

Alberto Muñoz

Instituto de Investigaciones Biomédicas, Madrid

1,25-Dihydroxyvitamin D3 and malignant melanoma:

the presence of receptors and inhibition of cell growth in culture

Colston, K., Colston, M.J., and Feldman, D.

Endocrinology 108, 1083-1086, 1981

Differentiation of mouse myeloid leukemia cells

induced by 1a,25-dihydroxyvitamin D3

Abe et al.,

PNAS 78, 4990-4994, 1981

Vitamin D and Cancer: the beginning

Dr. David Feldman

Stanford University School of Medicine

1930s, Peller y Stephenson

Tener un cáncer de piel proporciona inmunidad contra otros cánceres (personal Marina USA)

1941, Apperly

Existe una correlación inversa entre latitud y mortalidad por cáncer

1980, Garland y Garland

La vitamina D es la responsable de la correlación inversa entre la exposición a la radiación UV solar y

el riesgo de cáncer de colon

más tarde, se propone la misma relación con cáncer de mama, ovario… hasta 15 neoplasias

2015, la asociación más clara es con cáncer de colon/colorrectal, luego cáncer de mama.

450

500

400

500

450

350

300

300

350 300

300

350

400

350

Índice de mortalidad por cáncer de colon

varones, 1970-1994

Relación inversa entre irradiación solar y cáncer de colon

Garland et al., Vitamin D for Cancer Prevention: Global Perspective.

Annals of Epidemiology, 2009

Serum 25(OH)D3 (ng/ml) Serum 25(OH)D3

Correlación inversa entre los niveles de 25(OH)D3 en el suero y cáncer de colon

mortalidad incidencia

• Causal link between Vitamin D and colorectal/bowel cancer is probable • Growing evidence, not conclusive

• Need for prospective clinical trials and large-scale observational studies

Giovannucci, E. Epidemiology of vitamin D and colorectal cancer. Anticancer Agents Med Chem., 2013

“… high consistency and strongly suggestive of a causal association, Thus, improving vitamin D

status could be potentially beneficial against colorectal cancer incidence and mortality”

Randomized Trials on

Vitamin D and Cancer

Incidence and/or Mortality

118-125

Available data from published randomized controlled trials are

not sufficient to draw final conclusions

Deficiencies: biased, population (post-menopausic women), duration, basal

25(OH)D3 levels, compliance, false placebos…

• Enroll people at the lower end (VitD deficient)

• Supplement with sufficient vitamin D3 to raise their serum 25(OH)D3 level to near the upper end

• Measure 25(OH)D level at the time of enrollment and remeasure at the end of the study

• Consider other sources of vitamin D; avoid false placebos

(ideally the agent in the trial must be the only source of the agent)

• Ensure that important cofactors (Ca2+) are optimized

• Consider individual heterogeneity (VDR polymorphisms…)

• Ensure an appropriate duration of the trial

Summary

Low serum concentrations of 25-hydroxyvitamin D (25[OH]D) have been associated with many non-skeletal disorders. However, whether low 25(OH)D is

the cause or result of ill health is not known. We did a systematic search of prospective and intervention studies that assessed the effect of 25(OH)D

concentrations on non-skeletal health outcomes in individuals aged 18 years or older. We identified 290 prospective cohort studies (279 on disease

occurrence or mortality, and 11 on cancer characteristics or survival), and 172 randomised trials of major health outcomes and of physiological parameters

related to disease risk or inflammatory status. Investigators of most prospective studies reported moderate to strong inverse associations between 25(OH)D

concentrations and cardiovascular diseases, serum lipid concentrations, inflammation, glucose metabolism disorders, weight gain, infectious diseases,

multiple sclerosis, mood disorders, declining cognitive function, impaired physical functioning, and all-cause mortality. High 25(OH)D concentrations were

not associated with a lower risk of cancer, except colorectal cancer. Results from intervention studies did not show an effect of vitamin D supplementation

on disease occurrence, including colorectal cancer. In 34 intervention studies including 2805 individuals with mean 25(OH)D concentration lower than 50

nmol/L at baseline supplementation with 50 μg per day or more did not show better results. Supplementation in elderly people (mainly women) with 20 μg

vitamin D per day seemed to slightly reduce all-cause mortality. The discrepancy between observational and intervention studies suggests that low 25(OH)D

is a marker of ill health. Inflammatory processes involved in disease occurrence and clinical course would reduce 25(OH)D, which would explain why low

vitamin D status is reported in a wide range of disorders. In elderly people, restoration of vitamin D deficits due to ageing and lifestyle changes induced by ill

health could explain why low-dose supplementation leads to slight gains in survival.

Is vitamin D deficiency cause or consequence

(“reverse causality”) of the disease status?

Prostate Colon

Criterios para establecer causalidad en un sistema biológico

Robert Koch (tuberculosis/bacteria, Rev Infect Dis 4, 1270-1274, 1882)

1. Grado elevado de asociación

2. Consistencia: observación repetida en numerosas poblaciones distintas

3. Especificidad: un agente, un resultado

4. Temporalidad: la exposición/causa precede al efecto

5. Gradiente biológico: relación dosis-respuesta

6. Conocer el mecanismo

7. Coherencia: compatibilidad con la historia natural y biología de la enfermedad

R.A. Weinberg.

The Biology of Cancer, 2007/2013

CTTNB1/b-catenin

AXIN

R-Spondin (RSPO2/3)

RNF43

TCF7L2/TCF4

La alteración genética inicial en la mayoría de cánceres colorrectales es probablemente

conocida: la activación aberrante de la vía de señalización Wnt/b-catenina

Over 94% have a mutation in one or more members of the Wnt signaling pathway

E-Cadh E-Cadh

Genes diana REPRIMIDOS

TCF

Frizzled LRP

b-Cat

Actina

Uniones

adherentes

b-Cat b-Cat APC

Axina

CKI

GSK3b

P

Proteasoma

b-Cat

Vía de señalización Wnt/b-catenina

Epitelio normal, OFF

E-Cadh E-Cadh

TCF

Wnt

b-Cat

Actina

Target genes REPRESSED

Uniones

adherentes

Frizzled LRP

b-Cat

Axin

b-Cat b-Cat b-Cat

b-Cat

b-Cat

b-Cat

Genes diana ACTIVADOS

CKI

GSK3b

P

P

b-Cat APC

Axina

CKI

GSK3b

b-Cat APC

CKI

GSK3b

Dvl

b-Cat b-Cat

Proteasoma

b-Cat

P

Vía de señalización Wnt/b-catenina Factores Wnt, ON

E-Cadh E-Cadh

TCF

b-Cat

Actina

Uniones

adherentes

Vía de señalización Wnt/b-catenina

b-Cat

b-Cat

Genes diana ACTIVADOS proliferación, invasividad, metástasis

b-Cat b-Cat b-Cat

b-Cat

Frizzled LRP

b-Cat APC

Axina

CKI

GSK3b

mut

Cáncer colon, ON

1,25(OH)2D3 induce un fenotipo epitelial diferenciado y reduce la proliferación mediante:

a) la inducción de E-cadherina y b) la relocalización de b-catenina

E-cadherina

b-catenina

Control

1,25(OH)2D3 16 h

1,25(OH)2D3 48 h

Células SW480-ADH

Pálmer et al.,

J. Cell Biol., 2001

Kremen

Arrow/

LRP5/6

Wnt

Frizzled

Wnt Wnt

Wnt

DKK-1

Wise

SFRPs WIF

Cerberus

Inhibitors of Wnt signalling

Intracellular inhibitors

Chibby, TAK/NLK, I-mfa, ICAT, HBP-1, lines, Sox3, Sox17a/b…

Via direct binding to Wnt factors

sFRPs, WIF-1, Cerberus

Via binding to components of the

Wnt receptor complex

DICKKOPF (DKK-1-4), Wise

C1q/Cs complt. complex

Carboxypeptidase E, Tiki

endocytosis

Extracellular inhibitors

1a,25(OH)2D

3

TCF4

b-Cat

TCF4

b-Cat

b-Cat

b-Cat

b-Cat

b-Cat b-Cat

E-Cadherina

b-Cat

Genes diana

activados

Genes diana

reprimidos

1

2

TCF4

E-Cadherina

Genes diana

reprimidos

b-Cat

b-Cat

Células epiteliales

normales

Células de c. de colon

tratadas con 1a,25(OH)2D3

Células de

carcinoma de colon

APC

APC mut

1,25(OH)2D3 inhibe la vía Wnt/b-catenina en células de cáncer de colon:

Tres mecanismos

SW

48

0-A

DH

SW

48

0-A

DH

1a,25(OH)2D3 Vehiculo

DKK-1

DKK-1

3

Snail1 induce Transición Epitelio-Mesénquima (TEM)

Células epiteliales

Células mesenquimales

(invasivas)

Snail1

Células Snail (-) Células Snail (+)

Área invasiva del tumor primario

Células tumorales

no-invasivas

Células tumorales

invasivas

Rotura de la

membrana basal

Membrana basal

Modificado de Nieto, MA, Nat Rev Mol Cell Biol 3, 155-166, 2002

No reported:

VDR gene mutations

Epigenetic silencing

Transcriptional repression

Controversial role of several polymorphisms

Does Snail1 repress VDR expression?

exon 1A

promoter

Snail1

Human VDR gene

Three putative

Snail1 sites/E-boxes

Control 1a,25(OH)2D3 1a,25(OH)2D3 Control

Mock Snail-HA

Snail inhibe la expresión de VDR y su inducción por vitamina D

Proteína RNA

E-cadherin

E-Cadherina

Snail1 inhibe la acción antitumoral action del análogo de la vitamin D

EB1089/Seocalcitol en ratones xenotransplantados

Placebo

EB1089

Placebo

EB1089

Mock

Snail1-HA

}

}

Placebo

EB1089

SW480-R }

Tumor growth

La inducción de SNAIL se correlaciona con la represión de VDR

en cáncer de colon humano

r (Spearman) = –0.47

P = 0.007

P = 0.0001 Wilcoxon test

The transcription factor SNAIL represses vitamin D receptor expression and responsiveness in human colon cancer

(n = 32) Pálmer et al. Nat. Med. 10, 117-119 (2004)

E-cadherin and vitamin D receptor regulation by Snail and ZEB-1 in colon cancer: clinicopathological correlations

(n = 114) Peña et al. Human Mol. Genet. 14, 3361-3370 (2005)

1,25(OH)2D3

VDR

Efectos

genómicos

Efectos

no-genómicos

Snail1, Snail2

Señalización

Wnt/b-catenina

Diferenciación

Vía Wnt/b-catenina

Inhib. proliferación

Apoptosis

E-cadherina,…

p21CIP1, p27KIP1,…

Ciclina D1,…

BAX, BAK,…

BCL2, IAP,…

+

-

+

-

+

-

La 1,25(OH)2D3 tiene efectos anti-estrogénicos en células de cáncer de mama

Vitamin D and breast cancer Inhibition of

estrogen synthesis and signaling

Krishnan AV, Swami, S, and Feldman, D

J Steroid Biochem Mol Biol, 2010

Tissue-selective regulation of aromatase

expression by Calcitriol: Implications for

Breast Cancer therapy

Krishnan AV, Swami, S, Peng, L, Wang, J,

Moreno J, and Feldman, D

Endocrinology, 2010

J. Clin. Invest., 124, 859-870, 2014

Clinical Breast Cancer, 2014, in press

Mayor supervivencia libre de enfermedad

no modifica surpervivencia global

J. Clin. Oncol., 32, 3242-3248, 2014

2015, in press

Ongoing Phase III Clinical trials on Vitamin D and

Cancer Risk or Progression/Survival

Feldman, D., Pike, J.W. and Adams, J.S.

Vitamin D, 3rd Ed., Academic Press, 2011

Ensayo D-Health

Australia, 25,000 people aged 64-80

5 years

60,000 U one monthly injection = 2,000 U/day

`

Placebo: 500 U/day allowed and other 100 U/day are calculated from diet

Comparison between 2,000 vs 100-600 U/day

Younger population without accumulated risk?

Solid tumors are heterotypic: they contain neoplastic cells and also several types of stromal

cells (fibroblasts, endothelial, immune cells…) that play crucial roles in tumor progression

Effect of 1,25(OH)2D3 on human colon normal and tumor organoids (stem cells)

Day 0 Day 1 Day 2 Day 7

Antonio Barbáchano Asun Fernández-Barral

Drs. Ramón Cantero y Damián G Olmo

Serv. Cirugía General, Hosp. Univ. La Paz and

Fund. J. Díaz, Madrid

Normal organoids

Tumor organoids

Day 4 Day 0

Effect of 1,25(OH)2D3 on fibroblasts from normal (NF) and tumoral (CAF)

human colon biopsies

Mª Jesús Larriba Gemma Ferrer

Federico Rojo, FJD, Madrid

VDR

high epithelium,

high estroma

Global transcriptomic study 7 patients, matched NF/CAF, 2 days vitD/vehicle: 28 arrays

Ferrer-Mayorga et al., submitted

Estudios epidemiológicos y preclínicos indican un efecto protector de la vitamina D

frente a numerosos cánceres, sobre todo el colorrectal, reduciendo el riesgo/la

incidencia y, sobre todo, la mortalidad por cáncer colorrectal y total (overall mortality)

Por todo ello, parece aconsejable EVITAR LA DEFICIENCIA y continuar los

estudios epidemiológicos y clínicos prospectivos mejorando su diseño

Prevención

Combinación con terapias

Selección y seguimiento de pacientes, dosis adecuadas, duración…

Antonio García de Herreros, IMIM-UPF, Barcelona

Carlos López-Otín, Univ. Oviedo Miguel Lafarga, Univ. Cantabria, Santander

Félix Bonilla, Hosp. Univ. Puerta de Hierro, Madrid

Collaborators

José María Rojas, ISCIII, Madrid

Eva Hernando, New York Univ., USA

Francisco X. Real, CNIO, Madrid

Federico Rojo, Fund. Jiménez Díaz, Madrid

Héctor G. Pálmer, VHIO, Barcelona

David Lyden/Héctor Peinado, Cornell Univ., NY, USA/CNIO

Ramón Cantero/Damián G.Olmo, HU La Paz/FJD, Madrid Ignacio Casal, CIB, CSIC, Madrid

Eduard Batlle, IRB, Barcelona

Javier de las Rivas, CIC, Salamanca

Funding

COLOMICS2