Bacterial infection and cancer
In the last century, cancer research thoroughly established the role of major carcinogenic agents of different nature, including infectious agents. However, although there is a general agreement that some viruses, such as hepatitis B virus (HBV), Epstein-Barr virus (EBV) and human papilloma virus (HPV) can cause cancer, the involvement of bacteria in carcinogenesis remains controversial. The role of viral infections in tumor onset is widely accepted because of the direct action of single viral genes (oncogenes) that result in cell transformation [
1]. By contrast, the molecular mechanism(s) by which bacteria might promote tumorigenesis are still poorly characterized. Hence, one of the main challenges, nowadays, is to define the impact of bacterial infections as a cause of cancer and eventually design strategies for their prevention and control.
Bacterial infections are usually believed to cause acute diseases, but it is now becoming clear that some bacteria can contribute to the establishment of chronic diseases, including cancer [
2]. The concept that bacterial infection could be involved in carcinogenesis was first proposed in the late nineteenth and early twentieth centuries, based on the discovery of bacteria at the sites of tumors, although there was no proof that the bacteria were in any way causative [
3]. Since then, the putative link between chronic infection and cancer acquired a widespread interest with the discovery that
Helicobacter pylori is able to establish chronic infections in the stomach and that this infection is associated with an increased risk of gastric adenocarcinoma [
4] and mucosa associated lymphoid tissue (MALT) lymphoma [
5]. In this context, it is worth noting that
H. pylori is classified as a class I carcinogenic factor [
6]. Other chronic bacterial infections have been linked to human carcinogenesis although the underlying mechanisms remain to be defined (reviewed in [
2]). The strongest epidemiological case is for
Salmonella enterica serovar typhi (
S. typhi), the agent of typhoid, which can also lead to chronic bacterial carriage in the gallbladder [
7‐
11]. Surveys of typhoid outbreaks have shown that those who become carriers have an increased risk of developing hepatobiliary carcinoma compared with people who have had acute typhoid and have cleared the infection [
9].
A recurring theme in the link between bacterial infection and carcinogenesis is that of chronic inflammation, which is often a common feature of persistent infection [
2,
12]. One of the key molecules that link chronic inflammation and cancer is represented by the NF-kB family of transcription factors [
12,
13]. In particular, different mouse studies provide strong and direct genetic evidence that the classical, IKK-β dependent NF-kB activation pathway is indeed a crucial mediator of tumor promotion [
14‐
16]. This pathway is triggered by bacterial and viral infections, as well as by pro-inflammatory cytokines, such as TNF-α and IL-1, all of which activate the IKK complex [
17]. This complex phosphorilates the NF-kB inhibitors IkBs, thereby targeting them for proteosomal degradation and freeing NF-kB to enter the nucleus and mediate transcription of target genes. It is worth noting that many of the genes able to mediate alterations characterizing a tumor cell are under the transcriptional control of NF-kB (reviewed in [
18,
19]). For example, the activity and expression of cyclin D1, CDK2 kinase, c-myc, p21, p53 and pRb, which are involved in the control of cell cycle and are altered in several types of cancer, are NF-kB-dependent. The expression of numerous cytokines, that are growth factors for tumor cells (IL-1β, TNF, IL-6, EGF) are also regulated by NF-kB. Tissue invasion and metastasis, two crucial events of tumor progression, are regulated by NF-kB-dependent genes, including metalloproteases (MMPs), urokinase type of plasminogen activator (uPA), IL-8, the adhesion molecules VCAM-1, ICAM-1 and ELAM-1. NF-kB is also involved in the regulation of angiogenesis, the process by which tumor cells promote neo-vascularization. Finally, altered expression of genes involved in suppression of apoptosis (i.e. Bcl-2 family members and IAP proteins), a key feature of cancer cells, is often due to deregulated NF-kB activity.
Concerning this last point, several pathogenic bacteria, particularly those that can establish a persistent intracellular infection, activate NF-kB in the host cell and suppress cell death, thus creating a niche in which the bacterium can survive, in spite of the attempts of the host immune system to destroy the infected cell [
20]. As a consequence, the suppression of apoptosis by a pathogen might also allow a partially transformed cell to evade the self-destructive process and to progress to a higher level of transformation.
Another important feature of inflammation-associated cancer is the production of reactive oxygen species (ROS) and nitric oxide (NO) by inflammatory and epithelial cells. This leads to increased mutations and altered functions of important enzymes and proteins in inflamed tissue, thus contributing to the multistage carcinogenetic process [
21]. For example, during a chronic
H. pylori infection, production of ROS and nitroxides and the associated inflammatory response are assumed to contribute to the induction of a gastric carcinogenic process [
22,
23]. These chemical species are mainly produced by inflammatory cells to fight infection and are source of oxidative DNA damage, thus contributing to carcinogenesis [
22,
23]. In particular, it has been demonstrated that within 6 hours,
H. pylori infection had a mutagenic effect on gastric epithelial cells [
24]. The major form of oxidative DNA damage is the formation of 8-oxoG lesions, specifically repaired by the OGG1 DNA glycosylase. The inactivation of this enzyme inhibits the level of inflammatory lesions and abolishes the mutagenic effect induced by the infection at the gastric level, thus strengthening a close relation between chronic inflammation and genotoxicity [
24].
Bacterial toxins and cancer
As stated above, there is increasing evidence that some pathogenic bacteria can contribute to specific stages of cancer development. In particular, chronic infections triggered by bacteria can facilitate tumor initiation or progression since, during the course of infection, normal cell functions can undergo the control of factors released by the pathogen [
2]. These bacterial factors, namely virulence factors, can directly manipulate the host regulatory pathways and the inflammatory reaction [
3].
Bacteria express a wide range of virulence factors, including protein toxins that have evolved to interact with eukaryotic cellular machinery in a precise way. These toxins interfere with key eukaryotic processes, such as cellular signaling components, and some directly attack the genome [
25‐
27]. These last can damage DNA via different mechanisms: i) directly by enzymatic attack, ii) indirectly by provoking an inflammatory reaction that produces free radicals, or even iii) by affecting DNA repair mechanisms. Nougayrède and colleagues [
28] have recently identified a novel hybrid peptide-polyketide compound from
Escherichia coli that leads to DNA damage. This novel compound is produced by pathogenic and, most interestingly, commensal isolates. Although it is not yet clear how the peptide-polyketide compound functions at the molecular level, it is possible that it contributes to bacterial pathogenesis and bacterially-induced carcinogenesis.
Any bacterial product that interferes with signaling, resulting in the disruption of the normal balance of growth, cell division and apoptosis, could facilitate tumor promotion. Similarly, the ability to promote anchorage-independent growth could favor metastatic potential and lead to cancer progression. So far, the best example of potentially carcinogenic toxin is
H. pylori CagA that interferes with cellular signaling mechanisms in a way that is characteristic of tumor promoters. Indeed, CagA intracellularly interacts, in a phosphorylation-dependent and independent way, with many host proteins that regulate cell growth, motility and polarity, thus leading to gastric epithelial proliferation, cell-cell dissociation and increased cell scattering and motility (for a review [
29]). In particular, Bagnoli and coworkers [
30] showed that CagA is sufficient to disrupt the mechanisms that maintain normal epithelial differentiation, including cell adhesion, cell polarity, and the inhibition of migration. Since the cellular behavior induced by CagA is reminiscent of oncogenes that disrupt cytoskeletal signaling, the authors proposed that altered cell-cell and cell matrix interactions may serve as an early event in
H. pylori-induced carcinogenesis [
30]. Very recently, in experimental studies dealing with
H. pylori strains carrying or not CagA, it has been demonstrated that this factor activates host cell survival and anti-apoptotic pathways to overcome self-renewal of the gastric epithelium, thus enhancing bacterial colonization of the stomach and helping sustained
H. pylori infection. In this context, it is interesting to note that, patients infected with
H. pylori encoding the
cag pathogeniticy island (PAI) are associated with an increased risk of gastric cancer [
31].
In addition to the link between
H. pylori and stomach cancers, very recent studies evidenced that some other toxins may contribute to bowel and urogenital tract cancers [
3]. In this context, it has been reported that adherent and invasive strains of
Escherichia coli are a risk factor for patients with pre-cancerous and cancerous colon diseases [
32,
33]. Interestingly, in one of these studies, 3 out of 8 cancer-associated
E. coli were reported to possess the cytotoxic necrotizing factor 1 (
cnf1) gene [
32], the gene coding for the protein toxin CNF1. The aim of this review is to highlight the main cell responses to CNF1, particularly those related to signaling pathways linked to inflammation and to cell transformation.