A review of coumarin derivatives in pharmacotherapy of breast cancer.

The coumarin (benzopyran-2-one, or chromen-2-one) ring system, present in natural products (such as the anticoagulant warfarin) that display interesting pharmacological properties, has intrigued chemists and medicinal chemists for decades to explore the natural coumarins or synthetic analogs for their applicability as drugs. Many molecules based on the coumarin ring system have been synthesized utilizing innovative synthetic techniques. The diversity oriented synthetic routes have led to interesting derivatives including the furanocoumarins, pyranocoumarins, and coumarin sulfamates (COUMATES), which have been found to be useful in photochemotherapy, antitumor and anti-HIV therapy, and as stimulants for central nervous system, antibacterials, anti-inflammatory, anti-coagulants, and dyes. Of particular interest in breast cancer chemotherapy, some coumarins and their active metabolite 7-hydroxycoumarin analogs have shown sulfatase and aromatase inhibitory activities. Coumarin based selective estrogen receptor modulators (SERMs) and coumarin-estrogen conjugates have also been described as potential antibreast cancer agents. Since breast cancer is the second leading cause of death in American women behind lung cancer, there is a strong impetus to identify potential new drug treatments for breast cancer. Therefore, the objective of this review is to focus on important coumarin analogs with antibreast cancer activities, highlight their mechanisms of action and structure-activity relationships on selected receptors in breast tissues, and the different methods that have been applied in the construction of these pharmacologically important coumarin analogs.

[1]  J. Mohler,et al.  An updated review of the clinical development of coumarin (1,2-benzopyrone) and 7-hydroxycoumarin , 2005, Journal of Cancer Research and Clinical Oncology.

[2]  S. Mohr,et al.  An estradiol-porphyrin conjugate selectively localizes into estrogen receptor-positive breast cancer cells. , 2002, Bioorganic & medicinal chemistry.

[3]  K. Gumireddy,et al.  Synthesis of new coumarin 3-(N-aryl) sulfonamides and their anticancer activity. , 2004, Bioorganic & medicinal chemistry letters.

[4]  E. Bickoff,et al.  Coumestrol, a new estrogen isolated from forage crops. , 1957, Science.

[5]  Atul Purohit,et al.  Docking studies of sulphamate inhibitors of estrone sulphatase in human carbonic anhydrase II. , 2003, Bioorganic & medicinal chemistry letters.

[6]  F. Jensen,et al.  Synthesis, computational study and cytotoxic activity of new 4-hydroxycoumarin derivatives. , 2008, European journal of medicinal chemistry.

[7]  J. Mohler,et al.  Phase II evaluation of coumarin (1,2‐benzopyrone) in metastatic prostatic carcinoma , 1992, The Prostate.

[8]  V. B. Lohray,et al.  Novel coumarin derivatives of heterocyclic compounds as lipid-lowering agents. , 2003, Bioorganic & medicinal chemistry letters.

[9]  David W. Anderson,et al.  Effects of SP500263, a novel, potent antiestrogen, on breast cancer cells and in xenograft models. , 2002, Cancer research.

[10]  I. Pollard,et al.  The oestrogenic and anti-oestrogenic activity of some synthetic steroids and non-steroids. , 1968, Steroids.

[11]  M. Hung,et al.  Antitumor agents. 258. Syntheses and evaluation of dietary antioxidant--taxoid conjugates as novel cytotoxic agents. , 2007, Bioorganic & medicinal chemistry letters.

[12]  B. Potter,et al.  Potent active site-directed inhibition of steroid sulphatase by tricyclic coumarin-based sulphamates. , 2000, Chemistry & biology.

[13]  H. J. Woerdenbag,et al.  Structure -Cytotoxicity Relationships of a Series of Natural and Semi-Synthetic Simple Coumarins as Assessed in Two Human Tumour Cell Lines , 1997, Zeitschrift fur Naturforschung. C, Journal of biosciences.

[14]  B. Halliwell,et al.  Interactions of a series of coumarins with reactive oxygen species. Scavenging of superoxide, hypochlorous acid and hydroxyl radicals. , 1992, Biochemical pharmacology.

[15]  N. Swamy,et al.  Synthesis and estrogen receptor binding affinity of a porphyrin-estradiol conjugate for targeted photodynamic therapy of cancer. , 1999, Bioorganic & medicinal chemistry letters.

[16]  I. Kostova,et al.  Synthesis, Characterization, and Cytotoxic Activity of New Lanthanum(III) Complexes of Bis-Coumarins , 2006, Bioinorganic chemistry and applications.

[17]  J. Liehr,et al.  Genotoxicity of the steroidal oestrogens oestrone and oestradiol: possible mechanism of uterine and mammary cancer development. , 2001, Human reproduction update.

[18]  M. Dukes,et al.  Arimidex®: A potent and selective fourth-generation aromatase inhibitor , 2004, Breast Cancer Research and Treatment.

[19]  S. Yoshida,et al.  Chemical aspects of coumarin compounds for the prevention of hepatocellular carcinomas. , 2005, Current medicinal chemistry. Anti-cancer agents.

[20]  N. Robert,et al.  Benefit with aromatase inhibitors in the adjuvant setting for postmenopausal women with breast cancer. , 2005, MedGenMed : Medscape general medicine.

[21]  O. Wolf,et al.  Actions of dehydroepiandrosterone and its sulfate in the central nervous system: effects on cognition and emotion in animals and humans , 1999, Brain Research Reviews.

[22]  P. Lønning,et al.  In vivo inhibition of aromatization by exemestane, a novel irreversible aromatase inhibitor, in postmenopausal breast cancer patients. , 1998, Clinical cancer research : an official journal of the American Association for Cancer Research.

[23]  S. Milano,et al.  Synthesis and sulfatase inhibitory activities of non-steroidal estrone sulfatase inhibitors , 1996, The Journal of Steroid Biochemistry and Molecular Biology.

[24]  J. Pasqualini,et al.  Importance of estrogen sulfates in breast cancer. , 1989, Journal of steroid biochemistry.

[25]  David W. Anderson,et al.  SP500263, a novel SERM, blocks osteoclastogenesis in a human bone cell model: role of IL-6 and GM-CSF. , 2003, Cytokine.

[26]  E Uriarte,et al.  Simple coumarins and analogues in medicinal chemistry: occurrence, synthesis and biological activity. , 2005, Current medicinal chemistry.

[27]  Stewart A. Brown,et al.  The natural coumarins : occurrence, chemistry, and biochemistry , 1982 .

[28]  A. Chaigneau,et al.  In vitro and in vivo models for the evaluation of new inhibitors of human steroid sulfatase, devoid of residual estrogenic activity , 2003, The Journal of Steroid Biochemistry and Molecular Biology.

[29]  A. Cavalli,et al.  Comparative molecular field analysis of non-steroidal aromatase inhibitors: an extended model for two different structural classes. , 1998, Bioorganic & medicinal chemistry.

[30]  G. Lukatela,et al.  Crystal structure of human arylsulfatase A: the aldehyde function and the metal ion at the active site suggest a novel mechanism for sulfate ester hydrolysis. , 1998, Biochemistry.

[31]  C. Owen,et al.  Review of estrone sulfatase and its inhibitors--an important new target against hormone dependent breast cancer. , 2002, Current medicinal chemistry.

[32]  F. Jänicke Are all aromatase inhibitors the same? A review of the current evidence. , 2004, Breast.

[33]  A. Børresen-Dale,et al.  Intratumoural mRNA expression of genes from the oestradiol metabolic pathway and clinical and histopathological parameters of breast cancer , 2003, Breast Cancer Research.

[34]  R. G. Morgan,et al.  Treatment of lymphedema of the arms and legs with 5,6-benzo-[alpha]-pyrone. , 1993, The New England journal of medicine.

[35]  Takeshi Usui,et al.  Pharmaceutical prospects of phytoestrogens. , 2006, Endocrine journal.

[36]  A. Katritzky,et al.  Comprehensive heterocyclic chemistry on CD-ROM , 1997 .

[37]  M. Degregorio,et al.  In vitro and in vivo biologic effects of Ospemifene (FC-1271a) in breast cancer , 2001, The Journal of Steroid Biochemistry and Molecular Biology.

[38]  N. Wenger,et al.  Postmenopausal hormone therapy, SERMs, and coronary heart disease in women , 1999, Journal of endocrinological investigation.

[39]  R. Nicholson,et al.  Non-steroidal and steroidal sulfamates: new drugs for cancer therapy , 2001, Molecular and Cellular Endocrinology.

[40]  T. Owa,et al.  Anticancer and antiviral sulfonamides. , 2003, Current medicinal chemistry.

[41]  B. Potter,et al.  In vivo activity of 4-methylcoumarin-7-O-sulfamate, a nonsteroidal, nonestrogenic steroid sulfatase inhibitor. , 1996, Cancer research.

[42]  T. Dierks,et al.  Residues critical for formylglycine formation and/or catalytic activity of arylsulfatase A. , 1998, Biochemistry.

[43]  B. Haynes,et al.  Metabolism of the 4-iodo derivative of tamoxifen by isolated rat hepatocytes. Demonstration that the iodine atom reduces metabolic conversion and identification of four metabolites. , 1990, Biochemical pharmacology.

[44]  B. Potter,et al.  Active site directed inhibition of estrone sulfatase by nonsteroidal coumarin sulfamates. , 1996, Journal of medicinal chemistry.

[45]  G. Feuer,et al.  Inhibition and enhancement of mammary tumorigenesis by 7,12-dimethylbenz (a) anthracene in the female sprague-dawley rat. , 1974, International journal of clinical pharmacology, therapy and toxicology.

[46]  B. Potter,et al.  Steroidal and nonsteroidal sulfamates as potent inhibitors of steroid sulfatase. , 1998, Journal of medicinal chemistry.

[47]  Yate-Ching Yuan,et al.  Biochemical and Biological Characterization of a Novel Anti-aromatase Coumarin Derivative* , 2004, Journal of Biological Chemistry.

[48]  C K Osborne,et al.  Selective estrogen receptor modulators: structure, function, and clinical use. , 2000, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[49]  Novel antineoplastic agents with efficacy against multidrug resistant tumor cells. , 1998, Bioorganic & medicinal chemistry letters.

[50]  D. McDonnell,et al.  The Molecular Pharmacology of SERMs , 1999, Trends in Endocrinology & Metabolism.

[51]  Alan R. Katritzky,et al.  Comprehensive Heterocyclic Chemistry IV , 1996 .

[52]  J. Rousseau,et al.  Synthesis, characterization, and estrogen receptor binding affinity of flavone-, indole-, and furan-estradiol conjugates. , 2007, Bioorganic & medicinal chemistry letters.

[53]  G. Mor,et al.  The potential of aromatase inhibitors in breast cancer prevention. , 1999, Endocrine-related cancer.

[54]  R. Kitz,et al.  Esters of methanesulfonic acid as irreversible inhibitors of acetylcholinesterase. , 1962, The Journal of biological chemistry.

[55]  B. Long,et al.  Aromatase inhibitors and their antitumor effects in model systems. , 1999, Endocrine-related cancer.

[56]  J R Hoult,et al.  Pharmacological and biochemical actions of simple coumarins: natural products with therapeutic potential. , 1996, General pharmacology.

[57]  M. Castiglione‐Gertsch New aromatase inhibitors: more selectivity, less toxicity, unfortunately, the same activity. , 1996, European journal of cancer.

[58]  B. Potter,et al.  Inactivation of steroid sulfatase by an active site-directed inhibitor, estrone-3-O-sulfamate. , 1995, Biochemistry.

[59]  T. Dierks,et al.  Crystal structure of an enzyme-substrate complex provides insight into the interaction between human arylsulfatase A and its substrates during catalysis. , 2001, Journal of molecular biology.

[60]  B. Potter,et al.  Inhibition of steroid sulphatase activity by tricyclic coumarin sulphamates , 2000, The Journal of Steroid Biochemistry and Molecular Biology.

[61]  L. Demers Effects of Fadrozole (CGS 16949A) and Letrozole (CGS 20267) on the inhibition of aromatase activity in breast cancer patients , 2004, Breast Cancer Research and Treatment.

[62]  T. Dierks,et al.  Sulfatases, Trapping of the Sulfated Enzyme Intermediate by Substituting the Active Site Formylglycine * , 1998, The Journal of Biological Chemistry.

[63]  B. Potter,et al.  Inhibition of MCF-7 breast cancer cell proliferation and in vivo steroid sulphatase activity by 2-methoxyoestradiol-bis-sulphamate , 2003, The Journal of Steroid Biochemistry and Molecular Biology.

[64]  S. Raleva,et al.  Structure-Activity Relationships of Synthetic Coumarins as HIV-1 Inhibitors , 2006, Bioinorganic chemistry and applications.

[65]  M. Ellis,et al.  Preoperative treatment of postmenopausal breast cancer patients with letrozole: A randomized double-blind multicenter study. , 2001, Annals of oncology : official journal of the European Society for Medical Oncology.

[66]  C. Siegers,et al.  Antitumor-activities of coumarin, 7-hydroxy-coumarin and its glucuronide in several human tumor cell lines. , 1998, Research communications in molecular pathology and pharmacology.

[67]  D. Fowlkes,et al.  Comparative Analyses of Mechanistic Differences Among Antiestrogens1. , 1999, Endocrinology.

[68]  G. Contesso,et al.  Estrogen receptors (ER) in human breast cancer. The significance of a new prognostic factor based on both ER protein and ER mRNA contents , 1994, Cancer.

[69]  D. Kingston,et al.  Design, synthesis, and bioactivities of steroid-linked taxol analogues as potential targeted drugs for prostate and breast cancer. , 2004, Journal of natural products.

[70]  B. Potter,et al.  In vivo inhibition of estrone sulfatase activity and growth of nitrosomethylurea-induced mammary tumors by 667 COUMATE. , 2000, Cancer research.

[71]  I. Soubeyran,et al.  Variation of hormonal receptor, pS2, c-erbB-2 and GSTpi contents in breast carcinomas under tamoxifen: a study of 74 cases. , 1996, British Journal of Cancer.

[72]  J. Henley,et al.  Treatment with coumarin to prevent or delay recurrence of malignant melanoma , 2005, Journal of Cancer Research and Clinical Oncology.

[73]  David W. Anderson,et al.  Differential Response of Estrogen Receptors α and β to SP500263, a Novel Potent Selective Estrogen Receptor Modulator , 2002 .

[74]  W. Yue,et al.  Preclinical studies using the intratumoral aromatase model for postmenopausal breast cancer. , 1998, Oncology.

[75]  R. Coombes,et al.  Phase I Study of STX 64 (667 Coumate) in Breast Cancer Patients: The First Study of a Steroid Sulfatase Inhibitor , 2006, Clinical Cancer Research.

[76]  B. Potter,et al.  The development of A-ring modified analogues of oestrone-3-O-sulphamate as potent steroid sulphatase inhibitors with reduced oestrogenicity , 1998, The Journal of Steroid Biochemistry and Molecular Biology.

[77]  G. Leclercq,et al.  Diethylstilbestrol-linked cytotoxic agents: synthesis and binding affinity for estrogen receptors. , 1989, Journal of medicinal chemistry.

[78]  Yate-Ching Yuan,et al.  What do we know about the mechanisms of aromatase inhibitor resistance? , 2006, The Journal of Steroid Biochemistry and Molecular Biology.

[79]  K. Kovács,et al.  Suppression of 7,12-Dimethylbenz(α) Anthracene-Induced Breast Carcinoma by Coumarin in the Rat , 1976 .

[80]  J. Haesslein,et al.  Improved antibacterial activities of coumarin antibiotics bearing 5',5'-dialkylnoviose: biological activity of RU79115. , 2000, Bioorganic & medicinal chemistry letters.

[81]  R. Tekmal,et al.  Aromatase overexpression and breast hyperplasia, an in vivo model--continued overexpression of aromatase is sufficient to maintain hyperplasia without circulating estrogens, and aromatase inhibitors abrogate these preneoplastic changes in mammary glands. , 1999, Endocrine-related cancer.

[82]  R. D. Murray The naturally occurring coumarins. , 2002, Fortschritte der Chemie organischer Naturstoffe = Progress in the chemistry of organic natural products. Progres dans la chimie des substances organiques naturelles.

[83]  C. Dorn,et al.  Mirestrol. I. Preparation of the tricyclic intermediate. , 1972, The Journal of organic chemistry.

[84]  J. Liehr,et al.  Estrogen, DNA damage and mutations. , 1999, Mutation research.

[85]  J. Harborne Progress in the chemistry of organic natural products , 1975 .

[86]  M. D. Lloyd,et al.  Crystal structure of human carbonic anhydrase II at 1.95 A resolution in complex with 667-coumate, a novel anti-cancer agent. , 2005, The Biochemical journal.

[87]  Angelo Carotti,et al.  Design, synthesis, and 3D QSAR of novel potent and selective aromatase inhibitors. , 2004, Journal of medicinal chemistry.

[88]  M. Lang,et al.  Highly selective inhibition of estrogen biosynthesis by CGS 20267, a new non-steroidal aromatase inhibitor , 1990, The Journal of Steroid Biochemistry and Molecular Biology.

[89]  P. Lønning,et al.  Influence of anastrozole (Arimidex), a selective, non-steroidal aromatase inhibitor, on in vivo aromatisation and plasma oestrogen levels in postmenopausal women with breast cancer. , 1996, British Journal of Cancer.

[90]  R. Santen,et al.  In situ estrogen production via the estrone sulfatase pathway in breast tumors: relative importance versus the aromatase pathway. , 1984, The Journal of clinical endocrinology and metabolism.

[91]  I. Henderson,et al.  Cancer of the breast: the past decade (first of two parts). , 1980, The New England journal of medicine.

[92]  T. Selmer,et al.  A novel amino acid modification in sulfatases that is defective in multiple sulfatase deficiency , 1995, Cell.

[93]  K. Korzekwa,et al.  Evaluation of the mechanism of aromatase cytochrome P450. A site-directed mutagenesis study. , 2001, European journal of biochemistry.

[94]  N. Harada,et al.  Steroid sulfatase expression is an independent predictor of recurrence in human breast cancer. , 1999, Cancer research.

[95]  R. Coombes,et al.  Aromatase inhibitors as adjuvant therapies in patients with breast cancer , 2003, The Journal of Steroid Biochemistry and Molecular Biology.

[96]  Y. Miyoshi,et al.  High expression of steroid sulfatase mRNA predicts poor prognosis in patients with estrogen receptor-positive breast cancer. , 2003, Clinical cancer research : an official journal of the American Association for Cancer Research.

[97]  J. Dodge,et al.  Selective estrogen receptor modulators (SERMs). , 1970, Current pharmaceutical design.

[98]  P. Goss,et al.  Summary of aromatase inhibitor trials: The past and future , 2007, The Journal of Steroid Biochemistry and Molecular Biology.

[99]  Hironori Arakawa,et al.  Photophysical and (photo)electrochemical properties of a coumarin dye. , 2005, The journal of physical chemistry. B.

[100]  A. Lerner,et al.  Melanotropin–daunomycin conjugate shows receptor-mediated cytotoxicity in cultured murine melanoma cells , 1977, Nature.

[101]  I. H. Hamelers,et al.  17β-Estradiol responsiveness of MCF-7 laboratory strains is dependent on an autocrine signal activating the IGF type I receptor , 2003, Cancer Cell International.

[102]  K. Grandien,et al.  Printed in U.S.A. Copyright © 1997 by The Endocrine Society Comparison of the Ligand Binding Specificity and Transcript Tissue Distribution of Estrogen Receptors � and � , 2022 .

[103]  B. Potter,et al.  Steroid sulphatase inhibitors for breast cancer therapy , 2003, The Journal of Steroid Biochemistry and Molecular Biology.

[104]  R. O’Kennedy,et al.  Studies on coumarins and coumarin-related compounds to determine their therapeutic role in the treatment of cancer. , 2004, Current pharmaceutical design.

[105]  P. Carrupt,et al.  Natural and synthetic geiparvarins are strong and selective MAO-B inhibitors. Synthesis and SAR studies. , 2002, Bioorganic & medicinal chemistry letters.

[106]  C. Strott Sulfonation and molecular action. , 2002, Endocrine reviews.

[107]  D. Egan,et al.  The pharmacology, metabolism, analysis, and applications of coumarin and coumarin-related compounds. , 1990, Drug metabolism reviews.

[108]  J. V. van Lier,et al.  Synthesis and biological activities of nucleoside-estradiol conjugates. , 2006, Bioorganic & medicinal chemistry letters.

[109]  A. Howell,et al.  The use of selective estrogen receptor modulators and selective estrogen receptor down-regulators in breast cancer. , 2004, Best practice & research. Clinical endocrinology & metabolism.

[110]  D. Hadjipavlou-Litina,et al.  Natural and synthetic coumarin derivatives with anti-inflammatory/ antioxidant activities. , 2004, Current pharmaceutical design.

[111]  M. Dowsett,et al.  Aromatase inhibition and very low dose estradiol add-back: A pilot study for novel breast cancer prevention. , 2006, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[112]  R. Moffett CENTRAL NERVOUS SYSTEM DEPRESSANTS. VII. PYRIDYL COUMARINS. , 1964, Journal of medicinal chemistry.

[113]  R. Tekmal,et al.  Overexpression of int-5/aromatase in mammary glands of transgenic mice results in the induction of hyperplasia and nuclear abnormalities. , 1996, Cancer research.

[114]  D. McDonnell Definition of the molecular mechanism of action of tissue-selective oestrogen-receptor modulators. , 1998, Biochemical Society transactions.

[115]  K. Gumireddy,et al.  Novel coumarin-3-(N-aryl)carboxamides arrest breast cancer cell growth by inhibiting ErbB-2 and ERK1. , 2005, Bioorganic & medicinal chemistry.

[116]  R. Thornes,et al.  The Rarity of Liver Toxicity in Patients Treated with Coumarin (1, 2-Benzopyrone) , 1989, Human toxicology.

[117]  D. Muchmore Raloxifene: A selective estrogen receptor modulator (SERM) with multiple target system effects. , 2000, The oncologist.

[118]  S. Bhagwat,et al.  Lead identification of a potent benzopyranone selective estrogen receptor modulator. , 2004, Bioorganic & medicinal chemistry letters.

[119]  J. Russo,et al.  Genotoxicity of steroidal estrogens , 2004, Trends in Endocrinology & Metabolism.

[120]  C. Bond,et al.  Structure of a human lysosomal sulfatase. , 1997, Structure.

[121]  D. Johnston,et al.  Effect of naturally occurring coumarins on the formation of epidermal DNA adducts and skin tumors induced by benzo[a]pyrene and 7,12-dimethylbenz[a]anthracene in SENCAR mice. , 1997, Carcinogenesis.

[122]  K. Butler,et al.  Phase I evaluation of coumarin (1,2-benzopyrone) and cimetidine in patients with advanced malignancies. , 1991, Molecular biotherapy.

[123]  S. Kirkiacharian,et al.  Synthesis and binding affinity to human α and β estrogen receptors of various 7-hydroxycoumarins substituted at 4- and 3,4- positions , 2004 .

[124]  M. Auer,et al.  New fluorogenic substrate for the first continuous steroid sulfatase assay. , 2000, Bioorganic & medicinal chemistry letters.

[125]  B. Potter,et al.  Steroid sulfatase: molecular biology, regulation, and inhibition. , 2005, Endocrine reviews.

[126]  L. Wattenberg,et al.  Inhibition of Chemical Carcinogen-induced Neoplasia by Coumarins and α-Angelicalactone , 1979 .

[127]  J. R. Casley-Smith,et al.  Frequency of coumarin hepatotoxicity , 1995, The Medical journal of Australia.

[128]  J. Jaén,et al.  Selective, covalent modification of beta-tubulin residue Cys-239 by T138067, an antitumor agent with in vivo efficacy against multidrug-resistant tumors. , 1999, Proceedings of the National Academy of Sciences of the United States of America.

[129]  A. Howell,et al.  A randomised trial comparing two doses of the new selective aromatase inhibitor anastrozole (Arimidex) with megestrol acetate in postmenopausal patients with advanced breast cancer. , 1996, European journal of cancer.

[130]  M. Różalski,et al.  Cytotoxic effects, alkylating properties and molecular modelling of coumarin derivatives and their phosphonic analogues. , 2003, European journal of medicinal chemistry.

[131]  J. DiGiovanni,et al.  Multistage carcinogenesis in mouse skin. , 1992, Pharmacology & therapeutics.

[132]  V. Goldmacher,et al.  Realizing the full potential of immunotoxins. , 1989, Cancer cells.

[133]  S. Akinaga,et al.  Estrogen sulfotransferase and steroid sulfatase in human breast carcinoma. , 2003, Cancer research.

[134]  V. Jordan,et al.  Selective estrogen receptor modulation: concept and consequences in cancer. , 2004, Cancer cell.