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Cancer:A growth disorder that results from the mutation of the genes that regulate the cell cycle.
Cellular Oncology 27 (2005) 293–318 293 IOS Press Opinion The chromosomal basis of cancer Peter Duesberg a,∗ , Ruhong Li a , Alice Fabarius b and Ruediger Hehlmann b a Departmentof Molecular and Cell Biology, Donner Laboratory, UC Berkeley, Berkeley, CA 94720, USA b III. Medizinische Klinik Mannheim of the University of Heidelberg at Mannheim, Wiesbadener Str. 7-11, 68305 Mannheim, Germany Abstract. Conventional genetic theories have failed to explain why cancer (1) is not heritable and thus extremely rare in new- borns, (2) is caused by non-mutagenic carcinogens, (3) develops only years to decades after initiation by carcinogens, (4) follows pre-neoplastic aneuploidy, (5) is aneuploid, (6) is chromosomally and phenotypically "unstable", (7) carries specific aneusomies, (8) generates much more complex phenotypes than conventional mutation such as multidrug resistance, (9) generates nonselec- tive phenotypes such as metastasis (no benefit at native site) and "immortality" (not necessary for tumorigenesis), and (10) does not contain carcinogenic mutations. We propose, instead, that cancer is a chromosomal disease. Accordingly carcinogenesis is initiated by random aneuploidies, which are induced by carcinogens or spontaneously. Since aneuploidy unbalances 1000s of genes, it corrupts teams of proteins that segregate, synthesize and repair chromosomes. Aneuploidy is therefore a steady source of chromosomal variations from which, in classical Darwinian terms, selection encourages the evolution and malignant progres- sion of cancer cells. The rates of specific chromosomal variations can exceed conventional mutations by 4–11 orders of magni- tude, depending on the degrees of aneuploidy. Based on their chromosomal constitution cancer cells are new cell "species" with specific aneusomies, but unstable karyotypes. The cancer-specific aneusomies generate complex, malignant phenotypes through the abnormal dosages of 1000s of genes, just as trisomy 21 generates Down syndrome. In sum, cancer is caused by chromo- somal disorganization, which increases karyotypic entropy. Thus, cancer is a chromosomal rather than a genetic disease. The chromosomal theory explains (1) non-heritable cancer because aneuploidy is not heritable, (2) non-mutagenic carcinogens as aneuploidogens, (3) long neoplastic latencies by the low probability of evolving new species, (4) nonselective phenotypes via genes hitchhiking with selective chromosomes, and (5) immortality because, through their cellular heterogeneity, cancers survive negative mutations and cytotoxic drugs via resistant subspecies. 1. Cause of cancer still a matter of debate tations during the lifetime of a patient [45,108,178, 225,235,286]. In addition, these theories postulate that, Despite over 100 years of cancer research the cause once generated by 4–7 mutations, cancer cells inde- of cancer is still a matter of debate between theories pendently progress further within "clonal" cancers to postulating either mutation or chromosomal alteration form evermore malignant and heterogeneous cancers or epigenetic events as causes of cancer [43,69,75,77, via evermore spontaneous mutations – while normal 79,85,94,102,107,114,137,169,170,185,189,190,215, cells of the same patient remain un-mutated [32,33, 225,234,248,251,257,261,264,265,269,273,286,306]. 46,104,108,154,178,214,280,286–288]. But these con- We propose here that the cancer problem is still un- ventional genetic theories cannot explain the following solved, because this debate has been monopolized by critical properties of carcinogenesis. conventional gene mutation theories, which hold that cancer is a "genetic disease" [33,104,154,178,210,214, 281,282,287,288]. 2. Discrepancies between conventional genetic These gene-based theories postulate that cancer is theories and cancer caused by clonal expansion of cells, which have ac- cumulated about 4–7 specific and complementary mu- 2.1. Cancer is not heritable * Corresponding author. Tel.: +1 510 642 6549; Fax: +1 643 6455; The best news about cancer is that we and other ani- E-mail: firstname.lastname@example.com. mals are virtually all born cancer-free and typically ac- 1570-5870/05/$17.00 2005 – IOS Press and the authors. All rights reserved 294 P. Duesberg et al. / The chromosomal basis of cancer Age Incidence <1 0.24 1–4 0.22 5–9 0.12 10–14 0.13 15–19 0.21 20–24 0.31 25–29 0.44 30–34 0.59 35–39 0.88 40–44 1.48 45–49 2.70 50–54 5.37 55–59 9.47 60–64 15.41 65–69 22.64 70–74 28.29 75–79 31.23 80–84 30.83 >85 29.77 Fig. 1. Age specific incidence of invasive cancers of males in the United States in 2001. The dominant contributors to the total number of invasive cancers are solid tumors. The growth is approximately exponential until about age 70 and then levels off. Data for the figure, shown in the table at the right, are from the National Program of Cancer Registries at <http://www.cdc.gov/cancer/npcr/index.htm>. Because cancer is primarily a disease of old age it is compatible with an acquired, but not with an inherited disease. quire cancer, if at all, only at advanced age [12,45,141, would have cancer, if cancer were heritable. Thus the 178,198,219]. This bias of cancer for old age is expo- mutation theory fails to explain the extremely low rates nential, increasing the cancer risk 300-fold with age, of cancer at young age. from near-zero rates in newborns and adolescents to Instead, the extremely low percentages of children rates of 1 in 3 in the last third of a human or animal life with cancer can be explained as the fringes of the span (Fig. 1). Thus cancer is a disease of old age. probability distribution of those events that cause can- But, if the prevailing gene-based cancer theories cer typically only after very long latencies, which last were correct, the age bias of cancer would be para- decades in humans (see below Sections 2.3, 3 and doxical. According to the gene mutation theories, can- Fig. 3). In addition, rare genetic diseases that increase cer should be common in newborns. For example, a those events that initiate and eventually cause cancer baby, which inherits 3 colon cancer mutations from his also explain some of the cancers in children (Sections mother and 2 from his father out of the about 6 that are 2.5, and 4.8.5). thought to cause colon cancer [178,189,286], should Moreover, if heritable cancer genes existed twins develop cancer at a very young age from just one more should have very similar cancer rates. But, according spontaneous mutation in any one of the billions of its to a multi-national epidemiological study of the cancer colon cells. Indeed many hypothetical cancer-causing incidence in twins, "Inherited genetic factors make a mutations, including those thought to cause colon can- minor contribution . . . the environment has the princi- cer, are heritable in transgenic mice [76,85] and also pal role in causing sporadic cancer" [171]. in humans [154,287] (see Box 1, The Achilles heels of the mutation-cancer theory, and Section 2.10). Ac- 2.2. Non-mutagenic carcinogens cause cancer cording to Vogelstein and Kinzler, "one of the cardi- nal principles of modern cancer research is that the Carcinogens are either chemical or physical agents same genes cause both inherited and sporadic (non- that initiate carcinogenesis [45,219]. Both chemical inherited) forms of the same tumors" [287]. But, there and even physical carcinogens can be either muta- is no colon cancer in newborns [189] (Fig. 1). genic or non-mutagenic. Examples of non-mutagenic The extremely rare cases of cancer in newborns carcinogens are asbestos, tar, mineral oils, naphtha- and children shown in Fig. 1 do not save the muta- lene, polycyclic aromatic hydrocarbons, butter yel- tion theory of cancer. Since cancer affects 1 in 3 hu- low, urethane, dioxin, hormones, metal ions such as man lives, large percentages of newborns and children Ni, Cd, Cr, As, spindle blockers such as vincristine P. Duesberg et al. / The chromosomal basis of cancer 295 Box 1 The Achilles heels of the mutation-cancer theory The currently prevailing cancer theory postulates that can- the current cancer risk of Americans and Europeans cer is caused by clonal expansion of one single cell that of about 1 in 3 lifetimes [141] (Fig. 1) in terms of 4 has accumulated about 4–7 complementary mutations dur- mutations, the mutation theory has to assume muta- ing the lifetime of a patient [45,108,178,225,235,286]. tion rates, which are about 103 times higher than in However, the mutation theory is hard to reconcile with the conventional mutation. In other words the rates of 4 following list of facts. mutations would have to be about 1012 times higher and that of a single mutation about 103 times higher (1) Non-mutagenic carcinogens. Contrary to the mutation [(103 )4 = 1012 ] than they are, to generate the known theory, many carcinogens are not mutagens, includ- cancer rates. ing some of the most potent ones. Examples are as- (4) No explanation for "neoplastic latency" after a suf- bestos, tar, mineral oils, naphthalene, polycyclic aro- ficient dose of carcinogen. The mutation theory has matic hydrocarbons, butter yellow, urethane, dioxin, no simple answer to the question why, after a critical hormones, metal ions such as Ni, Cd, Cr, As, spin- dose of carcinogen, carcinogenesis would only occur dle blockers such as vincristine and colcemid, extra- after exceedingly long "neoplastic latencies" of years nuclear radiation and solid plastic or metal implants to decades (Section 2.3) [286]. Instead evermore com- [29,44,76,81,172,176,203,219,304] (see Section 2.2). plex sequences of mutations [46] and even "transient" (2) No transforming genes. Despite over 25 years of ef- mutator genes (undetectable in subsequent cancers) forts no genes or combinations of genes from cancers are postulated without functional proof [179,180]. have been shown to transform normal cells to can- (5) Dependence of phenotype alterations in cancers on cer cells [4,169,170] or generate polyclonal tumors unrealistically high rates of mutation. The mutation in mice carrying such genes in their germ lines [72, theory has to assume mutation rates of up to 10−3 per 113,114,150,259,286]. In agreement with this lack of cell generation to explain the frequent, spontaneous function, many presumably cancer-specific mutations variation of phenotypes in highly aneuploid cancer are not detectably expressed in cancer cells [85,221, cells. Examples are the "high rates" (compared to 228,305] (Section 2.10). mutation) at which some cancers generate metastatic (3) Dependence of cancer on unrealistically high rates of cells [5,115], or generate drug-resistant variants [83, mutation. The mutation theory explains the exponen- 84,113,168] (Section 2.6). But the mutation rates of tial increase of the cancer incidence with age (Fig. 1) most cancers are not higher than those of normal cells by the low probability that conventional mutation [76,112,133,162,185,203,257,266,273,292]. would generate 4–7 specific mutations in the same cell (6) Heritable mutations of cancer cells, but no heritable [108,180,235,286]. This is so improbable, because the cancer. The multi-gene mutation theory predicts that spontaneous mutation rates in all species are natu- subsets of cancer causing mutations should be herita- rally restricted to about 10−7 per dominant gene and ble. Indeed, proponents of the mutation theory have to about 10−14 per recessive gene per cell genera- demonstrated that several of the 6 mutations thought tion, in order to maintain the integrity of the genome to cause colon cancer [286] can be introduced into [133,167,185,271,285]. Indeed, based on these con- the germ line of mice without breaching the viabil- ventional mutation rates, cancer via 4–7 mutations ity of these animals (see above, point 2 and Sec- would not even exist [77]. Even the most probable tion 2.10). According to one study animals with one cancer case predicted by the mutation theory, namely of these mutations, namely ras, were found "with- cancer via 4 specific dominant mutations, would occur out detectable phenotypic abnormalities" [150]. Ac- only once in 1012 human lifetimes. This is calculated cording to another study, "Surprisingly, homozygos- as follows: Since the spontaneous mutation rate per ity for the Apc1638T mutation [a hypothetical colon specific, dominant gene is about 10−7 , it takes 1028 cancer suppressor gene] is compatible with postnatal cells to generate one human cell with 4 specific muta- life" [259]. Thus subsets of colon cancer genes are tions. The expected cancer rate per human lifetime of heritable. Therefore, colon cancer should be common 1 in 1012 is then obtained by dividing 1028 by 1016 . in newborns, which are clonal for inherited subsets of 1016 is the number of cells that correspond to an aver- these 6 mutations (like transgenic mice). But there is age human lifetime [45,77]. Thus, in order to explain no colon cancer in newborns (Fig. 1) [45,141,189]. 296 P. Duesberg et al. / The chromosomal basis of cancer and colcemid, extra-nuclear radiation and solid plastic 297]. As a result cancer cells progress independently or metal implants [29,44,76,81,172,176,203,219,304] within individual cancers, to form evermore "polymor- (see also, Box 1). phic" [49] and phenotypically heterogeneous cancers Moreover the many agents that accelerate carcino- with evermore exotic karyotypes and phenotypes [90]. genesis, termed tumor promoters, are all non-mutagenic, Thus "initiation" confers on cells a lifelong variabil- or not directly mutagenic, as for example croton oil and ity that can generate new phenotypes and karyotypes phorbol acetate [139,219]. many cell generations or decades after it was estab- Conventional genetic theories, however, fail to ex- lished. plain carcinogenesis by non-mutagenic carcinogens But, the evolution of new phenotypes many cell gen- and non-mutagenic tumor promoters. erations or decades after mutagenesis is incompatible with conventional mutation, on which genetic theories 2.3. Long neoplastic latencies of cancer are based. Conventional mutation is imme- diate and just as stable as the parental genotype [94, Surprisingly, in view of the mutation theory, there 104,167,214]. It is for this reason that Cairns wrote in are no fast carcinogens. Nevertheless, many carcino- Cancer: science and society, "The conspicuous feature gens are very fast mutagens, as for example, X-rays, of most forms of carcinogenesis is the long period that UV light and alkylating agents. But all carcinogens, elapses between initial application of the carcinogen mutagenic or not, are very slow – causing cancer only and the time the first cancers appear. Clearly, we cannot after exceedingly long "neoplastic latencies" [90,219] claim to know what turns a cell into a cancer cell until of many months to years in rodents, and of many we understand why the time course of carcinogenesis years to decades in humans [25,26,29,45,77,90,136, is almost always so extraordinarily long" [45]. 219,286]. Examples are, (i) the solid cancers, which devel- 2.4. Exact correlations between cancer and oped in survivors of atomic bombs only 20 years af- aneuploidy ter exposure to nuclear radiation in1945 [45]; (ii) the breast cancers, which developed in former tuberculo- Exact correlations between cancer and aneuploidy sis patients only 15 years after treatments with X-rays have been reported since 1890 [17,18,111,124,155, in the 1950s [36]; and (iii) the lung cancers, which 245]. Likewise, abnormal expression of 1000s of developed in workers of a Japanese mustard gas fac- genes, proportional to the abnormal ploidy of the cor- tory only 30 years after it was closed in 1945 [70]. responding chromosomes, have recently been detected Similarly, the risk of lung cancer remains about 5– in all cancer cells that have been tested by hybridiza- 10× higher for ex-smokers than it is for non-smokers, tions of cellular RNAs with arrays of cellular genes [2, even decades after they stopped smoking [45,46,71, 95,221,283]. 129]. Thus an initiated cell evolves only gradually to Aneuploidy is defined by losses or gains of in- a visible cancer cell, even though it has received suffi- tact chromosomes or of segments of chromosomes cient carcinogen for carcinogen-independent carcino- [167]. Gained segments of chromosomes are typically genesis – much like a submarine volcano only gradu- rearranged either with the same chromosomes from ally becomes a visible island [25,26,90]. By contrast, which they derived or with other chromosomes. The the mutation theory would have predicted carcinogen- resulting hybrid chromosomes are termed marker chro- esis as soon as the above examples had received the mosomes. Owing to their unique structure, marker doses of carcinogen that eventually caused their can- chromosomes can serve as tracers for the origin of pos- cers. sibly metastatic cancer cells from primary cancers and Experimental carcinogenesis demonstrates even for the origin of primary cancer cells from possibly more directly that, once initiated, the evolution of can- aneuploid pre-neoplastic precursors [155,245]. A typ- cer cells is an autonomous, if slow, process that is in- ical example of a highly aneuploid cancer karyotype dependent of further exogenous influences [29,45,90, with numerous marker chromosomes, that of a breast 219,243]. Nevertheless, experimental carcinogenesis is cancer cell from the cell line MDA 231, is shown in accelerated by further carcinogens or tumor promoters Fig. 2. The figure also shows the karyotype of a normal [45,138,139,219,243] (Section 2.2). This autonomous male, human cell. In addition, cancer cells often in- evolution continues in cancer cells and their descen- clude extra-chromosomal forms of aneuploid segments dents both in vivo and even in vitro [29,90,120,164, of chromosomes, termed "amplicons", that are either P. Duesberg et al. / The chromosomal basis of cancer 297 Fig. 2. Metaphase chromosomes of the human breast cancer cell line, MDA 231, and of a normal cell of a human male. The metaphases were pre- pared and hybridized in situ with color-coded, chromosome-specific DNA probes from MetaSystems, Inc., Boston, MA, following published pro- cedures [168]. The numbers identify normal chromosomes. The group labeled "mar" (for marker chromosome) shows structurally abnormal chro- mosomes, which are either rearranged intra-chromosomally or inter-chromosomally to form various hybrid chromosomes. Such chromosomes are called "marker chromosomes", because they can be used as structurally unique, cytogenetic markers of a given cancer. The numbers above these marker chromosomes identify the chromosomal constituents of hybrid chromosomes in their relative order or signal intra-chromosomal alterations. The comparison of the two karyotypes shows that the cancer cell differs from the normal cell in numerous numerical and structural chromosomal alterations or aneusomies. microscopically detectable as "double minute" chro- Nevertheless, exceptions to the coincidence between mosomes [124,245,247] or maybe "submicroscopic" aneuploidy and cancer have been reported, as for ex- [207], depending on the microscopic technique used, ample "diploid" colon cancers with mismatch repair with sizes as low as 1 megabase (Mb) [194,258]. But deficiency [162]. But, further analysis of what ap- even extra- and intra-chromosomal amplicons [177] or peared to be diploid colon cancers by "array-based deletions of only 1 Mb are still nearly as large as an comparative genomic hybridization" has since indi- entire E. coli chromosome of about 3 Mb. Aneuploidy cated that about "5% of their entire genome" is seg- is thus a much more massive genetic abnormality than mentally aneuploid versus 20% of a control group the gene mutations that have also been found in cancer of colon cancers without mismatch repair deficiency cells (Section 2.10 and Box 1). [194]. Colon cancers with "normal karyotypes" have The ubiquity of aneuploidy in cancer is, however, also been described by Bardi et al. [21]. But, further not postulated nor predicted by the mutation theory. As scrutiny reveals that these normal karyotypes were ei- a consequence, cancer-defining aneuploidy is currently ther from "hyperplastic polyps" [23] or from "non- not even mentioned in the cancer chapters of the lead- neoplastic stromal cells" [22] or were considered to ing textbooks of biology [7,45,167,178,214]. be misidentified tumor cells showing "how dependent 298 P. Duesberg et al. / The chromosomal basis of cancer Fig. 2. (Continued.) findings in solid tumor cytogenetics are on method" gus and the cervix [3,20,34,38,125,128,129,181, [38] (Bardi G., personal communication, 2004). Thus 182,188,193,196,215,218,223,231,232,241,256,267, there is currently no unambiguous evidence for diploid 275,296]. Moreover, multinational, epidemiological cancer. studies have found that the relative cancer risk of peo- ple can be predicted from the degree of chromosomal 2.5. Accidental, genetic and congenital aberrations of peripheral lymphocytes [39,106]. pre-neoplastic aneuploidy Experiments undertaken to study the origin of ane- uploidy in animals treated with carcinogens, have also Intrigued by the aneuploidy in cancer and the long found aneuploidy prior to cancer in the liver, skin neoplastic latencies, many researchers have analyzed and subcutaneous tissues of carcinogen-treated rodents [42,56,59,64,184,224,278] (our unpublished observa- cancer-prone tissues for pre-neoplastic genetic and tions with Chinese hamsters). chromosomal alterations, particularly aneuploidy [16, Likewise, treatments of diploid human and animal 76,102,185,257,262]. cells in vitro with carcinogens were found to gener- Accidental pre-neoplastic aneuploidy. The first con- ate aneuploidy long before transformation. Unexpect- sistent evidence for pre-neoplastic aneuploidy was ob- edly, this pre-neoplastic aneuploidy proved to be vari- tained in 1960s by Caspersson [48] and Spriggs [262] able in subsequent cell generations – creating "de- in cervical tissues [16,114]. Similar studies have since layed" genomic instability or even "delayed reproduc- also found aneuploidy prior to carcinogenesis in pre- tive death" [24,27,57,58,60,62,76,80,89,92,134,176, cancerous tissues and neoplasias of the throat, colon, 274,279,290,300]. Aneuploidy also precedes transfor- lung, breast, skin, pancreas, prostate, gonads, esopha- mation of human and animal cells infected by Simian P. Duesberg et al. / The chromosomal basis of cancer 299 Virus 40 and other DNA tumor viruses [170,229,298]. or deletions as would be associated with the activa- Even spontaneous transformation of cells in vitro is tion of known oncogenes or tumor suppressor genes" preceded by aneuploidy [63,86,122,165]. [176]. When we tested pre-neoplastic aneuploidy with re- gard to its role in cancer, we found that experimen- 2.6. Karyotypic–phenotypic variations of cancer cells tal pre-neoplastic aneuploidy always segregated with at rates that are orders higher than conventional subsequent morphological transformation and tumori- mutation genicity [80,89]. Based on these data we have con- cluded that aneuploidy initiates carcinogenesis. This The chromosomes of cancer cells are extremely un- conclusion is directly supported by the high cancer stable compared to those of normal cells: 1 in 100 risks of heritable chromosome instability syndromes highly aneuploid human cancer cells loses or gains or and of congenital aneuploidies. We show next that in rearranges a chromosome per cell generation [168]. both of these conditions aneuploidy also precedes can- Since humans contain 23 chromosomes, 1 in 23 chro- cer. mosome alterations can be expected to generate a spe- cific aneusomy. In agreement with this, up to 1 in 1000 Genetic pre-neoplastic aneuploidy. Heritable diseases aneuploid cancer cells spontaneously generates a spe- that predispose to abnormally high rates of systemic cific new phenotype per cell generation – "at frequen- aneuploidy, termed "chromosome instability syn- cies considerably greater than conventional mutation" dromes", include Fanconi's anemia, Bloom's syn- [300] – as for example drug-resistance [83,84,113,168, drome, Ataxia Telangiectasia, Xeroderma, Werner's 271] or the ability to metastasize at "high rates" [5, and other syndromes. These chromosome instability 115] or the loss of heterozygosity at rates of 10−5 per syndromes also predispose to high rates of cancer and generation [287]. generate cancers at younger age than in normal con- This inherent karyotypic–phenotypic variability of trols [245] (see Section 4.8.5). In these syndromes, cancer cells is the reason, why most cancers are "enor- heritable mutations function as genetic aneuploidogens mously" heterogeneous populations of non-clonal and and carcinogens (Sections 3 and 4.8.5). partially clonal cells, which differ from each other Congenital pre-neoplastic aneuploidy. Minor, con- in "bewildering" [155] phenotypic and chromosomal genital aneuploidies are viable, while major congenital variations [124,248] – even though most cancers are aneuploidies are lethal [67,118]. The best known ex- derived from a common, primary cancer cell and amples are Down syndrome, Retinoblastoma, Wilms thus have clonal origins [45,49,51,90,113,120,124, tumor, Klinefelter's syndrome and others, summarized 151,162,176,199,245]. by Sandberg in 1990 [245]. Just like the chromoso- By contrast, conventional mutation of specific genes mal instability syndromes, the congenital aneuploidy is limited to 10−7 per cell generation for dominant syndromes carry high cancer risks and generate can- genes and to 10−14 for pairs of recessive genes in cers at younger age than in diploid controls [117,155, all species [133,167,185,270,271,285]. Surprisingly, 245]. The 20-times higher-than-normal incidence of in view of the genetic theories of cancer, even the leukemia in Down syndrome is one of the best-studied gene mutation rates of most cancer cells are not examples [117,155,245]. The same is true for congen- higher than those of normal cells [76,112,133,162,185, ital aneuploidy in mice, in which an artificial duplica- 203,257,266,272,273,292]. Thus specific, karyotypic– tion of only 1 megabase of chromosome 11 was found phenotypic variations of cancer cells are 4 to 11 or- to induce lymphomas and other tumors after latencies ders faster than conventional mutation, and therefore of several months [177]. not compatible mutational theories. However, the mutation-cancer theory does neither Following others [185,270,287], we have used here postulate nor predict the presence of pre-neoplastic an average, spontaneous mutation rate of 10−7 per aneuploidy – except, perhaps indirectly, by postulating human/mammalian genetic locus per cell generation. the generation of cancer genes via chromosomal re- These averages reflect mutation rates that range be- arrangements (Section 1). But, again the evidence for tween 10−5 and 10−9 [140] and 10−5 to 10−7 [285] cancer-specific mutations is missing [76] (Box 1). Ac- depending on the respective human phenotypes. Lower cording to a recent review by Little, "While radiation- rates of phenotype variation of 10−8 to 10−10 are ob- induced cancers show multiple unbalanced chromoso- served in bacteria and yeast [167,214]. The apparently mal rearrangements, few show specific translocations higher mutation rates of humans/mammals compared 300 P. Duesberg et al. / The chromosomal basis of cancer to bacteria probably reflect (a) the higher genetic com- 2.8. Cancer phenotypes too complex for conventional plexity of the respective human loci studied compared mutations to those of bacteria and yeast, and (b) the fact that "the rates in humans are calculated per gamete and The complexity of most cancer-specific phenotypes several cell divisions are required to produce a ga- far exceeds that of phenotypes generated by con- mete" [214]. Take for example the numerous mutant ventional mutation. Examples are the gross polymor- genes and clotting factors that cause the phenotype, phisms in size and shape of individual cells within indi- hemophilia [285]. Indeed, the mutation rates per unit vidual cancers [25,49,90]. Moreover, the kind of drug- X-irradiated genetic DNA are the same in all species resistance that is acquired by most cancer cells exposed [1]. to a single cytotoxic drug is much more complex than just resistance against the drug used to induce it. There- 2.7. Cancer-specific chromosomal alterations fore, this phenotype has been termed "multidrug re- sistance" [84,113,250]. It protects not only against the Despite the karyotypic instability of cancer cells and toxicity of the challenging drug, but also against many heterogeneity of cancers, partially specific or "non- other chemically unrelated drugs and is thus probably random" chromosomal alterations, also termed aneu- multigenic. somies, have been found in cancers since in the late Cancer-specific phenotypes such as grossly abnor- 1960s [14,15,17,20,22,23,89,124,143,155,204,208, mal metabolism, metastasis, transplantability to het- 209,283,301,302,303]. The majority of these non- erologous species [121] and "immortality" (also Sec- random chromosomal alterations have been detected tions 2.9, 4.4 and 4.6) [90,219] are also likely to be in cancers since the 1990s by the use of compar- ative and gene array-based genomic hybridization, multigenic, because all of these phenotypes correlate rather than by identifying specific aneusomies cyto- with altered expressions of thousands of genes [2,95, genetically [68,98,124,127,142,200,205,212,221,234, 178,221,283] and with highly abnormal concentrations 236,237,293]. Specific aneusomies have been linked of thousands of normal proteins [49,50,190,219]. Im- with the following distinct events of carcinogenesis: mortality is defined as the ability of cancer cells to grow indefinitely in culture or on transplantation [90, (i) Stages of neoplastic transformation in human 167]. In addition, the number of centrosomes is in- [68,93,128,132,149,155,205,237,295] and in creased up to five-fold (from a normal of 2 to around animal carcinogenesis [89], 10) in highly aneuploid cancer cells, and their struc- (ii) Invasiveness [132,187,295], tures are often altered at the same time [100,174,216, (iii) Metastasis [6,11,35,125,152,195,197,213], 217]. (iv) Drug-resistance [168,247,270], The complexities of these cancer-specific pheno- (v) Transplantability to foreign hosts [121], types, however, can not be achieved by the low, con- (vi) Cellular morphologies [289], ventional rates of gene mutations during the limited (vii) Abnormal metabolism [119,155], live spans of humans and animals (Section 2.6 and Box (viii) Cancer-specific receptors for viruses [155, 1). For example, it is virtually impossible that the up to 289]. five-fold increased numbers of centrosomes, which are Moreover, in cases where this has been tested, cancer- observed in highly aneuploid cancer cells [43,174,175, specific gene expression profiles are directly propor- 216], would be the result of mutations that increase tional to the dosages of the corresponding chromo- the numbers of the 350 different proteins that make up somes [2,95,178,221,283]. centrosomes [74]. Thus the mutation theory cannot ex- Cancer-specific or "nonrandom" chromosomal al- plain the complex phenotypes of cancer. terations, however, are neither postulated nor predicted Contrary to this conclusion, it has been argued by mutational theories of cancer. In fact they are a that multidrug resistance can be generated by singu- direct challenge of the mutation theory, because spe- lar genes [148,250]. However, it is biochemically im- cific chromosomal alterations generate specific phe- plausible that a single protein could protect against notypes, independent of mutation. The over 71 Down many, biochemically unrelated cytotoxic substances, syndrome-specific phenotypes, caused by trisomy 21 such as DNA chain terminators, spindle blockers and without any gene mutation, are a confirmed model [87, inhibitors of protein synthesis all at once [148,250]. 183,230,255]. Moreover it is improbable that only cancer cells would P. Duesberg et al. / The chromosomal basis of cancer 301 benefit from such genes, whereas normal cells of can- 2.10. No cancer-causing genes in cancer cer patients remain vulnerable [83,84,113]. In view of these discrepancies we have recently Numerous gene mutations have been found in can- proposed that chromosomal alterations are the cause cer cells since the 1980s [31–33,108,268,280,286]. of multidrug resistance [83,84,168]. To test this hy- The prevailing genetic cancer theories postulate that pothesis we have carried out two kinds of experi- these mutations cause cancer [33,108,178,287,288] ments: First, we have asked whether aneuploid mouse (Section 1). But this hypothesis is hard to reconcile cells, from which multidrug resistance genes had been with the following facts: deleted [8], could still become drug-resistant. In ac- (1) None of the mutations found in cancers are cordance with our prediction we have found that ane- cancer-specific [37,286]. uploid cells become multidrug resistant even without (2) In cases where this information is available, all known multidrug resistance genes of mice [83,84]. many perhaps most mutations are non-clonal Second, we have asked whether drug-resistance corre- [37,85,147]. lates with resistance-specific chromosomal alterations. (3) Expression of most hypothetically cancer-caus- Indeed, this too was confirmed recently [168]. In view ing mutations is not even detectable in most hu- of this, we conclude that multidrug resistance is chro- man cancer cells without artificial amplification mosomal and thus multigenic (also Section 4.6). methods [85,221,228,305]. (4) No mutant gene and no combination of mutant 2.9. Non-selective phenotypes: not helping cancer genes from cancer cells has been found that con- cells to compete for growth verts diploid human or animal cells into can- cer cells, despite enormous efforts in the last 25 years [4,76,114,169,170,225,248]. On Septem- Cancer-specific phenotypes can be divided into two ber 16, 2005, J. Michael Bishop confirmed that classes: Those, which are selective, because they ad- there is still no proven combination of mutant vance carcinogenesis by conferring growth advantages genes from cancer cells that is sufficient to cause to cancer cells such as invasiveness, grossly altered cancer (at a seminar, "Mouse models of human metabolism and high adaptability via high genomic cancer" at the Lawrence Berkeley Lab at Berke- variability [90,219], and those, which are not selective ley). for growth [30,76]. (5) In contrast to predictions of the mutation theory The non-selective phenotypes of cancer cells in- – mouse strains with hypothetical cancer genes clude metastasis, multidrug resistance and immortality. artificially implanted into their germline, and Metastasis is the ability to grow at a site away from others with hypothetical tumor suppressor genes the primary tumor. Therefore, it is not selective at the artificially deleted from the germline have sur- site of its origin [30]. Likewise, multidrug-resistance vived many generations in laboratories with ei- is not a selective advantage for natural carcinogenesis ther the same or slightly higher cancer-risks than in the absence of chemotherapy. Yet, a high percent- other lab mice [72,76,85,114]. For instance, one age of cancers is intrinsically multidrug-resistant [73, group observed that, "Surprisingly, homozygos- 103]. Moreover, acquired multidrug resistance protects ity for the Apc1638T mutation", an artificial against many more drugs than the cancer was ever ex- null mutation of the hypothetical tumor sup- posed to [83,84,250]. Even immortality is not a selec- pressor gene Apc, "is compatible with postna- tive advantage for carcinogenesis, because many types tal life" and that "animals that survive to adult- of human cells can grow over 50 generations accord- hood are tumor-free" [259] (see also Box 1). ing to the Hayflick limit [122], and thus many more Even more surprisingly – some mice with hy- generations than are necessary to generate a lethal can- pothetical cancer genes and others without hy- cer. Consider, that fifty cell generations produce from pothetical tumor suppressor genes fare even bet- one single cell a cellular mass equivalent of 10 humans ter than un-mutated controls. For example, the with 1014 cells each [77]. authors of one study state that, "Surprisingly", Non-selective phenotypes, however, are neither pos- the "germline expression of an oncogenic erbB2 tulated nor predicted by conventional gene mutation- allele (breast cancer gene, alias Her2 and Neu) selection mechanisms. . . . conferred resistance to mammary tumori- 302 P. Duesberg et al. / The chromosomal basis of cancer genesis" [10]. Yet another group reports that as comparative genomic hybridization and gene array- "unexpectedly" mice with null mutations of the based hybridization [194,221,258] (see also definition retinoblastoma gene, rb, "developed fewer and of aneuploidy in Section 2.4). smaller papillomas" than un-mutated controls The new chromosomal theory we propose is based [235]. on the following data, which were either generated by us recently or were collected from the literature: There are, however, reports about tumors in mice that can be induced and even reversed experimentally via (1) Exact correlations between aneuploidy and can- promoters that switch on and off hypothetical can- cer. The literature including that of our own lab cer genes, which have been artificially implanted into shows that chromosomal alterations, alias ane- the germline [252,294]. But the questions, why only uploidy, are ubiquitous in cancer (Section 2.4). local, and thus possibly clonal, tumors appeared in It follows that aneuploidy is necessary for car- these "transgenic" mice, rather than systemic ones, cinogenesis. and whether these reversible tumors were aneuploid or (2) Carcinogens induce aneuploidy. To test the were diploid hyperplasias have not been answered [85, chromosomal theory, we have collected stud- 252]. ies which have investigated the function of car- Twelve years ago, Vogelstein and Kinzler closed an cinogens and shown that they cause aneuploidy influential review of the mutation theory in 1993 (since [76,77,80,81,89]. For the same reason, we have cited in text books [284]) as follows, "The genetics of collected studies, which have searched for the cancer forces us to re-examine our simple notions of genetic targets of carcinogens, but have unex- causality, such as those embodied in Koch's postulates: pectedly obtained targets over >1000× larger how does one come to grips with words like 'neces- than a gene, and thus equivalent to the size of sary' and 'sufficient' when more than one mutation is chromosomes [76]. It follows that the common, required to produce a phenotype and when that pheno- cancer-relevant denominator of carcinogens is type can be produced by different mutant genes in vari- aneuploidization. ous combinations?" [286]. According to the brief sum- (3) Pre-neoplastic aneuploidy. In preliminary tests mary above and Bishop's seminar in 2005, the answer of the chromosomal theory we have found that to Vogelstein and Kinzler's question is still open – 12 the pre-neoplastic aneuploidy of initiated cells years and many studies later. segregates with subsequent malignant transfor- mation [80,89] (Section 2.5). It follows that pre- In sum: In the preceding Sections we have listed 10 neoplastic aneuploidy could be the evolutionary features of carcinogenesis that cannot be explained by precursor of cancer-specific aneuploidy. genetic cancer theories. These and other inconsisten- (4) Cancer-specific aneusomies. Despite the enor- cies between carcinogenesis and established genetic mous karyotypic heterogeneity of most cancer theories are the reasons why it is still debated, whether cells, cancer-specific or "nonrandom" aneuploi- mutations or aneuploidies or epigenetic alterations dies were discovered since the late 1960s (Sec- cause cancer [43,69,75,77,79,85,102,107,108,114,169, tion 2.7). It follows that specific chromosomal 170,185,189,190,215,225,234,248,251,257,264,265, alterations could be sufficient for carcinogene- 273,282,286]. sis. (5) Chromosomes of cancer cells vary at rates that are proportional to the degrees of aneuploidy. 3. A new, chromosomal theory of cancer In preliminary tests of the chromosomal can- cer theory we have observed that aneuploidy In view of the many discrepancies between car- catalyzes chromosomal variations in proportion cinogenesis and conventional genetic theories listed to the degree of aneuploidy [82,83,88,168,228] above, we present here a new, chromosomal theory (Section 2.6). Several labs have recently also of cancer. Chromosomal is defined here primarily by found that chromosomal variability of cancer what is seen microscopically by classical cytogenetics cells is proportional to the degree of aneuploidy [124,245]. It also includes amplicons, or deletions of [47,51,156,239]. Moreover, we have found that chromosomes down to about 1 megabase, which are the rates of specific chromosomal variations can "submicroscopic" according to some [207] but micro- go 4–11 orders higher than those of conven- scopic according to other more recent techniques such tional gene mutations [76,88,168]. It follows P. Duesberg et al. / The chromosomal basis of cancer 303 Fig. 3. The chromosomal cancer theory. (i) Initiation: A carcinogen or a spontaneous accident induces random aneuploidy either by nondisjunc- tion or by breaking and rearranging chromosomes. (ii) Pre-neoplastic chromosomal evolutions: By unbalancing 1000s of genes aneuploidy cor- rupts teams of proteins that segregate, synthesize and repair chromosomes. Aneuploidy is therefore a steady source of chromosomal variations, from which, in classical Darwinian terms, neoplastic karyotypes eventually evolve. Since pre-neoplastic aneuploidy is typically low, and since pre-neoplastic cells, by definition, do not grow better than normal cells, pre-neoplastic chromosomal evolutions are slow. Many aneuploid cells die because of nullisomies or other non-viable chromosome combinations. (iii) Neoplastic evolutions: Once a neoplastic chromosome combi- nation evolves, subsequent karyotypic variations are accelerated, because neoplastic cells are generally more aneuploid and thus more adapt- able than pre-neoplastic cells and because they form large pools by outgrowing normal cells. Thus neoplastic cells evolve independently within tumors forming ever-more heterogeneous and malignant phenotypes such as invasiveness, metastasis and drug-resistance at high rates. In sum: Malignancy can be seen as a consequence of autonomous chromosomal evolutions that increase karyotypic entropy to its biological limits, at or near 3n-aneuploidy. that the karyotypic heterogeneity of cancers is 163,166,189,199,211,226,227,272,306]. It fol- a consequence of the inherent chromosomal in- lows that the primary challenge for a new chro- stability of aneuploidy. mosomal theory was to find an explanation for (6) The chromosomal theory of cancer proposed the insidious chromosomal instability of cancer by Boveri and von Hansemann over 100 years cells. ago. Boveri and von Hansemann proposed over In an effort to integrate these data into a coherent the- 100 years ago that abnormal chromosome num- ory, which would also explain the above-listed discrep- bers were the cause of cancer [40,41,111]. ancies between carcinogenesis and conventional ge- This theory, however, was abandoned in the netic cancer theories, we arrived at our new, chromoso- 1950s and 1960s, because the karyotypic het- mal theory of cancer (summarized in Fig. 3). Accord- erogeneity of cancers was interpreted as a con- ing to this theory carcinogenesis is the result of the fol- sequence of an unknown, clonal cause [65,155, lowing chain of events: 240]. Ever since, "aneuploidy and other forms – Carcinogens and spontaneous mitotic errors in- of chromosomal abnormality" of cancer cells duce unspecific chromosomal alterations or ane- [113] are generally interpreted as "secondary" uploidies. events [113,114,124,144,155] – secondary to – Since chromosomal alterations unbalance 1000s hypothetical primary mutations [114,123,154, of genes, they corrupt teams of proteins that seg- 304 P. Duesberg et al. / The chromosomal basis of cancer regate, synthesize and repair chromosomes. Ane- and mice, independent of gene mutation [126,173,177, uploidy is thus a steady source of karyotypic– 186]. According to the cancer researcher Vogelstein phenotypic variations from which, in classical there is no "normal [animal] cell with an abnormal Darwinian terms, selection of specific chromo- karyotype" [185]. Thus the complex aneuploidies of somal alterations encourages the evolution and cancer cells can be expected to generate numerous ab- spontaneous progression of neoplastic cells. normal phenotypes including those of cancer. – The rates of these variations are proportional to By contrast, the effects of changing phenotypes of the degrees of aneuploidy. the cell by mutation without touching the karyotype are – Based on their chromosomal constitution cancer much more limited than those resulting from chang- cells are new cell "species" with specific or "non- ing the karyotype. Mutation without touching the kary- random" chromosomal alterations and transcrip- otype is analogous to changing specific components of tomes, but unstable karyotypes. This aneuploidy- an existing car model: There could either be positive based, chromosomal uncertainty principle had mutations, such as an improved carburetor, or negative become the nemesis of the Boveri–von Hanse- mutations such as an unreliable ignition, or neutral mu- mann theory in the 1950s and 1960s. tations such as a new color. None of such mutations – The specific chromosomal alterations of cancer cells generate complex, malignant phenotypes via would generate an exotic new car model with unpre- abnormal dosages of 1000s of genes. Down syn- dictable phenotypes. Indeed, none of the 1.42 million drome is a model for how aneuploidy generates gene mutations that distinguish any two humans [244] complex, abnormal phenotypes. have generated a new human species, nor have they – In sum, cancer is caused by chromosomal disor- even been sufficient to cause cancer in newborns. In ganization, which increases karyotypic entropy. view of this such mutations are euphemistically called Thus cancer is a chromosomal rather than a ge- "polymorphisms". netic disease. Moreover, the function of genes in biological assem- bly lines is strongly buffered against mutations: acti- Below, we offer a brief explanation of how aneuploidy vating mutations are buffered down by normal sup- generates new phenotypes, independent of mutation. plies and inactivating mutations are kinetically acti- By changing the numbers of chromosomes, aneuploidy vated by increased supplies from un-mutated compo- has the same effects on the phenotypes of cells as changing the assembly lines of a car factory on the phe- nents of the assembly line [61,116,145]. But, there is notypes of an automobile: no such buffering against aneuploidy. Changes of assembly lines that essentially maintain Thus aneuploidy is inevitably dominant, whereas the balance of existing components, alias genes, gener- mutation is nearly always recessive [285]. It is for this ate new, competitive car models. For example, the en- reason that gene mutations could never generate new gine could be moved from the back to the front via ad- phylogenetic species or even new cancer cell-species – justments in assembly lines without changing the bal- independent of karyotypic alterations. ance of genes. Similarly, phylogenesis generates new The following analogy illuminates the differences species by regrouping old genes of existing species, between mutation and aneuploidy from a slightly dif- without changing their balance, into new numbers and ferent perspective: Consider the cell as a book, the structures of chromosomes [201]. genes as words, and the chromosomes as sentences, However, if changes of assembly lines are made that paragraphs or chapters. Then most of us would be able alter the long-established balance and thus the stoi- to read Hamlet despite hundreds of typos, but the idea chiometry of many components, alias genes, abnormal of Hamlet would be lost very fast, if sentences, para- and defective products must be expected, as for exam- graphs and chapters were rearranged, lost and dupli- ple cars with three wheels or humans with Down syn- cated. drome. The human trisomy 21, which causes Down syndrome, is a classic example [87,255]. Although tri- In sum: The chromosomal theory provides a coher- somy 21 is only a tiny aneuploidy compared to that of ent explanation of carcinogenesis that is independent most cancers [245] (Fig. 2), it generates 71 (!) new, of mutation. Next we show that the chromosomal the- Down-specific phenotypes [183,230]. Likewise, exper- ory can explain each of the many idiosyncratic features imentally induced, congenital aneuploidies generate of carcinogenesis that are paradoxical in view of the numerous abnormal phenotypes in drosophila, plants mutation theory. P. Duesberg et al. / The chromosomal basis of cancer 305 Table 1 Features of carcinogenesis, which are paradoxical according to genetic theories but consistent with the chromosomal theory of cancer Genetic paradox Chromosomal solution 1 Cancer not heritable Aneuploidy is not heritable 2 Non-mutagenic carcinogens Carcinogens function as aneuploidogens 3 Long neoplastic latencies Autocatalyzed evolutions from cancer-initiating to cancer-specific aneuploidies 4 Exact correlation with aneuploidy Specific aneuploidies cause cancer 5 Pre-neoplastic aneuploidy Non-neoplastic aneuploidies that initiate carcinogenesis and evolve toward cancer- causing aneuploidy 6 High rates of karyotypic–phenotypic Aneuploidy catalyzes frequent karyotypic variations: the resulting chromosomal and phe- variations and "immortality" notypic heterogeneity includes subspecies resistant to otherwise lethal conditions 7 Cancer-specific chromosomal alter- Cancer-specific chromosomal alterations generate cancer-specific phenotypes ations 8 Complex phenotypes Cancer-specific aneuploidies alter functions of 1000s of genes via dosages 9 Non-selective phenotypes Non-selective genes hitchhiking with selective, cancer-specific chromosomal alterations 10 No carcinogenic genes in cancer Cancer is caused by specific karyotypes 4. Proof of principle: The explanatory value of the tiplied by the relatively slow, non-selective replica- chromosomal theory of cancer tion of aneuploid, pre-neoplastic cells (see also Section 4.2). The acid test of any theory is its ability to predict and explain a scientific problem. In the following we apply 4.2. Long neoplastic latencies this test to the chromosomal theory of cancer. Table 1 briefly summarizes, how the chromosomal theory ex- According to the chromosomal theory the long neo- plains each of the 10 idiosyncratic features of carcino- plastic latencies from initiation to cancer reflect the times that are necessary to evolve cancer-specific chro- genesis that are paradoxical in terms of conventional mosome alterations from initiating random aneuploi- genetic theories (Section 2). Further commentary is of- dies by autocatalyzed chromosomal variations (Sec- fered in Sections 4.1 to 4.8 on items 1, 3, 4 and 6–10 tion 3 and Fig. 3). of Table 1, which are not self-explanatory on the basis The theory predicts that pre-neoplastic chromoso- of our theory. mal evolutions are slow, because pre-neoplastic aneu- ploidies are typically minor, i.e. are near-diploid, and thus only weak catalysts of chromosomal variation, 4.1. Cancer not heritable and because pre-neoplastic aneuploidy, by definition, has no growth advantages compared to normal cells. The chromosomal theory predicts no cancer in new- Moreover, many non-neoplastic aneuploidies are likely borns and non-identical cancer risks in twins (Section to be fatal due to non-viable chromosome combina- 2.1), because aneuploidy is the initiating cause of can- tions [41,76,118,126,176,245,300] (Fig. 3). Therefore, cer and is not heritable as originally shown by Boveri pre-neoplastic cells would not form large clonal pop- [40]. Aneuploidies are not heritable, because they cor- ulations that would increase the probability of fur- rupt developmental programs [87,255], which is usu- ther evolutions. The non-clonality of the pre-neoplastic ally fatal [118,126]. Only some very minor congenital aneuploidies also hides any abnormal phenotypes, be- aneuploidies, such as Down syndrome and syndromes cause phenotypes of single cells are hard to recog- based on abnormal numbers of sex chromosomes, are nize. sometimes viable, but only at the cost of severe phys- By contrast, the chromosomal theory predicts rela- iological abnormalities and of no, or very low fertility tively short neoplastic latencies in patients with con- [26,104,245,285]. Thus ontogenesis is nature's check- genital aneuploidies and with chromosomal instability point for normal karyotypes. syndromes and thus cancer at young age. This follows, The exponential increase of the cancer risk with age because the number of aneuploid cells is much higher would then reflect the gradual accumulation of non- in these conditions than in normal counterparts (Sec- neoplastic or pre-neoplastic aneuploidy with age, mul- tions 2.5 and 4.8.5). 306 P. Duesberg et al. / The chromosomal basis of cancer Neoplastic "progression" of established cancer cells, man cells may hold a clue to this puzzle [78,83,84,88, however, is predicted to be faster than the chromoso- 168]. The evidence obtained so far, suggests that the mal evolutions during the pre-neoplastic phase for two chromosomal stabilities not only of normal but also reasons: (i) Neoplastic cells, through their selective of cancer cells are species-specific. In view of these phenotypes, will generate large "clonal" populations species-specific chromosomal stabilities Holliday pro- with high probabilities of further variations. (ii) The posed that the genetic control of chromosomal stability high degrees of aneuploidies of most cancer cells cat- is at least two times more redundant in humans than in alyze much higher rates of chromosomal variations rodents [133]. than those of non-neoplastic cells (Fig. 3). The chromosomal theory also predicts a certain endpoint of chromosomal evolutions in carcinogen- 4.3. Pre-neoplastic aneuploidy esis (Fig. 3). This endpoint would be an equilib- rium, at which maximal karyotypic disorganization The chromosomal theory predicts that pre-neoplastic or entropy coincides with maximal variability and aneuploidies are intermediates of the pre-neoplastic adaptability. Karyotypic disorganization and variabil- chromosomal evolutions that eventually generate can- ity are, of course, biologically limited by requirements cer-specific aneuploidy. for essential metabolic functions [47,54,76,265], also termed an "optimized genome" [238]. According to the 4.4. High rates of karyotypic–phenotypic variations chromosomal theory maximal chromosomal variabil- and "immortality" ity would correspond to near or above triploid chromo- some numbers (∼3n) [51,76,228,248]. Near triploid The inherent chromosomal instability of aneuploidy aneuploidy offers an optimal average redundancy of is directly predicted by the chromosomal cancer the- one spare chromosome for each normal chromosome ory. It is confirmed by numerous correlations (Section pair, and thus sufficient redundancy to compensate for 2.6) and is mechanistically linked to aneuploidy by any losses or genetic mutations of a given chromo- the proportionality between the instability and the de- some [76]. Accordingly, the karyotypes of most ma- gree of aneuploidy recently detected by our lab [82, lignant cancer cells are or "converge" [54,131,202] 88]. Further, it is entirely consistent with the criti- at near 3n [13,76,77,81,101,144,155,157,161,165,238, cal observation of Holmberg et al. in 1993 that "an 239,245,253]. increased frequency of sporadic chromosome aberra- Thus malignancy can be seen as a consequence tions was only observed in irradiated cells with aber- of autonomous chromosomal evolutions that increase rant karyotypes and not in irradiated cells with nor- karyotypic entropy to its biological limits – at or mal karyotypes, which suggests that the 'genomic in- near 3n-aneuploidy. The long-established, commer- stability' in these clones is associated with the abnor- cially available human cancer cell lines are models of mal karyotype rather than with the radiation exposure such stably unstable karyotypes with karyotypic en- as such" [134]. tropies close to their biological limits of aneuploidy The chromosomal theory also explains the immor- [47,51,157,238,239,248]. tality of cancer tissues via the diversity of phenotypes However, it is as yet unclear, why the neoplastic that are constantly generated de novo by the inher- latencies are very species-dependent, namely much ent karyotypic instability of aneuploid cells. Owing to shorter (over 10-fold) in rodents than in humans [96, the inherent instability of aneuploidy, populations of 133,158,260,276,286] (Section 2.3). It is also unclear, cancer cells are in fact "polyphyletic" [119] zoos of what makes the age bias of cancer compatible with the chromosomally distinct species (species are defined by lifespan of an animal, i.e. grants cancer-free decades karyotypes, see Section 3). Such populations of can- to humans (Fig. 1), but only a few years to rodents cer cells are relatively "immortal" via subspecies that [45,133]. Differential mutation- or growth rates are can survive mutations or conditions that are lethal to not the answer, because the rates of conventional mu- the majority of the cells of a cancer, as for example cy- tations are highly conserved in all species [167,285] totoxic drugs. By contrast, homogeneous populations and the cells of humans and rodents grow at about the of diploid cells would either all survive or all die in a same rates. Based on recent studies it appears to us given challenging condition. that the low chromosomal stability of aneuploid ro- An early description of the process of "immortal- dent cells compared to that of equally aneuploid hu- ization" by the cytogeneticist Koller matches this ex- P. Duesberg et al. / The chromosomal basis of cancer 307 planation exactly, "It seems that malignant growth is 190,219]. Likewise it explains, why the overproduc- composed of competing clones of cells with different tions of centrosomes by cancer cells are proportional and continuously changing genotypes, conferring the to the degrees of aneuploidy [100,174]. tumor with an adaptable plasticity against the environ- ment. The bewildering karyotypic patterns reveal the 4.7. Non-selective phenotypes multi-potentiality of the neoplastic cell; while normal cells and tissues age and die, through their inherent Conventional genetic theories explain the evolution variability, tumor cells proliferate and survive" [155]. of cancer cells by cancer-specific mutations and Dar- Thus, owing to their cellular heterogeneity cancers sur- winian selections. But this mechanism cannot explain vive negative mutations and cytotoxic drugs via resis- the non-selective phenotypes of cancer cells, such as tant subspecies. metastasis, acquired and intrinsic multidrug resistance and immortality. By contrast, the chromosomal theory of carcinogen- 4.5. Cancer-specific chromosomal alterations esis attributes non-selective phenotypes such as metas- tasis and intrinsic multidrug-resistance to non-selective The presence of specific or "nonrandom" chromo- genes hitchhiking with selective, cancer-causing aneu- somal alterations in cancer is correlative proof for the somies, because they are also located on these chromo- chromosomal theory in terms of Koch's first postu- somes. The same would be true for those resistances of late (Section 2.7). Functional proof that cancer-specific acquired multidrug-resistance that are directed against aneuploidy generates malignancy in terms of Koch's drugs to which the respective cancer was never ex- third postulate could be derived from evidence that the posed. (The non-selective phenotype, immortality, has degree of malignancy is proportional to the degree of been explained in Section 4.4.) nonrandom aneuploidy. Indeed, numerous correlations have confirmed the principle that the degree of malig- In sum: The chromosomal theory explains all fea- nancy of cancer cells is proportional to their degree tures of carcinogenesis that are paradoxical in view of of aneuploidy since 1930 [20,22,34,51,55,76,77,90, the competing genetic theories (Table 1). However, it 91,93,105,120,132,143,149,155,192,196,199,209,249, may still be argued that chromosomal cancer depends 262,275,295,297]. on mutation. Therefore, we analyze this question in the In addition, gene expression in cancer cells is di- next and last chapter of our article. rectly proportional to the gene dosage generated by the respective chromosomal alterations, which indi- 4.8. Is carcinogenesis dependent on mutation? cates that specific aneusomies carry out specific func- tions [2,19,95,178,191,221,283,305]. It is for this rea- Cancer coincides with aneuploidy as well as with son that 1000s of metabolic and structural proteins are mutations [77,102,114,185,248]. In the words of a re- over- or under-expressed in cancer cells [19,49,50,191, cent review in Science, "Cancer cells are chock-full of 219,242] (next section). mutations and chromosomal abnormalities" [185]. Therefore, it can be argued that: 4.6. Complex phenotypes (1) Chromosomal variations are sufficient for car- cinogenesis, as we have proposed here. Conventional genetic theories cannot explain the (2) Mutations are sufficient to cause cancer, as the generation of the complex, polygenic phenotypes of prevailing genetic theories propose (Section 1). cancer (Section 2.8). By contrast, the chromosomal But this argument must await unambiguous evi- theory of cancer explains the complexity of cancer- dence for diploid cancers, which is not available specific phenotypes by the complexity of the genetic now (Section 2.4) [76,77,81]. units that are varied, namely chromosomes with 1000s (3) Mutations are necessary for chromosomal can- of genes. Accordingly, the complex phenotypes of can- cer, as conditional mutation theories propose cer cells have recently been shown to correlate with [114,123,161,163,189,215,226,227,248]. over- and under-expressions of 1000s of genes [2,95, In view of the challenge that chromosomal cancer de- 178,221,283,305] (see also Section 4.5). This in turn pends on mutation, we adduce here 4 arguments, which confirms the long-known over- and under-productions indicate that carcinogenesis (of normal cells in normal of thousands of normal proteins by cancer cells [49,50, organisms) is not dependent on somatic mutation. 308 P. Duesberg et al. / The chromosomal basis of cancer 4.8.1. Initiation of carcinogenesis much more sis error-prone by unbalancing nucleotide pools [66]. probable via direct aneuploidization than via Thus, the simplest explanation of the many mutations mutation of cancer cells would be that these mutations are conse- Initiation of carcinogenesis by aneuploidy, result- quences of aneuploidy and thus not necessary for car- ing from chromosomes that have been fragmented cinogenesis. This hypothesis explains, why mutations or eliminated by mutagenic carcinogens, is about are frequently not detectable [292] or are non-clonal 35,000 times more likely than by aneuploidy resulting in cancers [85,147,180], and why they do not trans- from mutations generating specific "aneuploidy genes" form normal cells to cancer cells, and do not breach the [185] or "chromosomal instability genes" [189]. This livelihood of transgenic mice (Section 2.10 and Box is because mammals contain about 35,000 genes, and 1). Thus mutation of cancer cells is a consequence of thus only 1 in 35,000 specific mutations would gen- aneuploidy, rather than a cause. erate a specific chromosomal instability gene [75,159, 201]. Moreover, non-mutagenic carcinogens can nei- In sum: Based on the roles of chromosomal variation ther generate mutations nor aneuploidy by attack- and mutation in 4 distinct cancer-specific events – ini- ing DNA, because they are not "genotoxic". But, tiation, generation of complex phenotypes, high rates non-mutagenic carcinogens, as for example the poly- of karyotypic–phenotypic variations, and generation of cyclic hydrocarbons, cause aneuploidy by corrupting mutations via aneuploidy (4.8.1–4.8.4) – we conclude the spindle apparatus (Sections 2.2 and 3). Thus initi- that chromosomal carcinogenesis does not depend on ation of carcinogenesis is virtually independent of so- somatic mutation. matic mutation. In response to this conclusion, it may be argued that, at least, the cancers associated with heritable cancer- 4.8.2. Complex phenotypes of cancer much more disposition syndromes depend on mutation (Section probable via chromosomal alteration than via 2.5) – although sporadic cancers do not. In the fol- mutation lowing, however, we show that even the heritable mu- Chromosomal alteration is about 1500-times more tations of cancer-disposition syndromes cause cancers efficient in generating the complex phenotypes of can- only via aneuploidy. cer than mutation. This follows, because mammals, including us, contain about 35,000 genes and thus 4.8.5. Heritable cancer-disposition syndromes also about 1500 genes per average chromosome in humans generate cancer via aneuploidy (35,000/23) [159,201]. Since the rates of chromoso- Retinoblastoma, Xeroderma, Bloom syndrome, Fan- mal variations in aneuploid cells are also many orders coni anemia, Gorlin-syndrome, Ataxia Telangiectasia higher than mutation (Sections 2.6 and 4.8.3), we de- and Mosaic variegated aneuploidy are heritable cancer- duce that carcinogenesis is not dependent on somatic disposition syndromes with mutations that generate mutation for the generation of cancer-specific pheno- high levels of systemic aneuploidy [52,53,99,110, types. 130,135,146,160,178,245,254,263,282,300] and that predispose to high risks for non-systemic cancers 4.8.3. Phenotype variation of cancer cells via with aneuploidy [110,130,153,154,178,245,254,282, chromosomal variation is 4–11 orders faster 300] (see Section 2.5). In other words, these herita- than via mutation ble mutations are genetic equivalents of carcinogens, Chromosomal variation alters cancer-specific phe- which increase the cancer risk by inducing random notypes at rates that are 4 to 11 orders faster than con- aneuploidy at high rates. ventional gene mutation (Section 2.6). Indeed cancer, This view is supported by the presence of sys- based on spontaneous, somatic mutation would practi- temic aneuploidy in patients prior to carcinogene- cally not exist (see Box 1, 3). Thus phenotype variation sis [245], as for example in Mosaic variegated aneu- in cancer cells is independent of mutation. ploidy [110,146], Retinoblastoma and other chromo- 4.8.4. Mutations of cancer cells as consequences of somal eye syndromes [52,135,263], Ataxia Telang- aneuploidy iectasia and Fanconi anaemia [206,300], Bloom syn- Cancer-specific aneuploidy can generate gene mu- drome [99], Gorlin-syndrome [254], and Xeroderma tations by the same mechanism that varies the struc- [53,160,282]. This view is further supported by con- tures of chromosomes, e.g. by unbalancing teams of firmed correlations between aneuploidy and "herita- DNA repair enzymes (Section 3). In addition aneu- ble" cancers of Retinoblastoma- [9,28,97,109,220,222, ploidy is mutagenic, because it renders DNA synthe- 277], Fanconi anaemia- [246], Ataxia- [206], Mosaic P. Duesberg et al. / The chromosomal basis of cancer 309 variegated aneuploidy- [110,146], Xeroderma- [160, (7) What kind of mutation would alter the expres- 299] and Bloom syndrome-patients [99]. We conclude sions and metabolic activities of 1000s of genes, that the abnormally high rates of carcinogenesis in her- which is the hallmark of cancer cells? itable cancer disposition syndromes are dependent on (8) What kind of mutation would consistently co- the abnormally high rates of systemic aneuploidiza- incide with aneuploidy, although conventional tions that are generated by these heritable mutations. gene mutations generate infinite numbers of Thus heritable aneuploidy syndromes confirm and ex- new phenotypes without altering the karyotype? tend the chromosomal theory of carcinogenesis. (9) Why would cancer not be heritable via conven- The hypothesis that systemic aneuploidy defines tional mutations by conventional Mendelian ge- cancer risks is also supported by the epidemiologi- netics? cal studies described above, which have shown that this risk corresponds directly with the degrees of chro- The chromosomal theory, however, offers answers to mosomal aberrations in peripheral lymphocytes (Sec- each of these questions. tion 2.5). Moreover, if confirmed, the chromosomal theory would have revealed the first Achilles heel of can- cer yet: Pre-neoplastic aneuploidy. Pre-neoplastic ane- 5. Conclusions uploidy can be detected in routine biopsies, e.g. Pap smears, cytogenetically and thus offers new chances We conclude that the new chromosomal cancer the- for cancer therapy. Accordingly a prospective can- ory provides a coherent explanation of carcinogenesis cer could be detected and removed prior to, perhaps and can resolve all features of carcinogenesis that are years prior to malignancy via pre-neoplastic aneu- paradoxical in terms of the prevailing genetic theories ploidy. Several long-established, but as yet poorly ap- of cancer. Thus cancer is a disease of chromosomal preciated studies already prove this principle [34,79, disorganization rather than a genetic disease. 233,234]. In response to this conclusion it has been pointed The chromosomal theory could also improve chemo- out by proponents of the mutation theory such as therapy based on the presence or absence of resistance- G. Steven Martin (Berkeley), Manfred Schwab (Hei- specific aneusomies [168,291]. delberg) and Larry Loeb (Seattle) that the chromoso- Thus, if confirmed, the chromosomal theory is likely mal theory overlaps with the mutation theory and that to innovate cancer research and improve treatment. aneuploidy is just another, albeit extreme form of mu- tation. But the following absolute discrepancies be- tween the mutation and chromosomal theories indicate Acknowledgements that these ideas fall in the same gaps that they try to bridge: We thank Tom Bethell (Washington, DC), Harvey (1) How would non-mutagenic carcinogens cause Bialy (Institute of Biotechnology, Autonomous Na- cancer? tional University of Mexico, Cuernavaca, Mexico), (2) What kind of mutation would cause cancer only Alecia DuCharme (UC Berkeley), Siggi Duesberg, after delays of several decades and many cell George Miklos (Secure Genetics Pty Limited, Sydney, generations? Australia) and Rainer K. Sachs (Departments of Math- (3) What kind of mutation would alter the pheno- ematics and of Physics, UC Berkeley) for critical and type of mutant cells perpetually, despite the ab- constructive reviews of the manuscript. R.S. is partic- sence of further mutagens? ularly acknowledged for the preparation of Fig. 1. We (4) What kind of mutation would be able to al- also thank Alfred Boecking (Duesseldorf), Torsten En- ter phenotypes at rates that exceed conventional gelbrecht (Hamburg), Oliver Frank (Mannheim), Juer- gene mutations 4–11 orders of magnitude? gen Langenbach (Vienna), David Rasnick (Pretoria, (5) What kind of mutation would generate resis- South Africa), Albrecht Reith (Oslo), Thomas Ried tance against many more drugs than the one (Bethesda, MD) and Brandt Schneider (Lubbock, TX) used to select it? for valuable information. 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