Cancer Biomarkers: A Marker for Oncology Treatment Success?

Maheen Aslam and Claudia Thiruchelvam Regulatory Affairs Program, Humber College 205 Humber College Boulevard Toronto, ON M9W 5L7

Biomarkers are biological cursors that provide useful information about the body through biological substances in the blood and other bodily fluids. It also includes a broad range of biochemical entities such as nucleic acids, proteins, sugars, lipids and small metabolites, as well as biophysical characteristics of tissues (1, 2). These biomarkers are valuable indications of the presence or absence of a disease, monitoring of disease progression, treatment efficacy, and toxicity of treatment (1). A commonly known biomarker is cholesterol. Cholesterol is a biomarker that, in high levels, is indicative of predicting risk of cardiovascular disease (2). Patients with high cholesterol levels can have this risk mitigated through treatment and the effectiveness of treatment can also be measured by successive cholesterol level checks. This is the typical mechanism through which biomarkers work. In cancer, biomarkers can include substances released by tumour tissue into the body or they can be substances released by the body in response to a tumour as an immune system response (2). Cancer biomarkers are a critical tool in the early detection and effective treatment of cancer, two characteristics that are instrumental in achieving the concept of personalized medicine (3). Different roles of Cancer Biomarkers In recent years, cancer research has seen an increased focus on the discovery and uses of cancer biomarkers (4). During cancer initiation and progression, certain molecules are present in elevated amount in biological fluids and these molecules can serve as effective cancer biomarkers (5) Cancer biomarkers can be diagnostic, prognostic and predictive (5). Diagnostic biomarkers indicate the presence of a particular disease before it can cause symptoms in the body. It helps assess the likelihood of the patient developing cancer, based on indicators like

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genetic mutations or alterations which can affect the risk of developing a certain type of cancer. As an example, women who have a mutation in the BRCA1 or BRCA2 gene have an elevated risk of developing breast cancer (4) which makes the breast cancer type 1/2 protein (BRCA 1/2) the diagnostic cancer biomarker (5). In this case, genetic mutations can also be used as a biomarker for assessing the risk of developing cancer and preventing it by frequently screening patients that have those mutations (2). Biomarkers must have high specificity and sensitivity in order to be a valuable diagnostic tool (5). Prognostic biomarkers, on the other hand, are indicative of the course of a disease and its recurrence, if the patient is left untreated (6). This type of biomarker indicates how the cancer can grow and helps determine how aggressive and targeted its therapy should be (5). It is imperative to consider the variability between individuals when it comes to the levels or alterations of biomarkers because the same type of cancer can have a different outcome in different patients and can influence their response to a given treatment (4). Finally, predictive biomarkers can project a patients response to a drug based on the molecular characteristics of the tumour (5). These biomarkers identify patients into subpopulations of responders and non-responders to particular therapies, thereby allowing doctors to identify the most efficacious type of therapy for the individual, and may potentially assist in determining the effective dose (7). The most common use of biomarkers is for diagnosis and prognosis of cancer, as well as detecting recurrence of cancer (2, 4). One of the best ways to diagnose cancer early, aid in its prognosis, or predict its response to therapeutics is to use serum or tissue biomarkers (5). The best-known cancer marker that has been used to detect cancer early is the prostate-specific antigen (PSA) in the serum of prostate cancer patients. Healthy individuals with PSA between 4.0 ng/ml and 10.0 ng/ml are recommended for biopsy, though it should be noted that elevated

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PSA levels are not always indicative of cancer presence and many individuals undergo unnecessary biopsy due to false positives. A pathological tissue examination, therefore, is still used to clinically diagnose cancer. When it comes to detecting the spread of cancer, PSA levels on their own cannot determine whether it has metastasized; hence, other biomarkers such as thymosin B-15 are used as indications of metastatic prostate cancer. Since PSA levels indicate presence of a tumor, the surgical removal of the prostate or treatment of prostate cancer by radiation reduces the level of PSA in the blood and this reduction of PSA blood levels can be monitored overtime (4). If the level of PSA in blood increases after its initial reduction following the biopsy, then there is a good chance that the cancer has recurred (4). As a result, biomarkers such as PSA are reliable for detecting the recurrence of prostate cancer. Besides the use of PSA as a prostate cancer biomarker, there are no diagnostic or predictive markers for most other tumors, highlighting the need for screening markers that have high specificity and sensitivity (4). Types of Cancer Biomarkers In addition to the various roles of cancer biomarkers, there are three different cancer biomarkers classifications: genetic, epigenetic, and proteomic biomarkers (8). Genetic cancer biomarkers are genetic variations associated with cancer risk, such as chromosomal losses, gains and translocations (8). An example of a genetic biomarker is tumor protein p53 (TP53), which is a protein that acts as a tumor suppressor by regulating cell division. Loss of function of this tumor protein, by allelic loss or mutation, has been identified in advanced stage prostate cancer (8). Epigenetic cancer biomarkers are related to changes in DNA that are not involved with DNA sequence such as DNA methylation, mRNA profiles and chromatin modifications (8). A recent study conducted by Vera L Costa, Rui Henrique, Stine A Danielsen, et al investigated a panel of three epigenetic biomarkers (GDF15, TMEFF2 and VIM) for which methylation levels were

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higher in bladder cancer tissues than in normal bladder tissue, making it an effective biomarker for bladder cancer (9). This panel was found to be a highly specific and sensitive diagnostic biomarker for accurate detection of bladder cancer through urine samples (9). Proteomic biomarkers are related to changes with proteins, including the pattern of proteins that may be associated with cancers (8). These cancer-specific changes in proteins may have diagnostic and prognostic values. An example of a proteomic biomarker is prostate-specific antigen (PSA), which can be used in detection of presence of prostatic tumors and is also indicative of likelihood of post-therapeutic recurrence levels (9,10). Discovering Cancer Biomarkers The approach to cancer, in the absence of an effective treatment, has always been early diagnosis followed by surgical intervention before the cancer has a chance to metastasize, but patients are still diagnosed too late and treated without knowledge of whether their tumor has spread (4). A non-invasive urine or serum marker test is needed, as well as prognostic and predictive cancer biomarkers that can correctly predict the outcome of a specific disease and allow physicians and patients to make informed treatment decisions (4). An important goal behind the discovery of new biomarkers is to help make clinical decisions regarding issues such as need for treatment, surgery, radiation, the depth of surgical intervention, and the use systemic drug therapy (4). The discoveries resulting from implementing these strategies may substantially reduce the burden of cancer by providing prevention, individualized therapies, and improved monitoring following treatment; however, current studies of tumor markers are highly variable (5). New and improved genomic and proteomic technologies such as DNA and tissue microarray, two-dimensional gel electrophoresis, mass spectrometry, and protein assays with advanced bioinformatics tools can be used to develop biomarkers that are accurate and reliable (4, 5).

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However, it should be noted that even though these novel techniques may result in the discovery of new diagnostic markers, few have been approved for use (4). Some of the new strategies for biomarker discovery, as suggested by Kulasingam and Diamandis (2008), include geneexpression profiling which is a technique that can be used to predict the clinical behavior of tumors through DNA microarrays (5). The mass-spectrometry-based profiling assesses proteins released by cancer cells which can be identified through mass-spectrometry and used for diagnostic purposes. The peptidomics approach analyzes low-molecular-weight plasma or serum proteome that have been cleaved from larger proteins and generate a pattern that can be distinguished in patients with cancer. The cancer-biomarker-family approach proposes that if a member of a certain protein family is already an established biomarker, then other members of that family will be good biomarkers as well. Lastly, the secreted protein approach states that secreted proteins should be used as cancer biomarkers since they have the highest likelihood of entering circulation and can be found near the tumor site of origin (5). Impact/Importance of Cancer Biomarkers One of the significant reasons for the interest in biomarkers is their potential to facilitate personalized medicine (2). A good cancer biomarker can be utilized for early detection and targeted therapy and with such applications, eliminate the room for error in treatment effectiveness. However, there are no diagnostic or predictive markers for most types of tumors but there has been an increase in the number of markers being identified that aim to predict cancer outcome rather than to detect it early (5). Cancer biomarkers allow for characterization of diseases in the context of its patient, making personalized medicine a realistic goal. New screening markers that have high specificity and sensitivity are still needed for most cancers (4). Challenges of Cancer Biomarkers

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With cancer biomarkers being a fairly new field of discovery with limited application, there are many challenges associated with discovering a good cancer biomarker. These biomarkers must have two traits in order to provide relevant information concerning the presence, progression, recurrence and treatment of cancers. First, they must have high specificity and high sensitivity (2). Specificity is associated with receiving a positive result only when you have the condition being tested for. With cancer biomarkers, it is a challenge finding biomarkers that are specific to a type of cancer, as many may be associated with other conditions. Sensitivity is the likelihood of the presence of a biomarker in a person with cancer (2). These obstacles are being approached by techniques like using a panel of markers to supply information as opposed to relying on a single biomarker (11). These combined approaches have demonstrated higher specificity and sensitivity levels, and thereby resulting in a more accurate detection of cancer. Another

challenge in cancer biomarkers is tissue accessibility (2). Discovery of cancer biomarkers from easily derived bodily tissues and fluids would be optimal, but at times, research requires tissue samples from tumours, which are usually surgically removed (2). Lastly, another challenge associated with biomarkers is detection tests for biomarkers themselves. Tests to determine the presence biomarkers need to have high specificity, sensitivity, and also provide relevant clinical outcome (2). The designs of tests must also be in a way such that it eliminates the possibility for error: as simple as possible. Future of Cancer Biomarkers According to Brooks (2012), technological improvements in the measurement of biomarkers will ultimately propel the development of cancer biomarkers. As ultra-high-throughput sequencing technology improves and becomes cost-effective, whole genome sequencing of DNA would be able to identify rare, highly penetrant, high-risk alleles for many cancers which could be used to

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tailor cancer screening for individuals at high risk. The sequencing protocols could also be used to investigate the changes in the genome early in the malignant process. Furthermore, a

comparison of the sequences of early and late stage samples of tissues or cells could identify biomarkers associated with progressive disease (prognostic biomarkers). Sequencing of cell-free DNA from the serum or urine samples could be used to identify tumor-derived DNA pieces with mutations, methylation changes, or structural rearrangements that are indicative for specific cancers (12).

References
1) Biomarkers and Targeted Therapy [internet]. 2012 [cited 2012 Dec 6]. Available from: http://www.nccn.com/component/content/article/56-screening/927-biomarkers-and-targeted-therapy.html 2) Research Advocacy Network. Biomarkers in Cancer: An Introductory Guide for Advocates [internet]. 2010 [cited 2012 Dec 6]. Available from:http://researchadvocacy.org/images/uploads/downloads/BiomarkerinCancerReport5_14_reg_med.pdf 3) Committee on Developing Biomarker-Based Tools for Cancer Screening, Diagnosis, and Treatment. "Front Matter." Cancer Biomarkers: The Promises and Challenges of Improving Detection and Treatment. Washington, DC: The National Academies Press, 2007. Available from: http://www.nap.edu/openbook.php?record_id=11892&page=19 4) Chatterjee SK and Zetter BR. Cancer biomarkers: knowing the present and predicting the future. Future Oncology [internet]. 2005 [cited 2012 Dec 6]; 1(1): 37-50. Available from: http://www.futuremedicine.com/doi/pdf/10.1517/14796694.1.1.37 5) Kulasingam V and Diamandis EP. Strategies for discovering novel cancer biomarkers through utilization of emerging technologies. Nature Clinical Practice [internet]. 2008 [cited 2012 Dec 6]; 5(10): 588-599. Available from: http://www.nature.com/nrclinonc/journal/v5/n10/pdf/ncponc1187.pdf 6) Brnner N. What Is the Difference Between Predictive and Prognostic Biomarkers? Can you Give Some Examples? [internet]. 2009 [cited 2012 Dec 6]. Available from: http://www.dako.com/index/knowledgecenter/kc_publications/kc_publications_connection/kc_publications_con nection13-2.htm/28828_2009_conn13__difference_predictive_prognostic_biomarkers_brunner.pdf 7) Biomarkers and Targeted Therapy. [Internet]. 2012 [cited 2012 December 6]. Available from: http://www.nccn.com/component/content/article/56-screening/927-biomarkers-and-targeted-therapy.html 8) Verma M, Patel P, Verma M. Biomarkers in Prostate Cancer Epidemiology. Cancer [Internet]. 2011 [cited 2012 December 6] 3 (4):3773-3798. Available from: http://www.mdpi.com/2072-6694/3/4/3773 9) Costa V L, Henrique R, Danielsen S, Duarte-Pereira S, Eknaes M, Skotheim R I, Rodrigues , Magalhes J S, Oliveira J, Lothe R A, Teixeira M R, Jeronimo C, Lind G E. Three epigenetic biomarkers, GDF15, TMEFF2 and VIM, accurately predict bladder cancer from DNA-based analyses of urine samples. Clin Cancer Res [Internet]. 2010 [cited 2012 December 6] doi:10.1158/1078-0432. Available from: http://clincancerres.aacrjournals.org/content/early/2010/10/23/1078-0432.CCR-10-1312.full.pdf+html 10) Conrads T, Zhou M, Petricoin E, Liotta L,Veenstra T. Cancer Diagnosis Using Proteomic Patterns. Expert Rev. Mol. Diagn [Internet] 2003 [cited 2012 December 6] 3(4): 411-420. Available from: http://home.ccr.cancer.gov/ncifdaproteomics/pdf/ermd.pdf 11) Polanski M, Anderson N L. A List of Candidate Cancer Biomarkers for Targeted Proteomics. Biomarker Insights [Internet]. 2006 [cited 2012 December 6] 2: 1-48. Available from: http://www.plasmaproteome.org/Papers/Candidate%20Cancer%20Markers.pdf 12) Brooks J D. Perspective: Translational genomics: The challenge of developing cancer biomarkers. Genome Res. [Internet]. 2012 [cited 2012 December 6] 22: 183-187. doi:10.1101/gr.124347.111 Available from: http://genome.cshlp.org/content/22/2/183.full.pdf+html

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