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16 Escuyer, V. and Collier, R.J. (1991) Anthrax

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276, 1797617984

How bacteria could cause cancer:

one step at a time
Alistair J. Lax and Warren Thomas
Helicobacter pylori highlighted the potential for bacteria to cause cancer. It is
becoming clear that chronic infection with other bacteria, notably Salmonella
typhi, can also facilitate tumour development. Infections caused by several
bacteria (e.g. Bartonella spp., Lawsonia intracellularis and Citrobacter
rodentium) can induce cellular proliferation that can be reversed by antibiotic
treatment. Other chronic bacterial infections have the effect of blocking
apoptosis. However, the underlying cellular mechanisms are far from clear.
Conversely, several bacterial toxins interfere with cellular signalling
mechanisms in a way that is characteristic of tumour promoters. These include
Pasteurella multocida toxin, which uniquely acts as a mitogen, and Escherichia
coli cytotoxic necrotizing factor, which activates Rho family signalling. This
leads to activation of COX2, which is involved in several stages of tumour
development, including inhibition of apoptosis. Such toxins could provide
valuable models for bacterial involvement in cancer, but more significantly they
could play a direct role in cancer causation and progression.
Published online: 26 April 2002

Alistair J. Lax*
Warren Thomas
Dept of Oral
Microbiology,
Kings College London,
Guys Hospital, London,
UK SE1 9RT.
*e-mail:
alistair.lax@kcl.ac.uk

The discoveries in medical microbiology that were

made towards the end of the 19th century showed
how bacteria were the cause of some of the major
diseases of the time and so allowed progress to be
made towards improved treatment and survival.
Perhaps not surprisingly, this led some to suggest
that bacteria were implicated in all diseases and so
at this time the idea that bacterial infections might
lead to cancer was born. This proposition has had an
uneasy and controversial history, which has evolved
http://tim.trends.com

with our greater understanding of tumourigenic and

infectious processes. The early observations that
certain bacteria were present at the site of carcinomas
did not take account of the long time-lag between
initiation of the carcinogenic process and the onset of
overt disease. Thus, the presence of bacteria at the
site of a tumour does not in itself imply causation, in
the same way that bacterial infection in cystic fibrosis
patients would not be thought of as the basis of that
disease. Conversely, the initial cell transformation
event can occur many years before the manifestation
of cancer and so an infection could be cleared long
before its full consequences were seen.
The role of viruses such as hepatitis B virus (HBV),
EpsteinBarr virus (EBV) and human papilloma virus
(HPV) in carcinogenesis is accepted because of the
direct mechanistic effects of often single genes that
result in cell transformation [1]. The involvement of
bacteria in carcinogenesis remains controversial
partly because there is no clear agreement on the
molecular mechanism(s) by which they might promote
the development of cancer. Carcinogenesis is a
protracted, multistage process that can take decades
to reach its culmination (Box 1). Initially, mutations
arise that release the cells from normal growth-control
mechanisms, and then the transformed cells must
proliferate while avoiding destruction by the immune
system. Once a small tumour or focus has developed, it

0966-842X/02/$ see front matter 2002 Elsevier Science Ltd. All rights reserved. PII: S0966-842X(02)02360-0

Review

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TRENDS in Microbiology Vol.10 No.6 June 2002

Box 1. The development of cancer

Cancers arise from the transformation of a single cell so that its behaviour
is no longer under the control of normal regulatory pathways (Fig. I). Such
uncontrolled cells behave as distinct organisms and sub-populations arise
from these cells, which develop in a manner that is detrimental to the parent
organism. Each stage in tumour development requires mutations in additional
genes so that the development of cancer is the product of a small number of
mutations accumulated over a long time period and subjected to selection.
Initiation depends upon the acquisition of an oncogene from an invading virus or
the mutation of a cellular protooncogene so that it is expressed abnormally. The
probability of such a mutation occurring is greatly increased under conditions of
protracted stimulation of cell division through chronic inflammation or tissue
damage. The transformed cell proliferates in situ, unchecked by its own apoptotic
pathway and avoiding the surveillance of the immune system to form a small
focus. The developing tumour must redirect the bodys blood supply to continue
its growth beyond a very limited size. This process of angiogenesis requires the
abnormal expression of genes, particularly growth factors such as vascular
endothelial growth factor (VEGF), to promote the growth of capillaries from
nearby blood vessels. After time a subset of the cells in a tumour acquire
mutations in genes that regulate cell-to-cell adhesion and migration although
adhesion to the extracellular matrix. These cells continue to proliferate and
mutate and either migrate or are carried by the circulatory system to other parts
of the body where they develop into secondary tumours. These invading cells
cause major disruption to crucial physiological processes often at sites distant
from that of initiation, the consequences of which are often fatal.

Metastasis
Mutational events

Blood vessel
Initiation

Focus
formation

Proliferation
Immune evasion

Tumour
growth

Proliferation
Angiogenesis

Local
invasion

Proliferation
Migration
TRENDS in Microbiology

Fig.I. The different stages involved in tumour development.

must be supplied with blood to allow its further growth

(angiogenesis) and then dramatic changes in cell
behaviour are required to permit metastatic invasion
of other sites in the body. There is increasing evidence
that pathogenic bacteria can contribute to specific
stages in cancer development, particularly in chronic
infections where, for the duration of the infection,
normal cell processes can come under the influence
of factors released by the pathogen. The proposition
that bacterial infection could cause cancer acquired
widespread interest with the revelation that
Helicobacter pylori was able to establish chronic
infections in the stomach. Infection was linked first
to stomach ulcers then subsequently to some gastric
carcinomas [2] and mucosa-associated lymphoid
tissue (MALT) lymphomas [3]. Even though the
precise mechanisms remain uncertain, it is becoming
clear that H. pylori and several other bacteria and
their products have properties that might contribute
to different stages of tumour initiation and
progression (Box 2). In this review, we outline ways
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that bacteria could promote cancer both for bacteria

that are known to be involved in carcinogenesis and
also for those where there is no known link, but where
the effect of the bacterium on the host suggests that
such a link could exist.
Epidemiology of bacterial infection and carcinogenesis

The relationship between H. pylori and

carcinogenesis is not straightforward [4,5]. Much
of the evidence to link H. pylori with carcinogenesis
is epidemiological and thus open to different
interpretations. This is further complicated by the
diversity of H. pylori isolates, which mutate and
evolve within an individual such that any one person
is infected with several H. pylori quasispecies, each
having a different virulence potential. Consequently,
it is difficult to determine which virulence factors are
important in disease. Human genetic diversity is a
further complicating factor, reflecting different
susceptibilities to H. pylori infection and gastric
cancer development [6].
In other diseases, animal models have provided
convincing evidence for disease causation. Much
effort has been expended in trying to set up a relevant
animal model infection system for H. pylori, but the
pathology displayed is often different from that seen
in the human infection. There are two types of animal
model: those using H. pylori in a variety of animal
hosts and those using related Helicobacter species [7].
H. pylori infection of the Mongolian gerbil has
conclusively been shown to induce gastric
adenocarcinoma [8] and this model infection system
approximates reasonably well to the human disease
[9]. Several non-H. pylori models have been
described, most notably Helicobacter mustelae
infection in ferrets and Helicobacter felis infection
in mice [4,7]. H. felis, which has been widely used
to examine the link between inflammation and
Helicobacter-induced carcinogenesis, differs from
H. pylori in that it does not express either the
vacA gene or the cag pathogenicity island (PAI).
Strains that express cagA are most often associated
with gastric cancer [10,11], although cagA is only
one of several genes encoded by the cag PAI that
would be expected to encode related functions.
Nevertheless, MALT lymphoma can be induced by
H. mustelae in ferrets [12] and by H. felis in mice,
where it can be treated by antimicrobial therapy
[13,14]. Transgenic mouse models have also been
useful in exploring the importance of H. pylori
binding to human receptors [5].
Although most attention has focused on H. pylori,
other bacterial infections have been known for
some time to have a link with cancer. Perhaps the
strongest epidemiological case is for Salmonella
enterica serovar Typhi (S. typhi), the agent of
typhoid, which can also lead to chronic bacterial
carriage in the gallbladder. A case-control study
compared those who experienced acute infection with
those who subsequently became chronic carriers

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295

Box 2. Bacterial involvement in tumour development

Pasteurella multocida
PMT

TK

Bartonella spp.
G proteins

Escherichia coli
CNF

Migration
RhoA

Src

FAK

Angiogenesis,
COX2
survival

PKB

PI3K

Migration,
proliferation
CDKs

CagE

p53
E2F

Angiogenesis,
proliferation

BAD
Caspase-9 Survival

Cyclin D1 Proliferation

Rac

Ras

Rb

VEGF

NF-B

Citrobacter spp.
Lawsonia
intracellularis

Raf

Chlamydia spp. Bcl-2

Helicobacter
pylori
Proliferation

MAPK

P. gingivalis

Survival
TRENDS in Microbiology

Fig. I. Signalling pathways targeted by bacteria and bacterial toxins. The components of signalling
pathways that are known to be affected by various bacterial toxins are indicated. It should be noted that
these components are not necessarily the primary targets of these toxins. For some bacteria, the specific
bacterial product responsible has not been identified. Where there is a known association with cancer the
bacteria are shown in blue, whereas those with no proven link to carcinogenesis are in black. It should be
noted that the signalling pathways stimulated by known carcinogenic bacteria are not necessarily the
mechanism by which they influence carcinogenesis. Abbreviations: CDK, cyclin-dependent kinase; CNF,
cytotoxic necrotizing factor; COX, cyclooxygenase; E2F, elongation factor 2F; FAK, focal adhesion kinase;
MAPK, mitogen-activated protein kinase; NF-B, nuclear factor B; PI3K, phosphatidylinositol 3 kinase;
PKB, protein kinase B; Rb, retinoblastoma; TK, tyrosine kinase; VEGF, vascular endothelial growth factor.

following the 1922 typhoid outbreak in New York.

Those who became carriers were six times more
likely to die of hepatobiliary carcinoma than matched
controls [15]. More recent work analysing the 1964
typhoid outbreak in Aberdeen [16,17] has also
suggested a strong association between chronic
carrier status and hepatobiliary carcinoma and, in
addition, a weaker linkage with cancer at other sites.
People who contracted typhoid but who did not
become carriers were not at higher risk of cancer. A
similar linkage was found between S. typhi carriage
and gallbladder carcinoma in Northern India, where
both conditions have a high incidence [18,19]. The
molecular process by which chronic S. typhi carriage
promotes cancer development has yet to be
determined. However, it has been suggested that
the degradation of bile salts by enteric bacteria to
yield carcinogenic compounds could contribute to
carcinogenesis [20]. A further example of linkage
between bacterial infection and carcinogenesis is
provided by Citrobacter rodentium infection in mice,
which causes a colonic hyperplastic disease that can
lead to colonic cancer [21,22].
http://tim.trends.com

Schematic diagram showing how bacterial interference

with cell signalling can contribute to tumour development
(Fig. I). It is becoming clear that many bacterial infections
rely upon precise interactions between the pathogen
and components of the regulatory systems of the host
cell. As cancers arise through dysfunction of these
same regulatory systems, it seems inevitable that
some bacterial infections can contribute to tumour
development. Infections that induce cell proliferation
might increase the incidence of cell transformation and
the rate of tumour development through an increased rate
of genetic mutation. The stimulation of proliferation and
DNA replication through activation of mitogen-activated
protein kinase (MAPK) pathways and cyclin D1 occurs in
several infections. Several infections, particularly those in
which the pathogen becomes intracellular, are associated
with the suppression of apoptosis often through
modulation of the expression of Bcl-2 family proteins.
Another mechanism for suppressing apoptosis could be
through Ras-mediated activation of cyclin-dependent
kinases to overcome the tumour suppressive effects of
the retinoblastoma protein Rb. By blocking apoptosis,
bacterial infection could allow partially transformed
cells to escape destruction and progress to a higher
level of transformation, ultimately resulting in
tumourigenesis. Angiogenesis is an important feature
of tumour growth. The growth of blood capillaries is
observed in the pseudo-tumours induced by Bartonella
spp. The signalling molecules associated with cell
adhesion particularly those linked to the focal adhesion
complex such as focal adhesion kinase (FAK) and Src are
known to play a role in tumourigenesis and even to be
oncogenic themselves. The assembly of focal adhesions
can be regulated through the Rho family of small
GTPases that are targets for many bacterial toxins. By
perturbing Rho family proteins it is possible to affect
many signalling pathways because of the lateral
connections between the pathways, which ordinarily
allow for very precise regulation of cellular responses.
Rho proteins are pivotal in cellular control and the
consequences of their dysregulation by bacterial toxins
have yet to be fully investigated.

Immunological mechanisms involved in the induction

of carcinogenesis

Although the linkage between H. pylori infection

and gastric cancer is convincing, the molecular
mechanism or mechanisms responsible are unclear,
and both bacterial and host factors are implicated.
One view is that increased inflammation generates
reactive oxygen and nitrogen intermediates that
might lead directly to DNA damage [23,24]. The role
of the immune response, in particular a CD4+ T cell
response, is supported by work using H. felis
infection in mice, although it is noteworthy that
polymorphonuclear lymphocyte infiltration is not a
feature of this model, unlike H. pylori infection in
humans [25,26]. H. pylori infection also upregulates
signalling molecules; more specifically, the activation
of the extracellularly regulated tyrosine kinase (ERK)
signalling pathway results in an increase in
important transcription factors such as activator
protein 1 (AP-1) and serum response factor (SRF),
which might be responsible for the upregulation of
pro-inflammatory cytokines seen in H. pylori
infection [27].

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Inflammation is not always a feature of bacterial

infections associated with proliferative lesions.
Hyperplasia owing to C. rodentium infection is
sometimes but not always accompanied by
inflammation [28]. Lawsonia intracellularis infection
has not been associated with carcinogenesis, but
induces hyperproliferation with a minimal
inflammatory response [29]. Similarly, Pasteurella
multocida infections induce hyperproliferation
without evidence of any immune response [30].
Proliferative infections

It is known that protracted growth stimulation

can promote tumour formation by facilitating the
acquisition of mutations in genes encoding the
signalling and cell cycle proteins that control
proliferation. Several bacterial infections promote
cell proliferation and so could increase the rate of cell
transformation. H. pylori activates several genes
known to be associated with carcinogenesis, such as
cyclooxygenase 2 (COX2) [31], c-Jun amino-terminal
kinase (JNK) [27] and phospholipase A2 [32]. The
expression of cagE by H. pylori promotes activation
of the cell cycle regulatory molecule cyclin D1 in a
mitogen-activated protein kinase (MAPK)dependent manner [33]. Overexpression of cyclin D1
has recently been linked with poor prognosis in
cancers of several organs, including the colon and
lung [34,35]. Alternatively, it has been noted that
attachment of H. pylori to cells can lead to the
production of autoantibodies against Lewis
carbohydrate epitopes on the surface of acidproducing parietal cells [36]. This results in
loss of the parietal cells and the subsequent
hyperproliferation of gastric stem cells produces
an adenomatous lesion.
Bartonella spp. are emerging pathogens that can
cause conditions, such as trench fever, Carrions
disease and cat-scratch disease, which are
characterized by the development of proliferative
lesions. Bartonella bacilliformis [37] enters the
bloodstream through a wound inflicted by an infected
sandfly and, uniquely, colonizes circulating
erythrocytes, resulting in a persistent infection that
culminates in a potentially fatal haemolytic anaemia
[38]. B. bacilliformis and other Bartonella spp. can
also enter endothelial cells by a RhoA-dependent
invasion process with concurrent stimulation of the
focal adhesion complex and the formation of actin
stress fibres [39]. The infected cells acquire an
abnormal morphology and tumour-like structures
develop that contain fine blood capillaries. These
regress following the eradication of the bacteria
with antibiotics [40]. B. henselae pili promote the
production of vascular endothelial growth factor
(VEGF), although endothelial cell proliferation
appears to be independent of direct contact between
the bacterium and the host cells [41,42]. VEGF
is a potent mitogen and stimulator of tumour
angiogenesis and its induction by Bartonella spp.
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could therefore have important consequences in

terms of tumour initiation and progression, although
it is currently not suggested that Bartonella
infections are tumourigenic (See the Opinion
article by Volkhard Kempf et al. in this issue for a
discussion of the molecular mechanisms involved in
Bartonella-induced endothelial cell proliferation).
L. intracellularis is the aetiological agent of
proliferative enteropathy (PE) of pigs and other
animal species [29]. The pathogen enters mitotic and
partially differentiated cells in the tubular crypts
of the intestinal epithelium and promotes their
proliferation. These cells enlarge the crypts and
replace the mature, differentiated enterocytes of
the epithelium, giving rise to distinctive disease
lesions. The lesions resemble those seen in human
proliferative bowel disorders, such as Crohns disease
and ulcerative colitis, that are associated with
an increased risk of colorectal cancer [43]. The
L. intracellularis lesions are also similar to murine
colonic hyperplasia caused by C. rodentium, which
it is known can accelerate the formation of colon
adenomas in mice that have been treated with a
chemical carcinogen [21]. C. rodentium can also
initiate adenoma formation in mice defective in the
Apc tumour suppressor gene [22]. This is one of the
most convincing pieces of evidence that a bacterial
pathogen can promote the initiation of cancer through
cell transformation. Although the precise molecular
events by which tumourigenesis occurs have still to
be established, the 35-kb PAI encoding the locus for
enterocyte effacement has been implicated [28].
Interestingly, this PAI is shared with some
enteropathogenic and enterohaemorrhagic E. coli
(EPEC and EHEC, respectively).
The molecular mechanisms associated with these
examples have not been identified. Conversely, some
bacterial toxins are known to modulate intracellular
signalling pathways directly in a way that could
promote tumour development, although their
carcinogenic potential is only now beginning to
be explored. P. multocida toxin (PMT) is a potent
mitogen for quiescent cells and additionally can
overcome contact inhibition and is a strong inducer
of anchorage-independent growth [30]. The target
molecule for PMT is unknown but the toxin acts
intracellularly to stimulate several signalling
cascades mediated by protooncogenes including
those linked to phospholipase C, protein kinase C
and calcium mobilization. The subsequent
activation of the ERK-1 and -2 MAPKs stimulates
the cells to undergo DNA synthesis and
proliferation. PMT activation of tissue culture cells
also promotes RhoA-mediated signal transduction
events that result in activation of focal adhesion
kinase (FAK) and Src family kinases [30,44]. The
activation level of these proteins is often greatly
increased in many cancers and contributes to cell
transformation. Experimental infection with
P. multocida or injection of PMT is known to cause

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297

of EDIN, a toxin that modifies Rho proteins, induces

transient hyperplasia [47].

TNF-

The suppression of apoptosis

TNF-R
IB-P

DD

NF-B

Apoptosis () Transcription

JUN

Apoptosis (+) Transcription

TRAFs
IB/NF-B

TRAD
FADD

Caspase-8

ICAD

Caspase-3

Mitochondrion
Bid Bax
Bak
Caspase-3, -6, -7

CAD nuclease

Bcl-2
Bcl-xL
CytoC
Caspase-9
APAF-1

Death substrates
FAK, MEKK, laminin,
DARP or gelsolin

DNA fragmentation
Cell cycle
arrest

p53

p21
Nucleus

TRENDS in Microbiology

Fig. 1. Apoptosis or programmed cell death is an important process in the development of

multicellular organisms and can be induced through ligands that bind to integral membrane
receptors. Apoptosis also plays a role in helping to destroy infected or malignant cells and can be
triggered by factors released by activated CD8+ lymphocytes and macrophages. Tumour necrosis
factor (TNF-) acts through a membrane receptor (TNF-R) whose death domain (DD) interacts
with a group of proteins called TNF-receptor-associated factors (TRAFs), which are differentially
expressed and can regulate transcription factors such as JUN or nuclear factor (NF)-B, which
promote or suppress apoptosis, respectively. The activated TNF-R also complexes with the
protease caspase-8 through TNF-receptor-associated death domain protein (TRAD) and Fasassociated death domain protein (FADD) to activate the caspase cascade, which results in the
proteolytic degradation of proteins involved in cell adhesion, signalling and cytoskeletal regulation.
Caspase-3 activates the caspase-activated DNase (CAD) nuclease, which introduces single-strand
breaks into the genomic DNA resulting in activation of the p53 tumour suppressor and cell cycle
arrest. Caspase-8 also proteolytically activates the Bcl-2 family protein Bid allowing it to complex
to other family members such as Bax and Bak. This complex translocates to the mitochondria
and promotes the release of cytochrome c into the cytoplasm, which associates with apoptotic
protease-activating factor 1 (APAF-1) to activate caspase-9 and so activate the proteolytic cascade
by another route. The translocation of Bid to the mitochondria is blocked when it is complexed to
other Bcl-2 family proteins like Bcl-xL or Bcl-2 itself, which suppresses apoptosis. The Bcl-2 family
proteins have an important role in regulating apoptosis and it is interesting that some pathogenic
bacteria can enhance the expression of anti-apoptotic members of this family, presumably to
enhance intracellular survival.

cell proliferation at distal sites, including the

epithelium of the bladder and ureter, without
evidence of inflammation [45]. Toxigenic P. multocida
are principally associated with a pig nasal infection
that leads to bone loss, although they have also been
isolated from the sites of human wound infection and
chronic respiratory carriage [46]. The protracted,
mitogenic stimulation during the course of such
infections could contribute towards tumour
development although an epidemiological
investigation has yet to be carried out.
Another toxin that displays a proliferative role
is epidermal differentiation-inhibiting factor
(EDIN), which is expressed by some strains of
Staphylococcus aureus. Subcutaneous injection
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An important mechanism by which transformed cells

can normally be prevented from proliferating and
developing into tumours is through the induction
of pre-programmed cell death or apoptosis (Fig. 1).
Apoptosis results from several different extracellular
stimuli but, in the case of potential cancer cells, the
release of the serine protease granzyme B and
tumour necrosis factor (TNF-) from activated
CD8+ T cells are important mechanisms. Tumour
cells can have abnormal expression levels of
factors such as Bcl-2 family proteins that slow the
progression of apoptosis and elevated nuclear factor
(NF)-B-regulated transcription, which can inhibit
TNF--induced apoptosis [48]. Several pathogenic
bacteria, particularly those that can establish a
persistent, intracellular infection, can suppress
apoptosis in host cells. This strategy provides a niche
in which an intracellular pathogen can survive in
spite of the attempts of the host immune system to
destroy the infected cell by inducing apoptosis. As
a consequence, the suppression of apoptosis by a
pathogen might also allow a partially transformed
cell to evade the self-destructive process and so
progress to a higher level of transformation and
ultimately become tumourigenic.
Mycoplasmas, which can cause chronic
asymptomatic infections, can promote cell
transformation and block apoptosis. Prolonged in vitro
infection of tissue culture cells with Mycoplasma spp.
led to cell transformation and tumourigenicity in
mice, accompanied by enhanced expression of the
H-ras and c-myc oncogenes [49,50]. Mycoplasma
infection, or lipid-associated membrane proteins
extracted from mycoplasmas, inhibits apoptosis in
an NF-B-dependent manner.
The enzyme COX2 is activated by H. pylori. It has
recently been shown that localized overexpression of
COX2 in the mammary glands of transgenic mice
causes the development of tumours through the
overexpression of Bcl-2 and suppression of apoptosis
[51]. COX2 regulates the rate-limiting step in
prostaglandin biosynthesis and is involved in
physiological processes such as pain transmission,
cell cycle regulation and the inflammatory response.
COX2 is overexpressed in cancers of many organs
although its role in colorectal cancer has been most
extensively investigated. Here, the overexpression
of COX2 has been linked to tumour invasiveness,
which can be reduced using non-steroidal antiinflammatory drugs (NSAIDs) that inhibit the
enzymatic activity of COX2 [52]. COX2 induction has
been detected in gastric mucosal cells treated with
lysates extracted from H. pylori. This induction
is reduced in isogenic mutants of picA and picB,
H. pylori virulence determinants that induce cytokine
production in the gastric mucosa [31]. Because

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Questions for future research

What are the molecular mechanisms responsible for the carcinogenesis
promoted by bacteria such as H. pylori and S. typhi ?
Can any bacterial toxin be shown to promote cancer in a suitable animal model?
Is there any epidemiological evidence that prolonged carriage of bacteria
expressing such toxins leads to increased rates of malignancy in humans?
Do chronic bacterial infections in general predispose to cancer?
Does the suppression of apoptosis by bacteria and their products play a role in
carcinogenesis?

infection with H. pylori can last for a period of years,

the consequent chronic induction of COX2 during
the course of these infections could allow the survival
of transformed cells that would otherwise become
apoptotic and die.
Cytotoxic necrotizing factor (CNF), a toxin found
in many uropathogenic E. coli, induces elevated
expression of COX2 in murine fibroblasts [53], and
is the first toxin shown to affect COX2 expression.
CNF-expressing E. coli establish a persistent,
intracellular infection of the urogenital tract [54] and
CNF itself can suppress apoptosis by affecting the
transcription levels of the Bcl-2 family proteins [55].
The suppression of apoptosis by this toxin
presumably enhances the survival of cells occupied
by the pathogen to facilitate a chronic infection and
could be a consequence of COX2 induction. There is
also a strong correlation between CNF-positive E. coli
and prostatitis, and experimental prostate infections
show that expression of CNF is linked to a greater
inflammatory response, leading to the suggestion
that CNF might contribute to prostate cancer [56].
Bacterial toxins and Rho protein activation

Acknowledgements
We thank the Guys and
St Thomas Charitable
Foundation for financial
support (project grant
R 001136).

The Rho family of small GTPases act as key

molecular switches that integrate signals from
several different signal transduction pathways.
These also control and regulate movement and
other aspects of cytoskeletal changes. It is becoming
clear that these proteins can play a key role in
carcinogenesis [57], either through their aberrant
activation, which can result in uncontrolled
proliferation and growth transformation, or by
regulating processes downstream of other oncogenes
such as Ras. Indeed, RhoC has recently been
implicated as a marker for highly angiogenic and
aggressive breast cancer with a high metastatic
ability [58]. Interestingly, the Rho proteins are
targets for several bacterial toxins, some of which
have already been discussed, that can promote or
inhibit their activation [59]. Transient activation
of Rho proteins, particularly RhoA, often occurs
during bacterial attachment to a host cell or during
internalization, for example in the case of Bartonella
spp. invading endothelial cells [31]. The development
of stress fibres and focal adhesion signalling
complexes indicative of RhoA activation is also
observed in cells treated with PMT [30], but
two bacterial toxins the dermonecrotic toxin of
http://tim.trends.com

Bordetella spp. and CNF each act directly on

Rho family proteins to bring about their irreversible
activation [59]. CNF constitutively activates RhoA,
Rac1 and Cdc42 to stimulate dramatic cytological
effects through the rearrangement of actin filaments.
The action of CNF on the Rho proteins also leads
to perturbation of the cell cycle by inducing DNA
synthesis while inhibiting cytokinesis and also
modulates the activity of factors that affect apoptosis
as we have indicated. As CNF-expressing E. coli
establish chronic infections, the protracted
stimulation of Rho protein-regulated signalling
pathways during the course of the infection could
have a role in carcinogenesis.
Conversely, EDIN and related toxins from
Bacillus cereus and Clostridium spp. modify a subset
of Rho family proteins to inactivate them, whereas
another group of toxins inactivate all members of
the Rho family [59]. Although it is known that EDIN
can induce hyperplasia, the potential proliferative
effects of this latter group of toxins has not been
investigated.
Conclusion

The number of examples where epidemiological

evidence has linked prior and chronic bacterial
infection to tumour formation is growing, but the
molecular mechanisms involved remain far from
clear. For example, despite much research, it remains
uncertain which of the many virulence factors
produced by H. pylori have most significance for
cancer development. Conversely, several bacteria and
their products have properties that could advance
carcinogenesis although there is currently no known
link between these bacteria and tumour formation.
Many pathogenic bacteria subvert host cell signalling
pathways and so control cell behaviour to enhance
survival of the pathogen. The regulation of these
signalling factors is central to the development or
inhibition of tumour formation. Perturbation of
host signalling appears to be a particular feature of
chronic infection with intracellular bacteria, in that
chronic bacterial infection requires that infected cells
proliferate and are resistant to the normal control
mechanisms. Such infections can mimic some of the
gross effects seen in tumourigenesis, and indeed the
pseudocancerous lesions formed in such infections
can regress with antibiotic treatment and clearance
of the bacteria. A more generally applicable
conclusion is that chronic infection with bacteria that
perturb cell signalling processes is highly likely to
contribute to cell transformation by facilitating an
anti-apoptotic, proliferative state that encourages
tumour initiation and promotion. Greater
understanding of the consequences of long-term
infections and the mechanisms that allow this
balance between the host and the pathogen to be
maintained will allow us to state with certainty to
what extent and by which mechanisms bacteria
cause cancer.

Review

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