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Chemoprevention
Peter Greenwald, MD, DrPH
Gary Kelloff, MD
Cynthia Burch-Whitman
Barnett S. Kramer, MD, MPH

Introduction
The term chemoprevention was coined
18 years ago by Michael Sporn to define
the inhibition or reversal of carcinogenesis by the use of noncytotoxic nutrients
or pharmacologic compounds that protect against the development and progression of mutant clones of malignant
cells.1,2 This approach to cancer prevention recognizes that, in reality, cancer is
not simply caused by a single threshold
event; rather, it is an evolving multistep
molecular and cellular process, namely,
carcinogenesis, which is characterized by
an inapparent period of many years between the initiation of carcinogenesis
and the onset of the invasive and
metastatic phases of the disease.3,4
Carcinogenesis may arise as a result
of chemical, physical, biologic, and/or genetic insults to cells. Specific external
causative factors that may initiate the
process include smoking, occupational
and environmental chemicals, radiation,

Dr. Greenwald is the Director in the Division of

Cancer Prevention and Control of the National
Cancer Institute in Bethesda, Maryland.
Dr. Kelloff is a Branch Chief in the Division of
Cancer Prevention and Control of the National
Cancer Institute in Bethesda, Maryland.
Ms. Burch-Whitman is a Program Analyst in the
Division of Cancer Prevention and Control of the
National Cancer Institute in Bethesda, Maryland.
Dr Kramer is an Associate Director in the Division
of Cancer Prevention and Control of the National
Cancer Institute in Bethesda, Maryland.

Vol. 45 No. 1 January/february 1995

dietary factors, and specific viruses.5 Endogenous compounds such as the steroid
sex hormones may be promoters for cancers of hormone-responsive tissues, including the breast, endometrium, ovary,
and prostate.6,7 In addition, genetic factors have an important influence on an
individuals susceptibility to cancer development.
Because the multistep nature of carcinogenesis includes an initiation step (or
steps) that involves changes at the genetic level followed by a number of promotion and progression steps that lead to
malignancy, opportunities exist for intervention at early as well as later stages of
the process, as indicated in the figure.3,5,8,9 In general, inhibitors of carcinogenesis may be classified by the point in
the carcinogenic process at which they
are effective: (1) compounds that prevent the formation or absorption of carcinogens (initiation); (2) blocking agents
that prevent carcinogens from reaching
or reacting with cellular targets (initiation); and (3) suppressing agents that
suppress the expression of neoplasia in
cells exposed to doses and durations of
carcinogens that otherwise would cause
cancer (promotion). Some inhibitors
have been found to have both blocking
and suppressing capabilities.3,10
Potential chemopreventive agents
being investigated are diverse with respect to source, chemical structure, and
physiologic effects and include micronutrients such as vitamins (e.g., folic acid
31

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Steps in
Carcinogenesis
Exposure to environmental/
external factors
Carcinogen formation,
absorption

Types of
Inhibitors

Inhibitors preventing
formation/absorption
of carcinogens
Blocking agents

Reactions with cellular targets,

DNA damage, mutagenesis
Suppressing agents
Neoplastic manifestations

Diagram of the stages of carcinogenesis and the opportunities that exist for intervention using
chemopreventive agents.

and vitamins A, C, and E); minerals (e.g.,

selenium, molybdenum, and calcium);
natural products (e.g., carotenoids, isothiocyanates, and flavonoids); and synthetics (e.g., vitamin A or D derivatives,
piroxicam, tamoxifen, 2-difluoromethylornithine [DFMO], and oltipraz). The
most widely studied class of chemopreventive agents is the retinoidsnatural
and synthetic derivatives of vitamin A
(retinol).2 Retinoids are potent regulators
of cell differentiation and proliferation in
essentially all epithelia that are sites for
the development of invasive carcinoma.
They also are able to restore some carcinogen-induced premalignant lesions to
a more differentiated state.4,11,12 Much of
the highly successful early preclinical and
clinical work focused on the retinoids.
One retinoid, 13-cis-retinoic acid, has significant clinical potential. This compound
reduces risk of squamous cell skin carcinoma and oral leukoplakia; has been
shown clinically to prevent second primary tumors following initial treatment for
head and neck cancers; is effective in pre32

venting squamous cell carcinoma of the

cervix and skin when administered with
interferon alpha; and is being evaluated
for its ability, alone and in combination
with interferon alpha, to prevent bronchial neoplasia.13

Identifying Candidate
Chemopreventive Agents
EPIDEMIOLOGIC LEADS
Dietary epidemiologic studies have provided the initial leads for the identification of several naturally occurring candidate chemopreventive agents, including
vitamin A, -carotene (provitamin A), vitamin B12, vitamin C, vitamin E, folic
acid, and the minerals calcium and selenium.14-20 The amount and consistency of
data vary considerably, with the epidemiologic evidence supporting a protective
association between foods high in carotene and lung cancer. For example,
studies indicate that individuals who consume large amounts of carrots and green
and yellow vegetablesall rich in vitamin
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A and -caroteneare at significantly reduced risk for lung cancer.18,21 Additional

studies suggest reduced risk for lung,
esophageal, and/or gastric cancer among
individuals with high plasma -carotene
levels, an indicator of -carotene intake.17,18,22,23 The strength of this evidence
has provided the basis for several ongoing
clinical trials to evaluate the efficacy of carotene and retinol, alone or in combination with other chemopreventive
agents, in preventing or modulating precancerous lesions in the oral cavity, lung,
and skin (Table 1). One such clinical trial
is the Alpha-Tocopherol, Beta Carotene
(ATBC) Cancer Prevention Study conducted in Finland.24 Results from this trial, which showed an unexpected higher
incidence of lung cancer among male
smokers who received -carotene, are
described in detail later in this paper in
the discussion of large-scale chemoprevention trials.
Although research evidence supports the potential effectiveness of
retinoids and carotenoids as chemopreventive agents, the epidemiologic studies
do not distinguish the effectiveness of
these substances from the many other
constituents of vegetables and fruits that
may contribute to the potential anticarcinogenic action of these foods. For example, many fruits and vegetables that
appear to reduce cancer risk are also rich
in vitamin C (ascorbic acid) and vitamin
E (-tocopherol).16,17,20 Further, foods
rich in vitamin A and -carotene contain
significant quantities of nonnutritive
compounds, such as indoles, isothiocyanates, organosulfur compounds, glucosinolates, dithiolthiones, terpenes, and
phenolic antioxidants (e.g., ellagic acid),
that exhibit cancer-inhibitory activity in
experimental studies by acting as blocking and/or suppressing agents.3,10,16,20,25
Whether one, several, or all of these constituentsor whether compounds not yet
identified and testedare the primary
chemopreventive agents in fruits and vegetables remains to be determined.
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THERAPEUTIC LEADS
Strategies for cancer therapy also have
provided leads for promising chemopreventive agents. For example, tamoxifen, a
synthetic estrogen, and finasteride, a
testosterone analog, are synthetic compounds that may have potential for preventing breast and prostate cancers, respectively. Controlled clinical trials of
adjuvant tamoxifen used to treat patients
with early-stage resected breast cancer
demonstrated significant reduction in
contralateral breast cancer development,
supporting a clinical role for tamoxifen in
breast cancer prevention.26,27 Finasteride,
which is used for the treatment of benign
prostatic hyperplasia (BPH), inhibits 5reductase, an enzyme that converts
testosterone to 5-dihydrotestosterone
(DHT), the key intraprostatic androgen
that promotes prostate cell and organ
growth.26,28-30 Finasteride significantly reduces prostate volume in men with BPH,
and it has been approved by the US Food
and Drug Administration for treatment
of BPH.31,32 Currently, two trials, described in more detail below, are investigating the chemopreventive potential of
tamoxifen and finasteride.

Targeting Genetic Mechanisms of

Cancer
Understanding the mechanisms that trigger and drive the carcinogenic process is
critical to achieving the goal of prevention
via specific chemopreventive agents. The
study of cancerous tissues has led to the
identification of several genetic alterations
that regulate cell growth and proliferation.
Genetic mutations can activate oncogenes,
which are derived from the normally occurring proto-oncogenes, or inactivate tumor suppressor genes, causing the loss of
control over cell replication and differentiation characteristic of tumor cells.
For some types of cancers, the disease appears to result from an increase in
the number of genetic mutations, mostly
acquired, that accumulate in the genome
33

34

DFMO
4-HPR

Cervix

II
II

II

Patients with cervical intraepithelial neoplasia grade III

Patients with cervical intraepithelial neoplasia grade III

Resected superficial bladder cancer patients

III

DFMO

Patients with previous adenoma

III

Acarbose (-glucosidase)
inhibitor
Calcium carbonate

Bladder

Patients with previous adenoma aged 40 to 80 years

Familial adenomatous polyposis
History of multiple polyposis
Patients with previously resected adenomatous colon
polyps
Subjects at risk for colon cancer

II
II
III
III

Piroxicam
Sulindac
Sulindac
Aspirin

Biopsy negative and PSA 4 ng/ml

Men aged 55 years or older, normal DRE,
PSA 3ng/ml, no prostatic carcinoma

Colon

II
III

4-HPR
Finasteride

III
III

Tamoxifen
4-HPR

Women with atypical ductal hyperplasia, DCIS, or a

familial risk pattern
Women aged 35 years or older at increased risk
Previously resected unilateral stage I/II breast cancer
patients

Population

Prostate

II

Tamoxifen and 4-HPR

Breast

Phase

Agent

Organ

Table 1
Selected National Cancer Institute-Sponsored Clinical Trials

1 year
1 year

1 year

4 years

1 year

3 years
Completed
3 years
3 years

1 year
10 years

10 years
5 years

2 years

Duration

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III
II

III

-carotene
Retinol
4-HPR

-carotene, vitamin E
-carotene and aspirin*

Skin

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Multiple Sites

BCC = basal cell carcinoma

PSA = prostate-specific antigen

DFMO = 2-difluoromethylornithine

SCC = squamous cell carcinoma

DCIS = ductal carcinoma in situ

DRE = digital rectal examination

4-HPR = All-trans-N-(4-hydroxyphenyl) retinamide

Completed
5 years

C l i n

Heavy smokers aged 50 to 69 years (Finland)

Healthy physicians

5 years
5 years
6 months

4 years

4 years

5-10 years

6 months

Duration

Previous BCC or SCC of the skin

Previous BCC of skin; actinic keratosis
Actinic keratosis

Oral leukoplakia

Chronic smokers with prior resected head/neck, lung, or

bladder cancers with bronchial dysplasia
Heavy smokers and asbestos-exposed (men) and
asbestosis patients
Female nurses aged 45 years and older

Population

C a n c e r

*Aspirin part of the trial has been completed.

III

III

-carotene, vitamin E,
aspirin

13-cis retinoic acid,

-carotene, retinol

III

-carotene and retinol

Oral cavity

II

4-HPR

Lung

Phase

Agent

Organ

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Table 2
Some Known or Candidate Tumor Suppressor Genes
and Oncogenes
Gene

Gene Type

APC
DCC
p53
RB1
MYC

TS
TS
TS
TS
ONC

ERBB2
FOS
JUN
HRAS
KRAS2
NRAS

ONC
ONC
ONC
ONC
ONC
ONC

APC = adenomatous polyposis coli

RB1 = retinoblastoma
ONC = oncogene

Cancer Types

Hereditary Syndrome

Colon cancer
Colon cancer
Many cancers
Retinoblastoma
Breast cancer
Colon cancer
Small-cell lung cancer
Breast cancer
Lung cancer
Lung cancer
Pancreatic cancer
Colon cancer
Lung cancer
Other cancers

Familial adenomatous polyposis

Li-Fraumeni syndrome
Retinoblastoma

DCC = deleted in colon cancer

TS = tumor suppressor gene

Adapted from Marx,41 Srivastava and Kramer,42 Prasad et al,43 Schwartz et al,44 and Bos.45

of the evolving cancer cell.33,34 Because

the onset of acquired genetic changes
may occur at several points in the carcinogenic process, they provide possible
targets for successful prevention of neoplastic transformation. Vogelstein et al
have described a model where this hypothesis may be applicable. They demonstrated that the histopathologic changes
associated with the development of colorectal cancer are driven by the progressive accumulation of definable genetic
changes that include the activation of one
or more oncogenes plus the inactivation
of several tumor suppressor genes. These
genetic changes appear to drive the neoplastic progression from normal, healthy
36

epithelium to frank carcinomaa

process that can take decades and that
proceeds from cellular hyperproliferation
to small, benign adenomas to dysplastic,
larger adenomas that can become cancer
and ultimately metastasize.35,36
Whether this paradigm describes
how all or most cancers develop is not
certain. Two newly discovered genes,
hMLH1 and hMSH2, located on chromosomes 3 and 2 respectively, have recently
been linked to a hereditary form of colon
cancer. Neither oncogenes nor tumor
suppressor genes, hMLH1 and hMSH2
play a central role in the DNA repair
pathway. Mutations in these genes result
in an accumulation of genetic errors that
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may increase susceptibility to hereditary

nonpolyposis colon cancer.37,38
One of the earliest genetic changes
described in sporadic (i.e., noninherited)
colorectal cancer appears to involve deletions in chromosome 5. Deletions found
on the same chromosome in the familial
disease have been named mutated in
colon cancer (MCC). Further alterations, usually occurring relatively later in
tumor development, include loss of the
p53 tumor suppressor gene on chromosome 17 and loss of the deleted in colon
cancer (DCC) gene, another tumor suppressor gene, from chromosome 18.39
Mutations in the RAS oncogene (primarily KRAS2) are present in about half of all
intermediate- and late-stage adenomas
and colorectal cancers and also are found
in about 10 percent of small adenomas,
indicating a potentially early event in at
least some colorectal cancers.39,40 Because the pathologic changes associated
with colon cancer usually occur in individuals aged 40 to 70 years, chemopreventive intervention in middle age or
even late adulthood may present an opportunity to reduce the incidence and
mortality of the disease.
Researchers have thus far discovered more than 30 oncogenes and about
10 tumor suppressor genes that appear to
be involved in tumor development41,42;
Table 2 provides a partial list of the genes
associated with more common cancer
types.41-45 Some cancer genes, such as
MYC, HRAS1, and p53, are found in a
variety of tumors, indicating that a common set of genes may trigger or have a
central role in the progression of several
cancers. Preventing mutations in these
and other cancer genes is of great interest
in chemoprevention research, and, as
shown in Table 3,43,44,46,47 several agents
hold promise for the modulation of the
effect of genetic alterations that lead to
cancer. The reliability of these genetic alterations as markers of preneoplastic and
early stages of human cancers is currently
under study in several clinical trials.
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The National Cancer Institute

Chemoprevention Program
From its relatively modest beginning in
the early 1980s, when very few compounds were undergoing either preclinical or clinical testing, the National Cancer
Institutes Chemoprevention Program
has developed into a major effort in
which more than 400 potential chemopreventive agents are being studied, including more than 25 compounds in about 60
ongoing clinical trials. A systematic strategy that includes defined criteria and decision points based on efficacy and safety
data has been developed to track, prioritize, and focus the preclinical and clinical
evaluation of potential chemopreventive
agents. This strategy involves surveying a
broad spectrum of epidemiologic, laboratory, and clinical research for compounds
that demonstrate possible cancer-protective activity; evaluating the biologic effects of these agents in a series of in vitro
and in vivo assays; and assessing the ability of the most promising agents to prevent the onset or progression of neoplasia
in humans.48,49
A staged system for carrying out human intervention trials provides agent
safety and pharmacokinetic profiles
(phase I); develops biologic and biochemical intermediate biomarkers to serve as
surrogate endpoints for cancer and
demonstrates chemopreventive agent efficacy using these surrogate endpoints
(phase II); and demonstrates that the
agent reduces cancer risk or modulates
validated surrogate endpoints in a large
number of subjects over an extended period (phase III). A new strategic componentthe Prevention Trials Decision
Networkwill further streamline management of the growing body of data generated by researchers in the field of
chemoprevention, both nationally and internationally, and facilitate the implementation of large-scale clinical cancer
prevention trials.
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Table 3
Effects of Selected Chemopreventive Agents on Oncogene
Expression or Mutation In Vitro or in Animal Models

Agent

Oncogene

Cancer Cell or Tumor Type

Effect of Agent on
Oncogene Expression
or Mutation

Retinoic acid
Retinoic acid
Retinoic acid
Retinoic acid

MYC
MYC
MYC
MYC

HL-60
F-9
HL-60
Human neuroblastoma

Decreases
Decreases
Increases
No change

Retinoic acid
(plus calcium
ionophore A23187)
Vitamin E
Vitamin E
Vitamin D
Vitamin D
Vitamin D
Retinoic acid
Fucoxanthin
(a carotenoid)
Retinoic acid
Retinoic acid
Vitamin E

MYC

HL-60

Decreases
(synergistic)

MYC
MYC
MYC
MYC
MYC
MYCN
MYCN

B-16
NBP2
HL-60
BALB-3T3
NIH-3T3
Human neuroblastoma
Neuroblastoma

Decreases
Decreases
Decreases
No change
No change
Decreases
Decreases

F-9
F-9
Human, hamster oral
carcinoma cell lines
F-9
B-16
B-16
NBP2
BALB-3T3
NIH-3T3
BALB-3T3
NIH-3T3
1,2-DMH-induced colon tumors

Increases
Increases
Decreases

Retinoic acid
Retinoic acid
Vitamin E
Vitamin E
Vitamin D
Vitamin D
Vitamin D
Vitamin D
Calcium

ERBB2/NEU
FOS
FOS
HRAS
HRAS
HRAS
HRAS
HRAS
HRAS
KRAS
KRAS
KRAS

HL-60 = human promyelocytic leukemia cells

B-16 = murine melanoma cells
BALB-3T3 = murine fibroblasts
DMH = dimethylhydrazine

No change
Decreases
Decreases
Decreases
No change
No change
Increases
Increases
Decreases

F-9 = murine teratocarcinoma cells

NBP2 = murine neuroblastoma cells
NIH-3T3 = murine fibroblasts

Adapted from Prasad et al,43 Schwartz et al,44 Krinsky,46 and Llor et al.47

38

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Table 4
In Vitro Screens for Chemopreventive Agents*
Cell Substrate

Carcinogen

Promoter

Endpoint: Inhibition of

Human lung tumor cells (A427)

None

None

Anchorage independent growth

inhibition

Mouse epidermal cells (JB6)

None

TPA

Anchorage independent growth

inhibition

Rat tracheal epithelial cells

B(a)P

None

Transformed foci or colonies

Mouse mammary
organ culture

DMBA

TPA

Hyperplastic alveolar nodules

Human epidermal keratinocytes

None

TPA

Metabolic cooperation
enhancement

Primary human (foreskin) cells

Propane
sultone

None

Calcium tolerance inhibition

*The Chemoprevention Investigational Studies Unit, Division of Cancer Prevention and Control,
National Cancer Institute.
TPA = 12-O-tetradecanoylphorbol-13-acetate
B(a)P = benzo(a)pyrene
DMBA = 7,12 dimethylbenz(a)anthracene

PRECLINICAL TESTING
Agents chosen to undergo testing by the
NCI are identified by evaluating information from three primary sources: literature searches, input from experts, and
structure-activity analysis.50 Promising
compounds are prioritized initially for in
vitro screening systems (Table 4). Agents
with chemopreventive effect in these preliminary tests are then nominated for one
or more site-specific in vivo chemoprevention models to assess activity against
lung, trachea, colon, mammary, bladder,
prostate, pancreas, lymphatic, and/or skin
cancers (Table 5). In vitro screens also
are used to streamline the process of in
vivo model selection. For example, results of the rat tracheal epithelial cell
transformation assay predict the outcomes in hamster lung and trachea with
an accuracy of about 75 percent.50
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Results from the in vivo assays are

used to prioritize promising compounds
for extended efficacy and for preclinical
safety evaluation. Preclinical safety studies to qualify chemopreventive drugs for
phase I and II clinical trials are generally
the same as for other chronically administered drugs. These studies may include
assessment of acute and subchronic (and,
possibly, chronic) toxicity with pharmacokinetic measurements, effects on reproductive performance, and genotoxicity. Special toxicity tests (e.g., evaluation
of effects on hearing) may be conducted
as warranted by known or anticipated adverse effects of the drug. Compounds
found to have high efficacy and low toxicity at this phase of agent development
generally are assigned high priority for
clinical evaluation. In later stages of development, prior to or during phase II tri39

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als lasting more than one year and multiyear phase III trials, preclinical chronic
toxicity, carcinogenicity, and segment III
reproductive toxicity studies are undertaken, as appropriate.

Biomarkers and Biomarker

Endpoint Trials
BIOMARKERS
The term biomarkers describes the
specific targets of assays that monitor critical biologic aspects of a defined tumor
system.51 Specific markers can serve as
surrogate or intermediate endpoints for
cancer, that is, they represent changes in
the continuum of events between the initiation of carcinogenesis and the final expression of clinically evident disease.52
This biomarker concept is used in the
management of other diseases as well.
For example, cholesterol quantitation is
used to indicate the progression of atherosclerosis as a surrogate in determining
the risk of myocardial infarction.53
Modulation of key markers in the
causal pathway by chemopreventive
agents may be significant in reducing the
risk of consequent cancer occurrence.54-56
Identification and validation of such
markers is important in the design of
large-scale studies because fewer trial
subjects are required to achieve statistical
power and more agents can be evaluated
over less time than by using cancer as the
endpoint.52,54,57 Examples of potential
prevention biomarkers identified include
genetic markers (e.g., nuclear aberrations, such as micronuclei; gene amplification; and mutation); cellular markers
(e.g., differentiation markers and measures of proliferation, such as thymidine
labeling index); histologic markers (e.g.,
premalignant lesions, such as leukoplakia
and colonic polyps); and biochemical and
pharmacologic markers (e.g., ornithine
decarboxylase activity).52 Despite the
identification and investigation of several
potential biomarkers (Table 6),58-60 none
40

of these surrogates has yet been validated

as an accurate predictor of future cancer
incidence.
The development of standardized
biomarkers of intermediate endpoints
that can reveal very early or specific
stages of carcinogenesis and that are sensitive, specific, quantitative, and reproducible is critical to the design of effective
chemoprevention trials.55,57,61,62 When
possible, it is useful to complete a biomarker endpoint study before initiating a
large-scale phase III trial.
BIOMARKER ENDPOINT TRIALS
When the results of phase I safety trials
have determined that an agent can undergo further clinical evaluation, phase II
clinical trialsbiomarker endpoint trialsare conducted to evaluate the agents
biologic effect, generally in subjects at
high risk for specific cancers. The primary
objectives of these trials include identifying biologic and biochemical markers of
cancer that can be used to estimate the
potential for neoplastic progression and
determining whether the chemopreventive agent being tested can affect the incidence of that marker.
Examples of agents currently being
tested in early-stage clinical trials include
all-trans-N-(4-hydroxyphenyl)retinamide, which has been shown to be an
effective inhibitor of chemically induced
mammary, prostate, and bladder tumors
in animal models63; oltipraz, an antiparasitic that may be an effective breast cancer prevention agent and that has chemopreventive activity against lung, colon,
mammary, skin, bladder, pancreas,
forestomach, and liver tumors in animals50,61; and DFMO, an irreversible inhibitor of ornithine decarboxylase that
has demonstrated chemopreventive activity in lung, colon, mammary, and bladder animal tumor models.50 Other recently initiated phase II chemoprevention
trials include a study on piroxicam in a
population at high risk for colon cancer
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Table 5
In Vivo Chemoprevention Screening Systems (Animal Models)*
Organ Model

Species

Carcinogen

Endpoint: Inhibition of

Lung

Hamster

DEN

Adenocarcinoma

Trachea

Hamster

MNU

Squamous cell carcinoma

Colon

Mouse
Rat
Rat
Rat

MAM
AOM
AOM
PhIP

Adenocarcinoma
Adenocarcinoma
Foci of aberrant crypts
Adenocarcinoma

Mammary

Mouse (transgenic)
Rat
Rat

None
MNU
DMBA

Adenocarcinoma
Adenocarcinoma
Adenocarcinoma

Bladder

Mouse

OH-BBN

Transitional cell carcinoma

Skin

Mouse

DMBA/TPA

Papilloma, carcinoma

Pancreas

Hamster

BOP

Adenocarcinoma,
carcinoma

Prostate

Rat

MNU/Testosterone

Carcinoma

Lymphatic

Mouse (transgenic)

None

Lymphoma

*The Chemoprevention Investigational Studies Unit, Division of Cancer Prevention

and Control, National Cancer Institute.
DEN = N,N-diethylnitrosamine
MAM = methylazoxymethanol
PhIP = 2-amino-1-methyl-6-phenylimidazo
[4,5-f] pyridine

MNU = N-methyl-N-nitrosourea
AOM = azoxymethane
DMBA = 7,12-dimethylbenz(a)anthracene
OH-BBN = N-butyl-N-(4-hydroxybutyl) nitrosamine
TPA = 12-O-tetradecanoylphorbol-13-acetate BOP = N-nitroso-bis (2-oxopropyl)amine

and a study on calcium in a population at

high risk for colon cancer.
Although numerous biomarker trials are being carried out, there currently
is no system to record which biomarkers
are being used in these studies and how
results compare among studies. To fill
this gap, a comprehensive biomarker
data base is being established that will
help in the evaluation of surrogate cancer
endpoints in prevention trials and, based
Vol. 45 No. 1 January/february 1995

on this information, subsequently prioritize biomarkers for future applications.

Large-Scale Chemoprevention
Trials
Randomized, large-scale clinical trials
(phase III trials) generally are considered
the best means available to test whether
potential chemopreventive agents, selected by epidemiologic and experimental
41

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Table 6
Potential Cancer Prevention Biomarker Studies
Site

Agent

Population

Biomarker

Breast

4-HPR
DFMO
Ellagic acid
Selenium compounds

Stage I breast cancer

(low risk <10%)

Oncogene expression
Prostaglandins
DNA ploidy
Metaplasia/dysplasia
Incidence

Prostate

Finasteride
4-HPR
DFMO
Limonene

Elevated PSA
PIN
Scheduled for prostate
surgery

PIN, PSA
Ploidy
Nucleolar prominence
Vimentin

Colon

Piroxicam
DFMO*
DHEA*

Previous colonic
adenoma

Cell proliferation
Prostaglandins
Cell differentiation
Ornithine decarboxylase

Bladder

4-HPR
DFMO
Ellagic acid
Molybdate

Previous bladder
papilloma

Papilloma incidence
Oncogene expression
Metaplasia/dysplasia
Quantitative DNA analysis
Ornithine decarboxylase

Cervix

4-HPR

Cervical dysplasia

Dysplasia
Quantitative DNA analysis
Papilloma virus

Lung

Dithiolthiones
DFMO
Molybdate

Smokers

Squamous metaplasia/dysplasia
Micronuclei
Epidermal growth factor
Oncogene expression
Quantitative DNA analysis
Ornithine decarboxylase

Oral

4-HPR
Dithiolthiones
DHEA

Leukoplakia

Metaplasia/dysplasia
Micronuclei

Skin

4-HPR
DHEA
Dithiolthiones

Previous BCC or
SCC, or actinic
keratoses

Incidence

4-HPR = all-trans-N-(4-hydroxyphenyl) retinamide

DFMO = 2-difluoromethylornithine
PSA = prostate-specific antigen
PIN = prostatic intraepithelial neoplasia
DHEA = dehydroepiandrosterone
BCC = basal cell carcinoma
SCC = squamous cell carcinoma
Source of data: Kelloff et al,58 Greenwald et al,59 Kelloff et al.60

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studies, actually do reduce cancer risk.

Such trials are the logical and critical
next step in moving from basic science
to the application of research results for
disease prevention. These trials usually
involve thousands of subjects and multiinstitutional arrangements and can take
10 years or longer to complete. Besides
the incidence of specific cancers, endpoints in phase III chemoprevention trials include intermediate biomarkers as
surrogate endpoints for cancer. The long
duration of these trials allows for confirmation of the limited safety and efficacy
determined in phase I and II studies and
for determination of adverse effects or
agent efficacy not previously detected.64
Large-scale chemoprevention trials
in progress include studies in populations
at high risk for specific cancers as well as
studies in subjects recruited from the general population. Selected examples of
large-scale cancer chemoprevention trials, including trials using micronutrients
and pharmaceutical agents, are described
below.
TRIALS IN HIGH-RISK PATIENTS
Breast Cancer Prevention Trial
Initiated in 1992, the Breast Cancer Prevention Trial is a 10-year study testing the
ability of tamoxifen to prevent the development of breast cancer in healthy
women at increased risk for developing
the disease. Based on previous clinical trial experience with tamoxifen, it has been
estimated that tamoxifen may reduce the
incidence rate of breast cancer in highrisk women by at least 30 percent. This
study is focused on women at high risk for
breast cancer, because the potential benefits of tamoxifen must be weighed
against an increased risk for endometrial
cancer and other possible adverse effects.
For this trial, a womans risk is determined by age, number of first-degree relatives with breast cancer, age at first live
birth, number of benign breast biopsies,
age at menarche, and presence of atypical
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hyperplasia. About 16,000 high-risk

women older than 35 years are being randomized to receive oral tamoxifen (20
mg/day) or placebo for an initial period of
five years.26,27,65
Prostate Cancer Prevention Trial
The Prostate Cancer Prevention Trial is a
large-scale, double-blind, randomized
multicenter trial designed to investigate
the ability of finasteride to prevent the
development of prostate cancer in men
aged 55 years and older.66 Because the
development of early-stage prostate cancer appears to be strongly influenced by
androgens, particularly DHT, the inhibition of DHT synthesis by administration
of finasteride may lead to a significant reduction in the number of individuals who
develop prostate cancer. Half of the approximately 18,000 men in this trial will
receive 5 mg of finasteride orally per day
for seven years; the remaining participants will receive a placebo.
Beta-Carotene and Retinol Efficacy
Trial
The Beta-Carotene and Retinol Efficacy
Trial (CARET) for chemoprevention of
lung cancer in populations at high risk is
an ongoing lung cancer prevention trial
testing the efficacy of the combination of
retinol and -carotene in two high-risk
populations: male and female current and
former heavy smokers and males with extensive occupational asbestos exposure.67,68 This randomized, double-blind
trial compares a placebo with a daily
combination of 30 mg of -carotene and
25,000 units of retinol orally. A critical
design feature of CARET is that the vanguard study participants continued in the
efficacy study. Thus, any toxicity problems that may be due to cumulative doses
of supplements should be evident in these
participants before those recruited for the
full-scale trial. About 4,000 men exposed
to asbestos and 13,600 male and female
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smokers and nonsmokers have been accrued to CARET. Efficacy results are expected at the end of this decade.
Linxian Trials
The Cancer Institute of the Chinese
Academy of Medical Sciences and the
NCI collaborated on two randomized,
double-blind trials to determine whether
daily ingestion of specific vitamins and
minerals or multiple vitamin and mineral
supplements would reduce incidence and
mortality rates for cancer, particularly
esophageal and gastric cardia cancer. The
study was conducted in a high-risk population in Linxian, China, where about 20
percent of adults exhibit esophageal dysplasia, a precancerous lesion.69,70 The
General Population Trial began in 1986
and randomized more than 30,000 individuals according to a one-half replicate
of a 24 factorial design; participants received one or more of four combinations
of supplements at doses equivalent to one
to two times that of the US Recommended Daily Allowances each day for 51/4
years.70 Combinations included retinol
and zinc; riboflavin and niacin; vitamin C
and molybdenum; and -carotene, vitamin E, and selenium.70 The second study,
the Dysplasia Trial, included 3,318 individuals with cytologic evidence of
esophageal dysplasia; subjects were randomized to receive either a placebo or a
daily supplement of 14 vitamins and 12
minerals at two to three times the US
Recommended Daily Allowances for six
years.69
Results of the General Population
Study indicate a significant benefit for
those receiving the -carotene/vitamin
E/selenium combinationa reduction of
13 percent in the cancer death rate, due
largely to a drop of 21 percent in stomach
cancer mortality.70 A statistically significant reduction of nine percent for deaths
from all causes was reported for this
group, which also experienced a notable
but nonsignificant decrease in the inci44

dence of strokes and a decrease of four

percent in deaths from esophageal cancer. The effects of the -carotene/vitamin
E/selenium combination began to appear
within one to two years after the intervention began and continued throughout
the study. The three other combinations
did not affect cancer risk. A nonsignificant reduction of 16 percent in mortality
from esophageal cancer was reported for
the Dysplasia Trial.69 The results are encouraging but may not be directly applicable to Western cultures, which, in contrast to the Linxian community, tend to
be well nourished and not deficient in
multiple micronutrients. Thus, these
compounds need further study in Western populations.
Alpha-Tocopherol, Beta Carotene
Cancer Prevention Study
The ATBC cancer prevention studya
randomized, double-blind, placebo-controlled prevention study conducted in
Finland by the NCI and the National
Public Health Institute of Finlandinvestigated whether daily oral supplementation with -tocopherol (vitamin E), carotene, or both would reduce the
incidence of lung cancer and other cancers.24 In this 2x2 factorial study, 29,133
male cigarette smokers aged 50 to 69
years received either 50 mg of vitamin E
alone, 20 mg of -carotene alone, both vitamin E and -carotene, or placebo daily
for five to eight years. Results of this recently completed trial demonstrate a
minimal (two percent) and not statistically significant reduction in lung cancer incidence in men who received vitamin E.
In contrast, an 18 percent higher incidence of lung cancer was observed
among men who received -carotene;
this result is statistically significant. Men
who took both vitamin E and -carotene
showed an increase in lung cancer incidence similar to those taking -carotene
alone, indicating no significant interaction between the supplements. For canCaA cancer Journal for Clinicians

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cers other than lung cancer, researchers

found that vitamin E reduced prostate
cancer incidence by 34 percent (statistically significant) and colorectal cancer incidence by 16 percent (not statistically
significant). -Carotene had little or no
effect on the incidence of cancers other
than lung cancer. The results indicating
lack of benefit for -carotene coupled
with the possibility of harm are surprising given the large, consistent body of
epidemiologic evidence that suggests dietary -carotene is associated with a lower risk of lung cancer. The length of time
of supplementation may have been too
short to inhibit lung cancer development
in long-term smokers. Also, it is notable

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the primary prevention of cancer and cardiovascular disease in healthy postmenopausal women in the United
States.71,72 Begun in 1992, this study is expected to enroll about 41,000 female
nurses without a history of either cancer
or cardiovascular disease. The design, enrollment methods, and follow-up of the
Womens Health Study are analogous to
the Physicians Health Study, an ongoing
general population trial that is evaluating
the impact of aspirin and -carotene supplementation on the primary prevention
of cancer and cardiovascular disease in
about 22,000 male physicians. The Womens Health Study will use a 2x2x2 factorial design, and participants will be ran-

The field of chemoprevention has progressed to the point

where chemoprevention is now considered to be an extremely
promising approach to the prevention of invasive cancer.
that men in the control group with higher
blood levels of vitamin E or -carotene
before the study was initiated developed
fewer lung cancers. This suggests the
possibility that other constituents of
foods high in vitamin E or -carotene
may be responsible for the protective effect observed in epidemiologic studies.
Additional data from studies that investigate the effects of different supplement
doses and longer follow-up will be required to help resolve the questions that
have surfaced, particularly the question
of whether large doses of -carotene may
be harmful to smokers.
GENERAL POPULATION TRIALS
The Womens Health Study
This randomized, double-blind, placebocontrolled trial will test the risks and benefits of both low-dose aspirin and the antioxidants -carotene and vitamin E in
Vol. 45 No. 1 January/february 1995

domized to treatment or placebo groups

for two years following a three-month
nonrandomized run-in phase.
Womens Health Initiative
Begun in the Fall 1993, the Womens
Health Initiative is a randomized trial to
examine the effects of (1) a low-fat eating
pattern (20 percent of calories from fat)
that is high in fruits, vegetables, and fiber,
(2) hormone replacement therapy, and
(3) calcium supplementation on the prevention of cancer, cardiovascular disease,
and osteoporosis in about 57,000 postmenopausal women of all races and socioeconomic strata. In addition to the
randomized clinical trial, the Womens
Health Initiative will include prospective
surveillance of an additional 100,000
women for etiologic factors and predictors of future illnesses as well as community-based intervention studies that will
seek effective ways to promote behaviors
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aimed at preventing cancer, cardiovascular disease, and osteoporosis.

Targeting Diverse Groups

When developing the study design for a
chemoprevention trial, it is important to
devote considerable care to ensuring that
the study population represents the ultimate target population in terms of race,
ethnicity, and sex. As in other trials, this
may be difficult to achieve in chemoprevention studies. Without an extensive effort involving minority scientists or collaborators, ethnic minority groups tend to
be underrepresented, resulting in potential uncertainty about the significance of
study findings for these groups. Recruitment and retention of appropriate numbers of minorities in clinical trials are essential to help ensure that the data
generated are applicable to the US population as a whole. This principle applies
across the clinical research spectrum,
from small phase I and II trials to the
largest randomized, prospective phase III
trials.
Underrepresentation of minority
groups is not only a problem in chemoprevention research, it is a widespread
problem in all areas of biomedical and
behavioral research and has been attributed to cultural differences in health
beliefs and attitudes as well as socioeconomic barriers.73 The scientific community, including the National Institutes of
Health, is very concerned about this lack
of representation and recognizes that intensive outreach efforts are needed to offer individuals from underrepresented
groups the opportunity to participate in
trials.
Several fundamental steps are essential for a successful outreach approach.
First, the characteristics of the study population must be understood (e.g., socioeconomic status, language, education/literacy level, community structure, cultural
norms, needs and values, and reasons for
seeking health care). Next, explicit re46

cruitment and retention goals must be established. Researchers and health care
professionals must agree on the design
and implementation of recruitment and
retention strategies and must conduct
evaluations to assess the effectiveness of
the strategies. Finally, results of the study
must be disseminated to health care professionals and subjects participating in
the study to recognize them as research
partners. Clear lines of communication
among researchers, health care professionals, and trial participants that promote trust and confidence as well as continuing awareness and understanding of
study progress are vitally important to the
overall outreach effort.
Critical objectives in research on recruitment and retention of underrepresented groups are the identification of
key factors associated with the low numbers of minority participants in clinical
cancer trials and the development of
strategies to mitigate these factors and
ultimately increase the number of minorities who receive state-of-the-art prevention, diagnosis, and treatment interventions. For example, because there is
little information on the impact of social
customs, culture, or economic status on
achieving and maintaining a dietary pattern that reduces fat intake, the Womens Health Trial Feasibility Study in Minorities is evaluating strategies for
recruiting African-American and Hispanic women of diverse socioeconomic
status and enabling these women to
change their eating habits to a low-fat dietary pattern. Endpoints of this study include both the efficacy of recruitment
strategies and adherence to the low-fat
dietary pattern.

Chemoprevention and Future

Medical Practice
The field of chemoprevention research
has progressed to the point where chemoprevention is now considered to be an
extremely promising approach to the preCaA cancer Journal for Clinicians

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vention of invasive cancer. Cancer prevention strategies that use chemopreventive agents have the potential to make a
vital contribution to the reduction of cancer morbidity and mortality through early
intervention for individuals who are at increased risk. The key concept that must
be emphasized is early intervention, that
is, before carcinogenesis or before carcinogenesis progresses to invasive disease, when it still may be halted, slowed,
or reversed.
The importance of early intervention in carcinogenesis can be compared
with the benefits gained by early intervention in the disease process of atherogenesis.74 The significance of arterial precursor lesions such as fatty streaking of
arteries and plaque development as antecedents of symptomatic cardiovascular
disease has been the focus of many studies. In fact, for individuals with arterial
lesions, a chemoprevention approach is
frequently used: cholesterol-lowering, antihypertensive, and antiplatelet agents
are widely prescribed to prevent further
progression of atherogenesis.53,74
As with atherogenesis, the medical
community must recognize the biologic
significance of precursor lesions in carcinogenesis and the importance of the
earliest possible detection of these lesions
so that effective chemopreventive agents
can be used to prevent progression to invasive cancer.4,74 This should be coupled
with public health approaches to reduce

overall population risks. Given this emphasis, the development of new methods
for identifying individuals at increased
risk will be increasingly important. It may
be feasible for clinicians to develop risk
profiles for individuals based on genetic
factors, lifestyle and environmental exposures, a history of a precursor lesion, or
some combination of these that would
provide a rationale for defining specific
interventions to modulate risk.73,75 Further, the identification and validation of
biomarkers that can be used to reveal and
monitor very early or specific stages of
carcinogenesis and that are more sensitive, specific, quantitative, and reproducible than existing biomarkers will be
important for the effective use of chemopreventive agents in clinical trials.57
A major effort in applied chemoprevention research is under way. Our understanding of the biochemical and biologic mechanisms of carcinogenesis and
the identification of a number of chemopreventive agents have made it possible
to develop strategies for clinical intervention in the carcinogenic process that have
the potential to become an integral part
of standard medical practice in the future. Clinicians can play an important
role in identifying those patients who are
at high risk and will benefit from intervention with effective agents for chemoprevention and from participation in clinCA
ical trials.

References
1. Sporn MB: Approaches to prevention of epithelial cancer during the preneoplastic period. Cancer
Res 1976;36:2699-2702.
2. Lippman SM, Hittelman WN, Lotan R, et al:
Recent advances in cancer chemoprevention.
Cancer Cells 1991;3:59-65.
3. Wattenberg LW: Chemoprevention of cancer.
Cancer Res 1985;45:1-8.
4. Sporn MB: Carcinogenesis and cancer: Different
perspectives on the same disease. Cancer Res
1991;51:6215-6218.
5. Weinstein IB: Cancer prevention: Recent
progress and future opportunities. Cancer Res

1991;51:5080s-5085s.
6. Henderson BE, Ross RK, Pike MC, Casagrande
JT: Endogenous hormones as a major factor in
human cancer. Cancer Res 1982;42:3232-3239.
7. Henderson BE, Ross R, Bernstein L: Estrogens
as a cause of human cancer: The Richard and Hinda
Rosenthal Foundation Award Lecture. Cancer Res
1988;48:246-253.
8. Wattenberg LW: Inhibition of chemical carcinogenesis. J Natl Cancer Inst 1978;60:11-18.
9. Garewal HS, Meyskens FL Jr: Chemoprevention
of cancer. Hematol Oncol Clin North Am
1991;5:69-77.
10. Wattenberg LW: Inhibition of carcinogenesis by

Vol. 45 No. 1 January/february 1995

47

C h e m o p r e v e n t i o n

minor anutrient constituents of the diet. Proc Nutr

Soc 1990;49:173-183.
11. Sporn MB, Newton DL: Chemoprevention of
cancer with retinoids. Fed Proc 1979;38:2528-2534.
12. Sporn MB, Roberts AB: Role of retinoids in differentiation and carcinogenesis. Cancer Res
1983;43:3034-3040.
13. Lippman SM, Hong WK: Chemoprevention of
aerodigestive epithelial cancers. Adv Exp Med Biol
1992;320:151-161.
14. Block G, Patterson B, Subar A: Fruit, vegetables, and cancer prevention: A review of the epidemiological evidence. Nutr Cancer 1992;18:1-29.
15. Steinmetz KA, Potter JD: Vegetables, fruit, and
cancer. I. Epidemiology. Cancer Causes Control
1991;2:325-357.
16. Steinmetz KA, Potter JD: Vegetables, fruit, and
cancer. II. Mechanisms. Cancer Causes Control
1991;2:427-442.
17. Dorgan JF, Schatzkin A: Antioxidant micronutrients in cancer prevention. Hematol Oncol Clin
North Am 1991;5:43-68.
18. Ziegler RG, Subar AF, Craft NE, et al: Does
beta-carotene explain why reduced cancer risk is
associated with vegetable and fruit intake? Cancer
Res 1992;52:2060s-2066s.
19. Fontham ETH: Protective dietary factors and
lung cancer. Int J Epidemiol 1990;19(Suppl 1):S32S42.
20. Dragsted LO, Strube M, Larsen JC: Cancer-protective factors in fruits and vegetables: Biochemical
and biological background. Pharmacol Toxicol
1993;72(suppl 1):116-135.
21. Block G: Micronutrients and cancer: Time for
action? (editorial). J Natl Cancer Inst 1993;85:846848.
22. National Research Council, Committee on Diet
and Health, Food and Nutrition Board, Commission on Life Sciences: Diet and Health:
Implications for Reducing Chronic Disease Risk.
Washington, DC, National Academy Press, 1989.
23. Weisburger JH: Nutritional approach to cancer
prevention with emphasis on vitamins, antioxidants, and carotenoids. Am J Clin Nutr 1991;
53:226s-237s.
24. The Alpha-Tocopherol, Beta Carotene Cancer
Prevention Study Group: The effect of vitamin E
and beta carotene on the incidence of lung cancer
and other cancers in male smokers. N Engl J Med
1994;330:1029-1035.
25. Wattenberg LW: Chemoprevention of cancer by
naturally occurring and synthetic compounds, in
Wattenberg L, Lipkin M, Boone CW, Kelloff GJ
(eds): Cancer Chemoprevention. Boca Raton, Fla,
CRC Press, Inc., 1992, pp 19-39.
26. Kramer B, Brawley O, Johnson K, et al: NCI
studies in primary prevention of breast and prostate
cancer: Tamoxifen and finasteride. Cancer Res
Ther Control 1993;3:203-211.
27. Nayfield SG, Karp JE, Ford LG, et al: Potential
role of tamoxifen in prevention of breast cancer. J
Natl Cancer Inst 1991;83:1450-1459.
28. Petrow V: The dihydrotestosterone (DHT)

48

hypothesis of prostate cancer and its therapeutic

implications. Prostate 1986;9:343-361.
29. Moon TD, Sloane BB: Prostatic adenocarcinoma: Carcinogenesis and growth. J Am Geriatr Soc
1989;37:55-64.
30. Grino PB, Griffin JE, Wilson JD: Testosterone
at high concentrations interacts with the human
androgen receptor similarly to dihydrotestosterone.
Endocrinology 1990;126:1165-1172.
31. Stoner E, Bracken RG, Stein EA, et al: The clinical effects of a 5 alpha-reductase inhibitor, finasteride, on benign prostatic hyperplasia. J Urol
1992;147:1298-1302.
32. Imperato-McGinley JL, Cai L-Q, Orlic SD, et
al: Longterm treatment of benign prostatic hyperplasia with the 5-alpha-reductase inhibitor finasteride (MK906). J Urol 1991;145:265A.
33. Weinberg RA: Tumor suppressor genes.
Science 1991;254:1138-1146.
34. Moolgavkar SH, Luebeck EG: Multistage carcinogenesis: Population-based model for colon cancer. J Natl Cancer Inst 1992;84:610-618.
35. Vogelstein B, Fearon ER, Hamilton SR, et al:
Genetic alterations during colorectal-tumor development. N Engl J Med 1988;319:525-532.
36. Vogelstein B, Fearon ER, Kern SE, et al:
Allelotype of colorectal carcinomas. Science
1989;244:207-211.
37. Marx J: New colon cancer gene discovered.
Science 1993;260:751-752.
38. Service RF: Stalking the start of colon cancer.
Science 1994;263:1559-1560.
39. Goyette MC, Stanbridge EJ: Role of tumor suppressor genes in human colorectal cancer, in Steele
VE, Stoner GD, Boone CW, Kelloff GJ (eds):
Cellular and Molecular Targets for Chemoprevention. Boca Raton, Fla, CRC Press, 1992, pp
133-145.
40. Fearon ER: K-ras gene mutation as a pathogenetic and diagnostic marker in human cancer. J
Natl Cancer Inst 1993;85:1978-1980.
41. Marx J: Learning how to suppress cancer.
Science 1993;261:1385-1387.
42. Srivastava S, Kramer BS: Oncogenes in cancer
detection. Contemporary Oncology, April 1992:6372.
43. Prasad KN, Edwards-Prasad J, Kumar S,
Meyers A: Vitamins regulate gene expression and
induce differentiation and growth inhibition in cancer cells: Their relevance in cancer prevention.
Arch Otolaryngol Head Neck Surg 1993;119:11331140.
44. Schwartz JL, Antoniades DZ, Zhao S:
Molecular and biochemical reprogramming of
oncogenesis through the activity of prooxidants and
antioxidants. Ann NY Acad Sci 1993;686:262-279.
45. Bos JL: ras Oncogenes in human cancer: A
review. Cancer Res 1989;49:4682-4689.
46. Krinsky NI: Micronutrients and their influence
on mutagenicity and malignant transformation.
Ann NY Acad Sci 1993;686:229-242.
47. Llor X, Jacoby RF, Teng BB, et al: K-ras mutations in 1,2-dimethyhydrazine-induced colonic

CaA cancer Journal for Clinicians

C A

C a n c e r

C l i n

tumors: Effects of supplemental dietary calcium

and vitamin D deficiency. Cancer Res 1991;51:43054309.
48. Greenwald P, Nixon DW, Malone WF, et al:
Concepts in cancer chemoprevention research.
Cancer 1990;65:1483-1490.
49. Greenwald P, Sondik E, Lynch BS: Diet and
chemoprevention in NCIs research strategy to
achieve national cancer control objectives. Annu
Rev Public Health 1986;7:267-291.
50. Kelloff GJ, Boone CW, Malone W, Steele V:
Recent results in preclinical and clinical drug development of chemopreventive agents at the National
Cancer Institute, in Wattenberg L, Lipkin M,
Boone CW, Kelloff GJ (eds): Cancer Chemoprevention. Boca Raton, Fla, CRC Press, Inc., 1992,
pp 39-54.
51. Mulshine JL, Jett M, Cuttitta F, et al: Scientific
basis for cancer prevention: Intermediate cancer
markers. Cancer 1993;72:978-983.
52. Pillai R, Garewal HS, Wood S, Watson RR:
Biological monitoring of cancer chemoprevention.
J Surg Oncol 1992;51:195-202.
53. Manson JE, Tosteson H, Ridker PM, et al: The
primary prevention of myocardial infarction. N
Engl J Med 1992;326:1406-1416.
54. Malone WF, Kelloff GJ, Boone C, Nixon DW:
Chemoprevention and modern cancer prevention.
Prev Med 1989;18:553-561.
55. Kelloff GJ, Malone WF, Boone CW, et al:
Intermediate biomarkers of precancer and their
application in chemoprevention. J Cell Biochem
Suppl 1992;16G:15-22.
56. Greenwald P, Light L, McDonald SS, Stern HR:
Strategies for cancer prevention through diet modification. Med Oncol Tumor Pharmacother 1990;
7:199-208.
57. Lippman SM, Lee JS, Lotan R, et al:
Biomarkers as intermediate end points in chemoprevention trials. J Natl Cancer Inst 1990;82:555560.
58. Kelloff GJ, Malone WF, Boone CW, et al:
Progress in applied chemoprevention research.
Semin Oncol 1990;17:438-455.
59. Greenwald P, Witkin KM, Malone WF, et al:
Study of markers of biological effect in cancer prevention research trials. Int J Cancer 1992;52:189196.
60. Kelloff GJ, Boone CW, Steele VE, et al:
Progress in cancer chemoprevention: Perspectives
on agent selection and short-term clinical intervention trials. Cancer Res 1994;54:2015S-2024S.
61. Kelloff GJ, Boone CW, Crowell JA, et al:
Chemopreventive drug development: Perspectives
and progress. Cancer Epidemiol Biomarkers Prev
1994;3:85-98.
62. Boone CW, Kelloff GJ: Intraepithelial neopla-

Vol. 45 No. 1 January/february 1995

1 9 9 5 ; 4 5 : 3 1 - 4 9

sia, surrogate endpoint biomarkers, and cancer

chemoprevention. J Cell Biochem Suppl 1993;17F:
37-48.
63. Pienta KJ, Nguyen NM, Lehr JE: Treatment of
prostate cancer in the rat with the synthetic retinoid
fenretinide. Cancer Res 1993;53:224-226.
64. Goodman GE: The clinical evaluation of cancer
chemoprevention agents: Defining and contrasting
phase I, II, and III objectives. Cancer Res
1992;52:2752s-2757s.
65. Fisher B: Experimental and clinical justification
for the use of tamoxifen in a breast cancer prevention trial: A description of the NSABP effort. Proc
Annu Meet Am Assoc Cancer Res 1992;33:A567A568. (Abstract)
66. Brawley OW, Ford LG, Thompson I, et al: 5alpha-Reductase inhibition and prostate cancer
prevention. Cancer Epidemiol Biomarkers Prev
1994;3:177-182.
67. Goodman GE, Omenn GS, Thornquist MD, et
al: The Carotene and Retinol Efficacy Trial
(CARET) to prevent lung cancer in high-risk populations: Pilot study with cigarette smokers. Cancer
Epidemiol Biomarkers Prev 1993;2:389-396.
68. Omenn GS, Goodman GE, Thornquist MD, et
al: The Carotene and Retinol Efficacy Trial
(CARET) to prevent lung cancer in high-risk populations: Pilot study with asbestos-exposed workers. Cancer Epidemiol Biomark Prev 1993;2:381387.
69. Li JY, Taylor PR, Li B, et al: Nutrition intervention trials in Linxian, China: Multiple vitamin/mineral supplementation, cancer incidence,
and disease-specific mortality among adults with
esophageal dysplasia. J Natl Cancer Inst 1993;
85:1492-1498.
70. Blot WJ, Li JY, Taylor PR, et al: Nutrition intervention trials in Linxian, China: Supplementation
with specific vitamin/mineral combinations, cancer
incidence, and disease-specific mortality in the general population. J Natl Cancer Inst 1993;85:14831492.
71. Buring JE, Hennekens CH: The Womens
Health Study: Summary of the study design. J
Myocardial Ischemia 1993;4:27-29.
72. Buring JE, Hennekens CH: The Womens
Health Study: Rationale and background. J
Myocardial Ischemia 1993;4:30-40.
73. Daly MB: The chemoprevention of cancer:
Directions for the future. Cancer Epidemiol
Biomarkers Prev 1993;2:509-512.
74. Sporn MB: Chemoprevention of cancer. Lancet
1993;342:1211-1213.
75. Shields PG, Harris CC: Molecular epidemiology
and the genetics of environmental cancer. JAMA
1991;266:681-687.

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