Potentially Functional SNPs (pfSNPs) as Novel Genomic Predictors of 5-FU Response in Metastatic Colorectal Cancer Patients

5-Fluorouracil (5-FU) and its pro-drug Capecitabine have been widely used in treating colorectal cancer. However, not all patients will respond to the drug, hence there is a need to develop reliable early predictive biomarkers for 5-FU response. Here, we report a novel potentially functional Single Nucleotide Polymorphism (pfSNP) approach to identify SNPs that may serve as predictive biomarkers of response to 5-FU in Chinese metastatic colorectal cancer (CRC) patients. 1547 pfSNPs and one variable number tandem repeat (VNTR) in 139 genes in 5-FU drug (both PK and PD pathway) and colorectal cancer disease pathways were examined in 2 groups of CRC patients. Shrinkage of liver metastasis measured by RECIST criteria was used as the clinical end point. Four non-responder-specific pfSNPs were found to account for 37.5% of all non-responders (P<0.0003). Five additional pfSNPs were identified from a multivariate model (AUC under ROC = 0.875) that was applied for all other pfSNPs, excluding the non-responder-specific pfSNPs. These pfSNPs, which can differentiate the other non-responders from responders, mainly reside in tumor suppressor genes or genes implicated in colorectal cancer risk. Hence, a total of 9 novel SNPs with potential functional significance may be able to distinguish non-responders from responders to 5-FU. These pfSNPs may be useful biomarkers for predicting response to 5-FU.


Introduction
Every year, more than one million individuals worldwide will develop colorectal cancer [1], accounting for 10% of the global cancer burden. Colorectal cancer (CRC) is the most frequently diagnosed cancer in Singapore (7,909 new cases between 2005-2009) [2]. More than half of CRC patients develop metastatic disease (stage 4) either at diagnosis or at relapse following initial curative intent therapy. This translates to a substantial proportion of patients who may need treatment for the metastasis or relapse of colorectal cancer. 5-fluorouracil (5-FU) and its pro-drug, Capecitabine, are widely used in treating CRC. It has been proposed that there are two distinct modes of action for 5-FU. First, it acts as anti-metabolite whereby its active form, FdUMP, produced by Thymidine Phosphorylase (TYMP), inhibits Thymidylate Synthase (TYMS). Second, it can induce cell death, whereby incorporation of its active products FUTP and FdUTP into RNA and DNA, respectively, leads to subsequent cell apoptosis [3]. Uridine Monophosphate Synthetase (UMPS, also known as OPRT) is responsible for converting 5-FU to FUMP, which is the first step of producing FUTP and FdUTP. However, the two pathways may overlap, because the intermediate product in the ''cell toxicity'' pathway, FUDP, may also be converted to FdUDP and subsequently FdUMP and participate in the ''anti-metabolite'' pathway. 5-FU is catabolized into the inactive form of DHFU by Dihydropyrimidine Dehydrogenase (DPYD), and DPYD is the rate-limiting enzyme in degrading 5-FU.
At present, there are no reliable tests for early prediction of response to 5-FU. Developing a reliable early predictive biomarker of response to common chemotherapy, like 5-FU, in metastatic colorectal cancer has the potential to lead to appropriate tailoring of treatment for individual patients and help move us closer to a truly personalized care. Overall economic cost benefits are realized in both predicted responders and non-responders. Responders get appropriate treatment with confidence of anticipated response.
Predicted non-responders to conventional treatment avoid wasted expense of 3 cycles of futile treatment, unnecessary toxicities that themselves require remedies and time loss in terms of futile treatment and loss of a window of opportunity for effective treatment. These patients may be selected as candidates for novel therapies and combination chemotherapy.
It was interesting to note that the variants in the ''5-FU PK'' genes were mainly investigated for their association with 5-FU toxicity, not efficacy [14][15][16][17], despite the expression levels of these genes having been previously associated with 5-FU efficacy [18]. Limited efforts [8,19] attempted to explore the possible association for efficacy, but failed.
Furthermore, most studies on response to 5-FU treatment focused primarily on SNPs in a few candidate genes. Only one study examined 21 variants primarily in coding region of 11 genes involved in metabolism/action of 5-FU and other related pharmacological pathways [19]. However, this study still does not comprehensively interrogate all possible variants that may be involved in 5-FU response.
Another limitation of current studies is that only univariate analyses have, thus far, been employed and this may not have sufficient power for detection of association of drug response with less common/rare SNPs with small sample size. Multivariate model was successfully employed to estimate the appropriate dose of warfarin based on clinical and genetic data [20].
Hence, in this study, we employ a novel approach interrogating potentially functional SNPs (pfSNPs) in relevant drug and disease pathway to identify association with drug response. 1,547 potentially functional SNPs+1 VNTR (Variable Number Tandem Repeat) from 139 genes in the drug (both PK and PD pathway) and disease pathways were examined. Potentially functional SNPs were identified using the pfSNP Web Resource (http://pfs.nus. edu.sg/) [21] which included SNPs that were previously reported to be functional or associated with disease/drug response; SNPs that were inferred to be potentially functional from genetic approaches as well as those predicted to be potentially functional from sequence motifs.
As the number of samples was limited, a two-step study design was employed. In the first stage, we examined 62 patients who were only on Capecitabine, a pro-drug of 5-FU, to identify interesting SNPs that are marginally associated with drug response as measured by tumor shrinkage. These SNPs were then examined in another group of 27 patients who were treated with 5-FU and oxaliplatin. Combined Multivariate and Collapsing (CMC) analysis was employed to evaluate the less common (#5%), nonresponder-specific pfSNPs for their association with 5-FU drug response while a logistic regression based multivariate model using stepwise Akaike Information Criterion (stepAIC) procedure was used to interrogate the other pfSNPs for their association with 5-FU drug response in patients that do not carry the non-responderspecific pfSNPs.

Patient samples and clinical parameters
The shrinkage of liver metastatic CRC tumour was used as the clinical endpoint for measuring treatment efficacy. Response Evaluation Criteria In Solid Tumours (RECIST) [22] is used to determine tumour response. In the patients recruited, there was no patient belonging to the 'Complete Response' category. Patients with 'Partial Response' were deemed as 'Responders' and patients with 'Progressive Disease' or 'Stable Disease' were classified as 'Non-Responders' in the association analysis.
A total of 89 unrelated Chinese metastatic CRC patients were recruited. All patients had liver metastasis and were given neoadjuvant chemotherapy prior to operation for the liver lesion. Table 1 shows the characteristics of the patients in each study.
In group 1, 62 unrelated Stage IV CRC Chinese patients were recruited. These patients were treated with only Capecitabine and they have never been previously exposed to this drug. Of these 62 patients, 13 had partial response, 31 had stable disease, and 18 had progressive disease. Hence, the response rate of this group of patients is only ,21%, which is typical for single-agent treatment [23]. ,79% of the patients were male, and the median age of the cohort was 60 years.
In group 2, 27 unrelated Chinese liver metastatic CRC patients who were treated with 5-FU (a few had Capecitabine) alone (a few) or with oxaliplatin regime (most) as their neo-adjuvant chemotherapy were examined. Some of these patients had also been previously exposed to these drugs. Of these 27 patients, 12 had partial response, seven had stable disease, and eight had progressive disease. Hence, the response rate was ,45%, which is typical for patients undergoing 2-drug combination therapy [24]. Two-thirds of these patients are males, and had a median age of 62 years.

Ethics statement
This study has been approved by Singhealth

Selection of potentially functional SNPs (pfSNPs) for association study
The pfSNP resource (http://pfs.nus.edu.sg/) [21] was employed to identify SNPs in genes associated with 5-FU/Capecitabine, oxaliplatin as well as colorectal cancer. Approximately 2800 pfSNPs in 214 genes were found to be associated with keywords including ''fluorouracil'', ''5-fluorouracil'', ''capecitabine'', ''platinum'', ''oxaliplatin'' as well as ''colorectal cancer''. As only 1,536 SNPs can be genotyped within a single customized GoldenGate Genotyping Array (Illumina, Inc), the following criteria were employed to select a subset of these 2800 pfSNPs: all SNPs within the promoter, coding, 59/39 un-translated regions which has a GoldenGate Score (GGS: measure of assay quality by their platform) of greater than 0.5 were selected. For the introns, pfSNP with a GGS.0.7 were selected and monomorphic ones reported in HapMap CHB population were excluded, except for those previously reported as functional. For any adjacent SNPs that may interfere with each other in the assay, we selected the SNP according to the following order: ''Previously reported R Non-Synonymous R Synonymous R UTR R Intron''. A list of all of the SNPs included on the GoldenGate array is available as Table  S1.
Among the markers that were unsuitable to be genotyped by GoldenGate assay, 14 important markers in 5-FU response prediction were selected to be genotyped by other methods (listed in Table S2). The 14 markers include the previously well studied VNTR with embedded SNP [25] as well as the 6bps 39 UTR indel in the TYMS gene because GoldenGate technology could only genotype SNPs. Other markers are SNPs with low GoldenGate scores in the TYMS, TYMP and DPYD genes. A customized Sequenom's MassARRAY panel was used to genotype 11 of the 14 markers and 1 SNP was genotyped by ABI TaqMan. In addition, we developed a novel method to genotype the VNTR (rs2853542) and embedded SNP (rs34743033) in the TYMS gene. This VNTR can have either 2 or 3 repeats, and the SNP can occur in both the second and third repeat [26]. We developed a robust method using Sanger Sequencing for this purpose. A fragment of 486 bp was amplified using the primers (F-CTGCTGGCTTA-GAGAAGGCG and R-AGCGGAGGATGTGTTGGATC) and the amplicon was sequenced in both directions using the forward and reverse primers. Different genotypes would yield distinct patterns on the forward and reverse sequencing reads (As shown in Figure S1), allowing the genotype to be easily deduced.
The distribution of the SNPs and genes selected in the three categories (CRC, Fluorouracil and Platinum related) is depicted in Figure S2. More than half of the SNPs (863) are from fluorouracil-related genes and 702 SNPs are from platinumrelated genes. A considerable portion of the SNPs (656) are from CRC-related genes, although 40% (32 out of 80) of these genes and 88% (579 out of 656) of the SNPs are related to fluorouracil and/or platinum as well.
The numbers of SNPs in each gene region and function category covered in this study are shown in Figure S3. Each of the four gene regions, namely promoter, coding, intron and 39 UTR, are adequately covered in general. For promoter and 39UTR, most of the SNPs genotyped are those that change TF binding sites. In the coding region, SNPs that change ESE/ESS sites are the most abundant, and non-synonymous SNPs that cause deleterious effects are the second most abundant. The intron region SNPs are enriched with those with a signature of recent positive selection.
The distribution of SNP minor allele frequency for the intronic versus non-intronic region is shown in Table S3. For coding, 39UTR, and promoter regions, a number of SNPs not previously genotyped by HapMap has been genotyped in this study. As the study aims to also explore rare variants, a number of SNPs reported by HapMap to be monomorphic was also genotyped. For the intron region, since most of the SNPs are those with a signature of recent positive selection, they have MAF more than 5%. We did not genotype many monomorphic ones within introns.

Single marker association analysis
Hardy-Weinberg equilibrium and minor allele frequency were analysed using the Microsoft Excel-based SNP Statistics Calculator developed in-house. Single marker association analysis was performed using PLINK [27]. The P-value was calculated by the permutation-based method, and the Odds Ratio (OR) and corresponding 95% confidence interval were determined using regular allele-based association analyses, because the permutationbased method does not provide such information. The genotype of the VNTR (rs2853542) and embedded SNP (rs34743033) in the TYMS gene is re-coded as a bi-allelic SNP comprising the highexpression allele and the low-expression allele according to Kawakami et al [26].

Combined Multivariate and Collapsing (CMC) analyses for non-responder-specific SNPs
Combined Multivariate and Collapsing (CMC) method was first proposed as a method for analysing rare SNPs [28]. CMC utilizes Hotelling's T 2 test to analyse more than 2 groups of collapsed variants. When only 2 groups of such variants are analysed, Fisher's exact test can be used. In this study, we used the Fisher's Logistic regression based multivariate model using Akaike Information Criterion (stepAIC) procedure to predict drug response in patients who do not have nonresponder-specific SNPs Patients, who do not have any of the non-responder specific SNPs, were divided into 2 groups. Data from the first group comprising 80% of the patients was used to train a logistic regression based multivariate model by using the Akaike's Information Criterion (AIC) in a stepwise algorithm (using R package ''stepAIC'') while the data from the other 20% of patients were used to validate the model. The selected model was evaluated by the Area Under the Curve (AUC) of the Receiver Operating Characteristic (ROC) curves. The optimal cut-off point for the logistic regression was chosen where the maximum sum of sensitivity and specificity is obtained [29,30].

Results and Discussion
A high concordance (R 2 = 0.9494) was observed between allele frequencies of SNPs in our study and those from the CHB (Chinese in Beijing) population in HapMap (Release 27) ( Figure  S4) affirming the quality of our genotyping. A large proportion of the SNPs examined in this study were either monomorphic (36%) or had a high minor allele frequency (MAF$0.1, 46%) ( Figure  S5). Seventy-two and 66 SNPs in Groups 1 and 2, respectively, were found to significantly deviate from Hardy-Weinberg Equilibrium and were excluded from further analysis.
Genotype was successfully (97-100%) assigned in 9 out of 11 SNPs genotyped using the Sequenom's MassARRAY. Sanger sequencing successfully assigned genotype of the 2 SNPs to all the samples while TaqMan assay successfully assigned genotypes to 96% of the samples. All the SNPs successfully genotyped by these methods were found to be in Hardy-Weinberg equilibrium.
Single SNP association analysis identified three nonresponder specific SNPs in the UMPS gene that may represent potential predictive biomarker for nonresponse to 5-FU As the number of samples in this study was small, a cross validation approach was employed where the samples were segregated into 2 distinct groups for discovery and validation to enhance the robustness of our findings.
A total of 36 SNPs in 12 genes were found to be associated with drug response before multiple test correction in Group 1 patients ( Table 2). As the sample size was small (n = 62), none of these markers were statistically significant after Bonferroni correction.
Nonetheless, there were 68 low frequency pfSNPs in Group 1 that were uniquely found only in non-responders (non-responderspecific pfSNP). To evaluate if any of these non-responder-specific pfSNPs may represent potential predictive biomarker for nonresponse to 5-FU, we examined a second group of 27 patients. Of these 68 non-responder specific pfSNPs, 24 remained nonresponder-specific even in Group 2 and these are presented in Table 3. However, only 3 of the non-responder-specific SNPs in the Uridine Monophosphate Synthetase (UMPS) gene, namely rs2291078 (E/4/T1050A C350*), rs3772809 (E/6/A1336G H446Y) and rs3772810 (E6/3UTR/A28G) (  groups of patients were combined and analysed, these 3 SNPs remained statistically significant (p = 0.032 before multiple test correction). The observation that out of a total of 89 patients in the combined group, no responders were found to carry this allele suggests that this allele may be a ''causal'' allele for determining the response to 5-FU. The non-statistical significant data obtained (after multiple test correction) suggests that this may not be the only ''causal'' alleles for 5-FU response and there are likely other alleles that also play a role in 5-FU response suggesting ''locus heterogeneity'' of response to 5-FU. The UMPS gene is important in determining 5-FU response, as it converts 5-FU into its active metabolite, FUMP, which can participate in both the cell toxicity pathway as well as in the ''antimetabolite'' pathway. In the cell toxicity pathway, FUMP can be further converted into FUTP and FdUTP which is then incorporated into RNA and DNA respectively. In the ''antimetabolite'' pathway, FUMP can be converted into FdUMP and inhibits TYMS. These 3 alleles in the UMPS gene are in perfect linkage disequilibrium (LD) and hence will occur together all the time. The predicted molecular functions of the three alleles unique to the non-responders are all associated with the disruption of the UMPS gene function and support their unique presence in the non-responders (Figure 1).
The A allele of rs2291078 (UMPS E/4/T1050A C350*) was predicted to create a stop codon in exon 4 of the UMPS mRNA. UMPS mRNA containing this stop codon may be quickly degraded since stop codon appearing more than 50 bps from the last exon-exon junction would induce non-sense mediated decay of mRNA [31]. Therefore, patients carrying this A allele may have lower UMPS mRNA and protein abundance.
The co-occurrence of 39UTR pfSNP rs3772810 (UMPS E6/ 3UTR/A28G) with this pfSNP rs2291078 suggests that the expression of this gene may be further attenuated. The G allele of the 39UTR SNP rs3772810 (UMPS E6/3UTR/A28G) is predicted to create binding sites for miRNA 23a, 23b and 130a*. The miRNA 23a is shown to be up-regulated under hypoxic condition commonly found in tumors [32]. Notably, a recent publication reported that miRNA 23a is up-regulated in metastatic colorectal cancer [33] suggesting that patients with the G allele may be non-responsive to 5-FU since miRNA 23a may suppress the expression of UMPS mRNA containing the G allele.
Also co-occurring with these 2 pfSNPs, is the non-synonymous pfSNP rs3772809 (UMPS E/6/A1336G H446Y) which have the potential to alter the function of the UMPS gene. Hence, these 3 co-occurring pfSNPs, which accounted for 17.2% of all the nonresponders have the potential to be the causal variants affecting the function of UMPS and thus response to 5-FU although further experiments are required to validate the potential functionality of these pfSNPs.

Combined Multivariate and Collapsing (CMC) analyses revealed that a minimum of four non-responder specific pfSNPs that are not in linkage equilibrium can significantly distinguish non-responders from responders
We proceeded to determine if combination of non-responder specific pfSNPs ( Table 3) can account for a greater percentage of 5-FU non-responders than the abovementioned 3 non-responder specific UMPS pfSNPs in perfect LD that show statistical significance (before multiple test corrections). Since the 3 nonresponder specific UMPS pfSNPs are in perfect LD, only one was selected for further analyses. We then identify the minimum number of additional non-responder specific pfSNPs from Table 3 that can account for the maximum percentage of 5-FU non-responders and employed Combined Multivariate and Collapsing (CMC) analyses [28] to determine its statistical significance.
Notably, three other non-responder specific pfSNPs together with any one of the UMPS non-responder specific pfSNPs were found to account for 37.5% of all non-responders from the 2 groups of patients ( Table 4). CMC analyses revealed statistical significance (P = 0.0003) of these 4 non-responder specific pfSNPs (3 non UMPS plus any one of the 3 UMPS pfSNPs) suggesting significant association of these pfSNPs with non-responsiveness. SNP rs3218592 causes a non-conservative amino acid change in the REV3L gene which encodes the catalytic subunit of DNA Polymerase Zeta. DNA Polymerase Zeta was reported to be significantly down regulated in human colorectal cancer [34] and was suggested to be a tumour suppressor [35]. The T allele of the rs3218592 (E/26/C8285T, R2762Q) which is uniquely found in non-responder in our study is predicted to be damaging to the protein function by both Polyphen [36] and SIFT [37]. We thus hypothesize that the patients carrying this deleterious allele would have more aggressive disease and hence are more likely to be nonresponsive to treatment. pfSNP (rs8071253) resides in the promoter region of TK1 and is predicted to create a xenobiotic-stress activated TGA1a transcription binding site. The third SNP (rs501415) resides within the first intron of WDR7 and is predicted to disrupt AML1 (RUNX) transcription factor bind site. Since the entire RUNX family share the same binding site (TGt/cGGT) [19], we postulate that this SNP may also affect the binding of RUNX3. RUNX3 had been hailed as a tumour suppressor gene and reduced expression of RUNX3 has been previously associated with poorer survival in colorectal cancer patients [38]. Nonetheless, the role of WDR7 in 5-FU resistance remained unclear. It was reported to be associated with 5-FU by PharmGKB [39] but the publication [39] was recently retracted [40].
The logistic regression-based multivariate model identified an additional 5 pfSNPs which are not nonresponder-specific that may distinguish responders from non-responders In addition to the non-responder specific pfSNPs that are associated with patients who do not respond to 5-FU, we proceeded to identify additional pfSNPs that may be associated with 5-FU drug response by training a logistic regression-based multivariate model with the stepAIC method using data from the other pfSNPs. The multivariate model identified 5 additional pfSNPs, namely, rs2289310 (DLG5, E/23/G4442T, P1481Q), rs1047840 (EXO1, E/12/G1765A, E589K), rs17431184 (PTEN, I/7/T-400C), rs2236722 (CYP19A1, E/2/A115G, W39R) and rs17160359 (ABCB1, 5UR//G-4254T) ( Table 5) that may distinguish responders from non-responders. The AUC (Area Under Curve) for ROC (Receiver Operating Characteristic) curve of these 5 SNPs is 0.875 (Figure 2). A predicted value of 0.794 was identified as the optimal cut-off point to predict drug response, with sensitivity of 62.5% and specificity of 100%. With this threshold, the logistic-based multivariate model can correctly identify 39.1% (25/64) of non-responders. Together with the 37.5% of non-responders predicted by the non-responder-specific SNPs, a total of 76.6% (49/64) of non-responders can be correctly identified by both models.
It is noteworthy that the SNPs in the multivariate model are primarily localized within tumor suppressor gene (PTEN) or in genes which are mainly associated with colorectal cancer (DLG5, EXO1, CYP19A1 and ABCB1) ( Table 5). Notably, one of the non-responder-specific SNP (rs3218592, REV3L E/26/C8285T, R2762Q) ( Table 4) residing in the gene, Rev3L, has also been implicated to be a tumor suppressor gene [41].
The PTEN (phosphatase and tensin homolog) gene is a wellknown tumor suppressor gene that was recently reported to control DNA repair and sensitivity to genotoxic stress [42]. The higher frequency of the C allele in the responders (26% in the responders vs. 12% in the non-responders) suggests that patients with this allele may exhibit lower tolerance to genotoxic stress caused by DNA damaging agents like 5-FU.
The DLG5 (Disks large homolog 5) gene encodes a member of the membrane-associated guanylate kinase (MAGUK) family of scaffolding proteins which is involved in maintaining the epithelial integrity [43]. The T allele of rs2289310 (DLG5, E/23/G4442T, P1481Q) causes a non-conserved amino acid change in the vicinity of one of the PDZ domains in this gene (aa 1391-1472; Prosite score 13.531). This variant was postulated to impair the scaffolding functions of DLG5 [44] and enhance the tight junction-mediated gut permeability [45]. This polymorphism has also been associated with increased risk of Inflammatory Bowel Disease [45] which may lead to increased risk for colorectal cancer [46]. Since enhanced gut permeability was reported to lead to higher 5-FU absorption in rats [47], we hypothesize that the T allele would lead Table 4. The list of less-common SNPs with non-responder specific allele and their predicted molecular functions.  to better drug absorption and thus better response. Consistent with our hypothesis, more responders have the T allele (MAF of 34% in responder vs 17% in non-responder) in this study. The EXO1 (exonuclease 1) gene has been implicated to play roles in DNA replication, recombination, repair, telomere integrity [48] as well as damage signalling decisions [49]. The A allele of rs1047840 (EXO1, E/12/G1765A or E/13/G1765A, E589K) causes a non-conserved amino acid change and is predicted to reside within a region that is highly conserved amongst the XP-G/ RAD2 DNA Repair Endonuclease Family (HMMPanther PTHR11081). In the Kin-cohort analyses, the A allele has been associated with higher risk of colorectal cancer in a UK population [50]. This SNP has also been associated with higher risk for various other cancers in the Chinese population [51][52][53][54][55][56][57]. We hypothesize that the increased cancer risk associated with this SNP could be due to less efficient repair of DNA damage in individuals carrying the A-allele. As the metabolites of 5-FU gets incorporated into DNA damaging the host DNA, the inefficient repair mechanisms of individuals carrying the A-allele of this SNP may result in greater cell death hence enhancing the effectiveness of 5-FU treatment. This is consistent with our observations that greater percentage of responders carries the A-allele of this SNP compared to non-responders (30% versus 16%). CYP19A1 (cytochrome P450, family 19, subfamily A, polypeptide 1) or Aromatase is a member of the cytochrome P450 superfamily of enzymes and plays an important role in the metabolism of oestrogens. Oestrogen has been associated with lower risk of colorectal cancer [58][59][60]. Although several SNPs in the CYP19A1 gene had been reported to be associated with risk for colorectal cancer in a Caucasian population [61], SNP rs2236722 (E/2/A115G or E/3/A115G, W39R) was not examined in that study as it is monomorphic in HapMap CEU population. Nonetheless, this SNP (rs2236722), which occurs at a frequency of 3.3% in HapMap CHB population and 9.5% in our study, causes a non-conserved amino acid change from hydrophobic tryptophan to charged arginine in the CYP_P450 family domain and is predicted by Polyphen [36] to be a deleterious alteration. Hence, it is possible that this deleterious change in CYP19A1 may lead to lower oestrogen levels leading to higher colorectal cancer risk. We thus hypothesize that patients with the minor G-allele may have more progressive disease and hence are less responsive to 5-FU treatment.
The final gene implicated by the multivariate model to be associated with 5-FU response is the ABCB1 (ATP-Binding Cassette, Sub-Family B (MDR/TAP), Member 1) or the MDR1 (multidrug resistance protein 1). Although 5-FU is not a substrate of MDR1 protein, there's some, albeit controversial evidence that SNPs within the ABCB1 gene, may be associated with CRC risk [62,63]. Nonetheless, the SNP rs17160359 (ABCB1, 5UR/G-4254T) which is implicated in the multivariate model to be associated with drug response in CRC patient, resides in the promoter region and the T allele of the SNP creates a binding site of a transcription factor called HMGA1 which is expressed at very low level in adult human tissues but highly expressed in various tumours [64]. In summary, three perfect LD, non-responder-specific pfSNPs within the UMPS gene which plays a role in 5-FU metabolism together with 3 other non-responder-specific pfSNPs and 5 other pfSNPs in genes that may play roles in modulating tumor risks may collaborate to influence the patient's response of CRC drugs. This study thus provides one of the building blocks for subsequent meta-analysis in larger cohort of patients. Figure S1 The different sequencing patterns generated by the different genotype of the VNTR and embedded SNP in the TYMS gene promoter region.