NSAIDs Modulate CDKN2A, TP53, and DNA Content Risk for Progression to Esophageal Adenocarcinoma

Background Somatic genetic CDKN2A, TP53, and DNA content abnormalities are common in many human cancers and their precursors, including esophageal adenocarcinoma (EA) and Barrett's esophagus (BE), conditions for which aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) have been proposed as possible chemopreventive agents; however, little is known about the ability of a biomarker panel to predict progression to cancer nor how NSAID use may modulate progression. We aimed to evaluate somatic genetic abnormalities with NSAIDs as predictors of EA in a prospective cohort study of patients with BE. Methods and Findings Esophageal biopsies from 243 patients with BE were evaluated at baseline for TP53 and CDKN2A (p16) alterations, tetraploidy, and aneuploidy using sequencing; loss of heterozygosity (LOH); methylation-specific PCR; and flow cytometry. At 10 y, all abnormalities, except CDKN2A mutation and methylation, contributed to EA risk significantly by univariate analysis, ranging from 17p LOH (relative risk [RR] = 10.6; 95% confidence interval [CI] 5.2–21.3, p < 0.001) to 9p LOH (RR = 2.6; 95% CI 1.1–6.0, p = 0.03). A panel of abnormalities including 17p LOH, DNA content tetraploidy and aneuploidy, and 9p LOH was the best predictor of EA (RR = 38.7; 95% CI 10.8–138.5, p < 0.001). Patients with no baseline abnormality had a 12% 10-y cumulative EA incidence, whereas patients with 17p LOH, DNA content abnormalities, and 9p LOH had at least a 79.1% 10-y EA incidence. In patients with zero, one, two, or three baseline panel abnormalities, there was a significant trend toward EA risk reduction among NSAID users compared to nonusers (p = 0.01). The strongest protective effect was seen in participants with multiple genetic abnormalities, with NSAID nonusers having an observed 10-y EA risk of 79%, compared to 30% for NSAID users (p < 0.001). Conclusions A combination of 17p LOH, 9p LOH, and DNA content abnormalities provided better EA risk prediction than any single TP53, CDKN2A, or DNA content lesion alone. NSAIDs are associated with reduced EA risk, especially in patients with multiple high-risk molecular abnormalities.

[1]  H. El‐Serag,et al.  Meta-Analysis: Obesity and the Risk for Gastroesophageal Reflux Disease and Its Complications , 2005, Annals of Internal Medicine.

[2]  A. Feinberg,et al.  Microallelotyping defines the sequence and tempo of alleiic losses at tumour suppressor gene loci during colorectal cancer progression , 1995, Nature Medicine.

[3]  N. Sharpless,et al.  INK4a/ARF: a multifunctional tumor suppressor locus. , 2005, Mutation research.

[4]  B. Reid.  p53 and neoplastic progression in barrett's esophagus , 2001, American Journal of Gastroenterology.

[5]  D. Beer,et al.  Selective inhibition of cyclooxygenase-2 suppresses growth and induces apoptosis in human esophageal adenocarcinoma cells. , 2000, Cancer research.

[6]  Carissa A. Sanchez,et al.  Genetic clonal diversity predicts progression to esophageal adenocarcinoma , 2006, Nature Genetics.

[7]  D. Forman,et al.  Prospective study of cyclin D1 overexpression in Barrett's esophagus: association with increased risk of adenocarcinoma. , 2000, Journal of the National Cancer Institute.

[8]  P. O’Connell,et al.  Genetic pattern of prostate cancer progression , 1999, International journal of cancer.

[9]  David Neil Cooper,et al.  Encyclopedia of the Human Genome , 2003 .

[10]  M. Blaser,et al.  Population attributable risks of esophageal and gastric cancers. , 2003, Journal of the National Cancer Institute.

[11]  A. Sonnenberg,et al.  Medical decision analysis of chemoprevention against esophageal adenocarcinoma. , 2003, Gastroenterology.

[12]  B. Reid,et al.  Focus on Barrett's esophagus and esophageal adenocarcinoma. , 2004, Cancer cell.

[13]  G. Falk,et al.  The incidence of adenocarcinoma and dysplasia in Barrett's esophagus: Report on the cleveland clinic barrett's esophagus registry , 1999, American Journal of Gastroenterology.

[14]  F. Bosman,et al.  p16 inactivation by methylation of the CDKN2A promoter occurs early during neoplastic progression in Barrett's esophagus. , 2002, Gastroenterology.

[15]  The incidence of adenocarcinoma and dysplasia in Barrett's esophagus: Report on the cleveland clinic barrett's esophagus registry , 1999 .

[16]  Carissa A. Sanchez,et al.  Evolution of neoplastic cell lineages in Barrett oesophagus , 1999, Nature Genetics.

[17]  Susan Halabi,et al.  A randomized trial of aspirin to prevent colorectal adenomas in patients with previous colorectal cancer. , 2003, The New England journal of medicine.

[18]  S. Lippman,et al.  Frequent microsatellite alterations at chromosomes 9p21 and 3p14 in oral premalignant lesions and their value in cancer risk assessment , 1996, Nature Medicine.

[19]  E. Negri,et al.  Aspirin use and cancers of the upper aerodigestive tract , 2003, British Journal of Cancer.

[20]  Kenneth K Wang,et al.  The effect of selective cyclooxygenase-2 inhibition in Barrett's esophagus epithelium: an in vitro study. , 2002, Journal of the National Cancer Institute.

[21]  Y. Benjamini,et al.  Controlling the false discovery rate: a practical and powerful approach to multiple testing , 1995 .

[22]  Patricia L. Blount,et al.  The Combination of Genetic Instability and Clonal Expansion Predicts Progression to Esophageal Adenocarcinoma , 2004, Cancer Research.

[23]  R. Cestari,et al.  Long-term endoscopic surveillance of patients with Barrett's esophagus. incidence of dysplasia and adenocarcinoma: a prospective study , 2003, American Journal of Gastroenterology.

[24]  K. Wada.  p16 and p53 gene alterations and accumulations in the malignant evolution of intraductal papillary-mucinous tumors of the pancreas. , 2002, Journal of hepato-biliary-pancreatic surgery.

[25]  S. Lippman,et al.  Cyclooxygenase-2 and epidermal growth factor receptor: pharmacologic targets for chemoprevention. , 2005, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[26]  M S Pepe,et al.  Phases of biomarker development for early detection of cancer. , 2001, Journal of the National Cancer Institute.

[27]  L. Bernstein,et al.  Hiatal hernia, reflux symptoms, body size, and risk of esophageal and gastric adenocarcinoma , 2003, Cancer.

[28]  G. Jenkins,et al.  Genetic pathways involved in the progression of Barrett's metaplasia to adenocarcinoma , 2002, The British journal of surgery.

[29]  R. Sutton,et al.  Loss of heterozygosity on chromosome 17p predicts neoplastic progression in Barrett's esophagus , 2003, Journal of gastroenterology and hepatology.

[30]  B. Czerniak,et al.  Genetic modeling of human urinary bladder carcinogenesis , 2000, Genes, chromosomes & cancer.

[31]  T. Shankey,et al.  Common patterns of genetic evolution in human solid tumors. , 1997, Cytometry.

[32]  M. Gammon,et al.  Body mass index and risk of adenocarcinomas of the esophagus and gastric cardia. , 1998, Journal of the National Cancer Institute.

[33]  W. Grady.  Genetic testing for high-risk colon cancer patients. , 2003, Gastroenterology.

[34]  Carissa A. Sanchez,et al.  Nonsteroidal anti-inflammatory drug use, body mass index, and anthropometry in relation to genetic and flow cytometric abnormalities in Barrett's esophagus. , 2002, Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology.

[35]  R. Haggitt,et al.  Barrett's esophagus, dysplasia, and adenocarcinoma. , 1994, Human pathology.

[36]  Patricia L. Blount,et al.  Predictors of progression in Barrett's esophagus III: baseline flow cytometric variables , 2001, American Journal of Gastroenterology.

[37]  D. Bostwick,et al.  Independent origin of multiple foci of prostatic intraepithelial neoplasia , 1998, Cancer.

[38]  P. Aló,et al.  DNA/protein flow cytometry as a predictive marker of malignancy in dysplasia-free Barrett's esophagus: thirteen-year follow-up study on a cohort of patients. , 1998, Cytometry.

[39]  B. Levin,et al.  The effect of celecoxib, a cyclooxygenase-2 inhibitor, in familial adenomatous polyposis. , 2000, The New England journal of medicine.

[40]  J. Soares,et al.  Losses of Heterozygosity on Chromosomes 9p and 17p Are Frequent Events in Barrett’s Metaplasia Not Associated With Dysplasia or Adenocarcinoma , 2003, American Journal of Gastroenterology.

[41]  M. Serrano,et al.  Specific Contribution of p19ARF to Nitric Oxide-Dependent Apoptosis1 , 2006, The Journal of Immunology.

[42]  Kenneth K Wang,et al.  Chemoprevention of esophageal adenocarcinoma by COX-2 inhibitors in an animal model of Barrett's esophagus. , 2002, Gastroenterology.

[43]  Prateek Sharma,et al.  p53 protein overexpression in low grade dysplasia (LGD) in barrett's esophagus: Immunohistochemical marker predictive of progression , 2001, American Journal of Gastroenterology.

[44]  M. Sporn,et al.  Treatment and Prevention of Intraepithelial Neoplasia: An Important Target for Accelerated New Agent Development: Recommendations of the American Association for Cancer Research Task Force on the Treatment and Prevention of Intraepithelial Neoplasia , 2002 .

[45]  C. Prives,et al.  p53: puzzle and paradigm. , 1996, Genes & development.

[46]  M. Feitelson,et al.  Genetic mechanisms of hepatocarcinogenesis , 2002, Oncogene.

[47]  S. Piantadosi,et al.  Treatment of colonic and rectal adenomas with sulindac in familial adenomatous polyposis. , 1993, The New England journal of medicine.

[48]  M. Gammon,et al.  Use of aspirin and other nonsteroidal anti-inflammatory drugs and risk of esophageal and gastric cancer. , 1998, Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology.

[49]  I. Bièche,et al.  Genetic pathways in the evolution of breast ductal carcinoma in situ , 2002, The Journal of pathology.

[50]  J. Manson,et al.  Aspirin Use and Colorectal Cancer: Post-Trial Follow-up Data from the Physicians' Health Study , 1998, Annals of Internal Medicine.

[51]  Kenneth K Wang,et al.  Updated Guidelines 2008 for the Diagnosis, Surveillance and Therapy of Barrett's Esophagus , 1998, The American Journal of Gastroenterology.

[52]  Patricia L. Blount,et al.  p16(INK4a) lesions are common, early abnormalities that undergo clonal expansion in Barrett's metaplastic epithelium. , 2001, Cancer research.

[53]  S. Baylin,et al.  p53 activates expression of HIC-1, a new candidate tumour suppressor gene on 17p13.3 , 1995, Nature Genetics.

[54]  J. Epstein,et al.  Papillary urothelial hyperplasia is a clonal precursor to papillary transitional cell bladder cancer. , 1999, International journal of cancer.

[55]  L. Brown,et al.  Epidemiologic trends in esophageal and gastric cancer in the United States. , 2002, Surgical oncology clinics of North America.

[56]  B. Reid,et al.  p53-mutant clones and field effects in Barrett's esophagus. , 1999, Cancer research.

[57]  Carissa A. Sanchez,et al.  Predictors of progression in Barrett's esophagus II: baseline 17p (p53) loss of heterozygosity identifies a patient subset at increased risk for neoplastic progression , 2001, American Journal of Gastroenterology.

[58]  M. Gammon,et al.  Tobacco, alcohol, and socioeconomic status and adenocarcinomas of the esophagus and gastric cardia. , 1997, Journal of the National Cancer Institute.

[59]  D. Wong,et al.  p16INK4a promoter is hypermethylated at a high frequency in esophageal adenocarcinomas. , 1997, Cancer research.

[60]  E. Hawk,et al.  Counterpoint: Because some surrogate end point biomarkers measure the neoplastic process they will have high utility in the development of cancer chemopreventive agents against sporadic cancers. , 2003, Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology.

[61]  R. Sampliner,et al.  Updated guidelines for the diagnosis, surveillance, and therapy of Barrett's esophagus , 2002, American Journal of Gastroenterology.

[62]  J. Minna,et al.  Molecular genetic changes found in human lung cancer and its precursor lesions. , 1994, Cold Spring Harbor symposia on quantitative biology.

[63]  M. Pepe,et al.  Inactivation of p16, RUNX3, and HPP1 occurs early in Barrett's-associated neoplastic progression and predicts progression risk , 2005, Oncogene.

[64]  A. Tarnawski,et al.  NSAID inhibition of GI cancer growth: clinical implications and molecular mechanisms of action , 2002, American Journal of Gastroenterology.

[65]  C. Sherr,et al.  Principles of Tumor Suppression , 2004, Cell.

[66]  C. Gutschow,et al.  Demographic variations in the rising incidence of esophageal adenocarcinoma in white males , 2001, Cancer.

[67]  Leslie Bernstein,et al.  A multiethnic population-based study of smoking, alcohol and body size and risk of adenocarcinomas of the stomach and esophagus (United States) , 2001, Cancer Causes & Control.

[68]  Mats Lindblad,et al.  Body mass, tobacco and alcohol and risk of esophageal, gastric cardia, and gastric non-cardia adenocarcinoma among men and women in a nested case-control study , 2005, Cancer Causes & Control.

[69]  P. Laird,et al.  Fields of aberrant CpG island hypermethylation in Barrett's esophagus and associated adenocarcinoma. , 2000, Cancer research.

[70]  J. Califano,et al.  Genetic progression and clonal relationship of recurrent premalignant head and neck lesions. , 2000, Clinical cancer research : an official journal of the American Association for Cancer Research.

[71]  C. Harris,et al.  The IARC TP53 database: New online mutation analysis and recommendations to users , 2002, Human mutation.

[72]  Brian J. Reid,et al.  Progressive Region-Specific De Novo Methylation of the p16 CpG Island in Primary Human Mammary Epithelial Cell Strains during Escape from M0 Growth Arrest , 1999, Molecular and Cellular Biology.

[73]  S. Meltzer,et al.  Biomarkers of Esophageal Adenocarcinoma and Barrett’s Esophagus , 2004, Cancer Research.

[74]  Carissa A. Sanchez,et al.  17p (p53) allelic losses, 4N (G2/tetraploid) populations, and progression to aneuploidy in Barrett's esophagus. , 1996, Proceedings of the National Academy of Sciences of the United States of America.

[75]  B. Reid,et al.  Loss of heterozygosity analysis using whole genome amplification, cell sorting, and fluorescence-based PCR. , 1999, Genome research.

[76]  M. Sporn,et al.  Treatment and prevention of intraepithelial neoplasia: an important target for accelerated new agent development. , 2002, Clinical cancer research : an official journal of the American Association for Cancer Research.

[77]  W. Zoller,et al.  [Controlled 15-year trial on screening for colorectal cancer in families with hereditary nonpolyposis colorectal cancer]. , 2001, Zeitschrift fur Gastroenterologie.

[78]  C. Williams,et al.  Randomized controlled trial of the effect of sulindac on duodenal and rectal polyposis and cell proliferation in patients with familial adenomatous polyposis , 1993, The British journal of surgery.

[79]  B. Vogelstein,et al.  Reduction to homozygosity involving p53 in esophageal cancers demonstrated by the polymerase chain reaction. , 1991, Proceedings of the National Academy of Sciences of the United States of America.

[80]  G. Beck,et al.  A randomized trial of aspirin to prevent colorectal adenomas. , 2003, The New England journal of medicine.

[81]  J. Goldblum,et al.  Chromosomal gains and genomic loss of p53 and p16 genes in Barrett's esophagus detected by fluorescence in situ hybridization of cytology specimens , 2004, Modern Pathology.

[82]  J. Lagergren,et al.  Association between Body Mass and Adenocarcinoma of the Esophagus and Gastric Cardia , 1999, Annals of Internal Medicine.

[83]  V. Moreno,et al.  Time trends incidence of both major histologic types of esophageal carcinomas in selected countries, 1973–1995 , 2002, International journal of cancer.

[84]  B. Vogelstein,et al.  A genetic model for colorectal tumorigenesis , 1990, Cell.

[85]  Rajnish A. Gupta,et al.  Cyclooxygenase-2 inhibitor therapy for the prevention of esophageal adenocarcinoma in Barrett's esophagus. , 2002, Journal of the National Cancer Institute.

[86]  T. Iwama,et al.  A randomized, double-blind, placebo-controlled trial of the effects of rofecoxib, a selective cyclooxygenase-2 inhibitor, on rectal polyps in familial adenomatous polyposis patients. , 2003, Clinical cancer research : an official journal of the American Association for Cancer Research.

[87]  E. Hawk,et al.  Chemoprevention in hereditary colorectal cancer syndromes , 1999, Cancer.

[88]  C. Maley,et al.  Natural selection in neoplastic progression of Barrett's esophagus. , 2005, Seminars in cancer biology.

[89]  S. Piantadosi,et al.  Poster 7: A Genetic Progression Model for Head and Neck Cancer: Implications for Field Cancerization , 1996, Cancer research.

[90]  Gary Longton,et al.  Predictors of progression to cancer in Barrett's esophagus: baseline histology and flow cytometry identify low- and high-risk patient subsets , 2000, American Journal of Gastroenterology.

[91]  T. Miyashita,et al.  A COX-2 inhibitor prevents the esophageal inflammation-metaplasia-adenocarcinoma sequence in rats. , 2004, Carcinogenesis.

[92]  A. Giménez,et al.  Flow cytometric DNA analysis and p53 protein expression show a good correlation with histologic findings in patients with barrett's esophagus , 1998, Cancer.

[93]  G. Lapertosa,et al.  Long-term endoscopic surveillance of patients with Barrett's esophagus. A prospective study , 2000 .

[94]  D. Beer,et al.  Selective inhibition of cyclooxygenase-2 inhibits growth and induces apoptosis in human esophageal adenocarcinoma cells , 2000 .

[95]  S. Lippman,et al.  Detection of chromosome instability of tissue fields at risk: In situ hybridization , 1996, Journal of cellular biochemistry. Supplement.

[96]  L. Melton,et al.  Secular trends in the epidemiology and outcome of Barrett's oesophagus in Olmsted County, Minnesota , 2001, Gut.

[97]  A. Lindgren,et al.  The role of tobacco, snuff and alcohol use in the aetiology of cancer of the oesophagus and gastric cardia , 2000, International journal of cancer.

[98]  J. Manson,et al.  Low-dose aspirin in the primary prevention of cancer: the Women's Health Study: a randomized controlled trial. , 2005, JAMA.

[99]  S. Lippman,et al.  Predicting cancer development in oral leukoplakia: ten years of translational research. , 2000, Clinical cancer research : an official journal of the American Association for Cancer Research.

[100]  G. Lindberg,et al.  Distribution of genetic variants in preneoplastic areas of colorectal tumours. , 2003, European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology.

[101]  R. López‐Ridaura,et al.  Effects of non-steroidal anti-inflammatory drugs on cancer sites other than the colon and rectum: a meta-analysis , 2003, BMC Cancer.

[102]  G. Triadafilopoulos,et al.  Rofecoxib inhibits cyclooxygenase 2 expression and activity and reduces cell proliferation in Barrett's esophagus. , 2002, Gastroenterology.

[103]  Michael J Thun,et al.  Nonsteroidal anti-inflammatory drugs as anticancer agents: mechanistic, pharmacologic, and clinical issues. , 2002, Journal of the National Cancer Institute.

[104]  Patricia L. Blount,et al.  Optimizing endoscopic biopsy detection of early cancers in Barrett's high-grade dysplasia , 2000, American Journal of Gastroenterology.

[105]  H. Comber,et al.  Nonsteroidal anti-inflammatory drugs and the esophageal inflammation-metaplasia-adenocarcinoma sequence. , 2006, Cancer research.

[106]  Roland Eils,et al.  Pathways of urothelial cancer progression suggested by Bayesian network analysis of allelotyping data , 2004, International journal of cancer.

[107]  Carissa A. Sanchez,et al.  Selectively Advantageous Mutations and Hitchhikers in Neoplasms , 2004, Cancer Research.

[108]  W. Hop,et al.  Dysplasia and aneuploidy as markers of malignant degeneration in Barrett's oesophagus. The Rotterdam Oesophageal Tumour Study Group. , 1994, Gut.

[109]  A. Gazdar,et al.  Loss of heterozygosity in benign breast epithelium in relation to breast cancer risk. , 2002, Journal of the National Cancer Institute.

[110]  N D Le,et al.  Use of allelic loss to predict malignant risk for low-grade oral epithelial dysplasia. , 2000, Clinical cancer research : an official journal of the American Association for Cancer Research.

[111]  K. Kerlikowske,et al.  Protective association of aspirin/NSAIDs and esophageal cancer: a systematic review and meta-analysis. , 2003, Gastroenterology.

[112]  A. Cameron,et al.  Barrett's esophagus: age, prevalence, and extent of columnar epithelium. , 1992, Gastroenterology.

[113]  J. Jansen,et al.  Biomarkers in Barrett's esophagus (review). , 1998, International journal of oncology.

[114]  Jing Yin,et al.  Frequent loss of heterozygosity on chromosome 9 in adenocarcinoma and squamous cell carcinoma of the esophagus. , 1994, Cancer research.

[115]  R. Sampliner,et al.  Discordance between flow cytometric abnormalities and dysplasia in Barrett's esophagus. , 1989, Gastroenterology.

[116]  S. Lippman,et al.  Aspirin induction of apoptosis in esophageal cancer: a potential for chemoprevention. , 2000, Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology.

[117]  D. Forman,et al.  TP53 and progression from Barrett’s metaplasia to oesophageal adenocarcinoma in a UK population cohort , 2006, Gut.

[118]  Carissa A. Sanchez,et al.  Clonal expansion and loss of heterozygosity at chromosomes 9p and 17p in premalignant esophageal (Barrett's) tissue. , 2000, Journal of the National Cancer Institute.

[119]  Carissa A. Sanchez,et al.  Non-steroidal anti-inflammatory drugs and risk of neoplastic progression in Barrett's oesophagus: a prospective study. , 2005, The Lancet. Oncology.

[120]  M. King,et al.  Breast and Ovarian Cancer Risks Due to Inherited Mutations in BRCA1 and BRCA2 , 2003, Science.

[121]  S. Piantadosi,et al.  Primary chemoprevention of familial adenomatous polyposis with sulindac , 2002 .