For those cancers known to have a specific external cause, the disease does not usually become apparent until long after exposure to the causal agent. The incidence of lung cancer, for example, does not begin to rise steeply until after decades of heavy smoking (Figure 20–7). Similarly, the incidence of leukemias in Hiroshima and Nagasaki did not show a marked rise until about 5 years after the explosion of the atomic bombs, and industrial workers exposed for a limited period to chemical carcinogens do not usually develop the cancers characteristic of their occupation until 10, 20, or even more years after the exposure. During this long incubation period, the prospective cancer cells undergo a succession of changes, and the same presumably applies to cancers where the initial genetic lesion has no such obvious external cause.
The concept that the development of a cancer requires a gradual accumulation of mutations in a number of different genes helps to explain the well-known phenomenon of tumor progression, whereby an initial mild disorder of cell behavior evolves gradually into a full-blown cancer. Chronic myelogenous leukemia again provides a clear example. It begins as a disorder characterized by a nonlethal overproduction of white blood cells and continues in this form for several years before changing into a much more rapidly progressing illness that usually ends in death within a few months. In the early chronic phase, the leukemic cells are distinguished mainly by the chromosomal translocation (the Philadelphia chromosome) mentioned previously, although there may well be other, less visible
Figure 20–7 Smoking and the onset of lung cancer. A major increase in cigarette smoking (red line) has caused a dramatic rise in lung cancer deaths (green line), with a lag time of about 35 years. Because global cigarette smoking peaked in 1990, global lung cancer deaths are expected to decline after a similar lag. (Data from R.N.
Proctor, Nat. Rev. Cancer 1:82–86, 2001).
genetic or epigenetic changes. In the subsequent acute phase, cells that show not only the translocation but also several other chromosomal abnormalities overrun the hemopoietic (blood-forming) system. It appears that cells from the initial mutant clone have undergone further mutations that make them proliferate even more vigorously, so that they come to outnumber both the normal blood cells and their ancestors with the primary chromosomal translocation.
Carcinomas and other solid tumors evolve in a similar way (Figure 20–8). Although many such cancers in humans are not diagnosed until a relatively late stage, in some cases it is possible to observe the earlier steps and, as we shall see later, to relate them to specific genetic changes
Tumor Progression Involves Successive Rounds of Random Inherited Change Followed by Natural Selection
From all the evidence, therefore, it seems that cancers arise by a process in which an initial population of slightly abnormal cells—descendants of a single abnormal ancestor—evolve from bad to worse through successive cycles of random inherited change followed by natural selection. Correspondingly, tumors grow in fits and starts, as additional advantageous inherited changes arise and the cells bearing them flourish. Tumor progression involves a large element of chance and usually takes many years, which may be why the majority of us will die of causes other than cancer.
At each stage of progression, some individual cell acquires an additional mutation or epigenetic change that gives it a selective advantage over its neighbors, making it better able to thrive in its environment—an environment that, inside a tumor, may be harsh, with low levels of oxygen, scarce nutrients, and the natural barriers to growth presented by the surrounding normal tissues. The larger the number of tumor cells, the higher the chance that at least one of them will undergo a change that favors it over its neighbors. Thus, as the tumor grows, progression accelerates. The offspring of the best-adapted cells continue to divide, eventually producing the dominant clones in the developing lesion (Figure 20–9).