Review
Mutagen Sensitivity: A Genetic Predisposition Factor for Cancer
Xifeng Wu, Jian Gu, and Margaret R. Spitz
Department of Epidemiology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
Abstract
Mutagen sensitivity, measured by quantifying the chromatid
breaks induced by mutagens in short-term cultures of peri-
pheral blood lymphocytes, has been used as an indirect
measure of DNA repair capacity. Numerous epidemiologic
studies have suggested that mutagen sensitivity is a cancer
susceptibility factor for a variety of epithelial cancers. A recent
classic twin study examined systematically the role of genetic
and environmental factors on the mutagen sensitivity pheno-
type and provided compelling evidence that mutagen sensi-
tivity is highly heritable. A new prospective analysis provides
further support to the notion that mutagen sensitivity
increases the risk of cancer. In this review, we briefly
summarize nearly two decades of epidemiologic and genetic
studies linking mutagen sensitivity and cancer risk. The
evidence is becoming increasingly convincing that mutagen
sensitivity is a risk factor for cancer development. [Cancer Res
2007;67(8):3493–5]
Introduction
It is widely recognized that both genetic and environmental
factors play a significant role in cancer initiation. Aberrations
in many cellular functions are involved in the etiology of cancer,
among which DNA repair is of fundamental importance in
maintaining genomic integrity and protecting against cancer.
There is considerable interindividual variation in DNA repair
capacity. Mutagen sensitivity, measured by quantifying the
chromatid breaks induced by mutagens in short-term cultures
of peripheral blood lymphocytes (PBL), has been used as an
indirect measure of DNA repair capacity (1). The theoretical basis
for mutagen sensitivity assay is that, in response to mutagen
exposure, higher levels of genetic damage accumulate in people
with suboptimal DNA repair capacity than in normal individuals.
Therefore, the level of chromatid breaks induced by a mutagen
challenge would reflect an individual’s ability to repair DNA
damage. This hypothesis is supported by the observations that
mutagen-induced chromatid breaks are highest in DNA repair
deficiency syndromes, such as Fanconi’s anemia, ataxia telangiec-
tasia, and xeroderma pigmentosum. The original mutagen
sensitivity assay was developed using bleomycin as the mutagen
challenge (1). The assay has since been expanded to use other
etiologically relevant mutagens to assess genetic susceptibility
to different cancers, such as benzo[a]pyrene diol epoxide, a
tobacco polycyclic aromatic hydrocarbon, for smoking-related
cancers (2); g-radiation for breast cancer (3); and UV light for
skin cancer (4).
Requests for reprints: Xifeng Wu, Department of Epidemiology, Unit 1340, The
University of Texas M. D. Anderson Cancer Center, 1155 Pressler Boulevard, Houston,
TX 77030. Phone: 713-745-2485; Fax: 713-792-4657; E-mail: xwu@mdanderson.org.
I2007 American Association for Cancer Research.
doi:10.1158/0008-5472.CAN-06-4137
www.aacrjournals.org
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Research.
In this review, we summarize nearly two decades of epidemi-
ologic and genetic studies of mutagen sensitivity and cancer risk,
highlighting evidences of genetic heritability.
Epidemiologic Evidence
Retrospective studies. Almost 100 epidemiologic studies have
been published evaluating the association between mutagen sensi-
tivity and cancer risk. There has been at least one positive study for
most major cancers, including cancers of lung, breast, prostate,
bladder, colorectum, brain, skin, head and neck, and soft tissue.
Mutagen sensitivity has also been linked to the risk of develop-
ing premalignant lesions (5). The odds ratios (OR) from larger
studies were generally in the range of 1.5 to 2.5, whereas smaller
studies tended to yield higher ORs. The largest epidemiologic study
of mutagen sensitivity with nearly 1,000 lung cancer cases and
controls produced ORs of 1.63 [95% confidence interval (95% CI),
1.36–1.97] for bleomycin sensitivity and 1.85 (95% CI, 1.42–2.42) for
benzo[a]pyrene diol epoxide sensitivity (6). Several studies sug-
gested that combining mutagen sensitivity with other risk factors
increases predictive power (2, 7). For example, joint effects between
mutagen sensitivity, tobacco smoking, and alcohol consumption
were observed in a multicenter case-control analysis of head and
neck cancer (7). High bleomycin sensitivity and heavy tobacco
smoking alone conferred 2.6-fold and 11.5-fold increased risk of
head and neck cancer, respectively. However, the risk increased
dramatically to 44.5-fold (95% CI, 17.4–114.0) in mutagen-sensitive
heavy smokers. The consumption of alcohol further increased the
risk to 57.5-fold (95% CI, 17.5–188.0). These high ORs underscore the
importance of mutagen sensitivity as a cancer susceptibility marker,
particularly when combined with other risk factors.
Prospective studies. There have been a few prospective studies
of mutagen sensitivity scored before the onset of secondary tumors
in head and neck cancer patients. The most recent study with 981
early-stage head and neck cancer patients reported that bleomycin
sensitivity was associated with a significantly increased risk of
developing secondary primary tumor and recurrence [hazard
ratio (HR), 1.38; 95% CI, 1.02–1.86; ref. 8]. Chao et al. (9) recently
reported the first prospective study before the onset of primary
cancer. They measured baseline bleomycin sensitivity in PBLs
from a cohort of 220 patients with Barrett’s esophagus, a pre-
cursor lesion of esophageal adenocarcinoma. They found that
higher bleomycin sensitivity was associated with a significantly
greater risk of developing aneuploidy, an intermediate end point
biomarker in esophageal adenocarcinoma (HR, 3.71; 95% CI,
1.44–9.53), and a nonsignificantly greater risk of esophageal
adenocarcinoma (n = 27; HR, 1.63; 95% CI, 0.71–3.75). Among
patients with loss of heterozygosity at the p53 locus, increasing
bleomycin sensitivity was associated with increased risk of both
aneuploidy (P trend = 0.005) and cancer (P trend < 0.001). This pro-
spective study provides strong support for the usefulness of
mutagen sensitivity as a risk predictor for cancer development,
particularly when combined with other events, such as loss of
tumor suppressor (e.g., p53) function.
3493 Cancer Res 2007; 67: (8). April 15, 2007
Cancer Research
Genetic Heritability
Because most of the reports supporting mutagen sensitivity as a
cancer susceptibility factor have been case-control studies that
compared mutagen sensitivity among unrelated individuals, the
merit of mutagen sensitivity, an intermediate phenotype, as a
cancer risk factor has often been questioned for the possibility
of ‘‘reverse causation.’’ It is imperative to establish mutagen sensi-
tivity as a heritable trait before it can be recognized as a genetic
susceptibility factor for cancer. Evidence for the genetic heritability
of mutagen sensitivity has been accumulating. A number of case-
control studies showed that mutagen sensitivity remained a
significant predictor of cancer risk independent of demographic
and environmental risk factors (7, 10), although a few studies found
the opposite (11). Family studies observed that first-degree relatives
of mutagen-sensitive individuals were also mutagen sensitive,
indicating genetic predisposition to mutagen sensitivity (3).
Roberts et al. (3) studied the heritability of radiation sensitivity
in PBLs in families of patients with breast cancer. They found that
62% of the first-degree relatives of radiation-sensitive patients were
also sensitive compared with 7% of the first-degree relatives of
patients with normal sensitivity. Segregation analysis of 95 family
members showed clear evidence of high heritability of radiation
sensitivity, pointing to a single major gene accounting for 82% of
the variance between family members (3). Adema et al. (12)
compared the numbers of chromatid breaks per cell in several
different lymphoblastoid cell lines on radiation or bleomycin
challenge and found a very strong correlation (r = 0.99, P < 0.001)
between the chromatid breaks induced by these two mutagens. The
strong correlation suggests that radiation and bleomycin sensitivity
may have similar underlying mechanisms.
The most powerful method to assess the relative contribution of
genes and environments to complex traits is the classic twin study
design. The twin model, comparing similarities between monozy-
gotic twins (genetically identical) and dizygotic twins (who share
half their genes), is an ideal model to partition interindividual
variability into components reflecting genetic and environmental
factors. In a pioneering classic twin study involving 25 pairs of
monozygotic twins and 14 pairs of dizygotes (twin pairs and
siblings), Cloos et al. (13) estimated a high heritability of 75% for
bleomycin sensitivity. A second twin study of 9 monozygotic twins
and 10 dizygotic twins by Tedeschi et al. (14) also reported higher
correlations of bleomycin sensitivity score in monozygotic twins
as compared with dizygotic twins and yielded a heritability of 58%.
In the third twin study with a substantially larger sample size
(148 pairs of monozygotic twins and 82 pairs of dizygotes), the
genetic heritability of mutagen sensitivity was evaluated using
a biometric genetic modeling (15). In addition to bleomycin,
other commonly used and biologically relevant mutagen chal-
lenges (benzo[a]pyrene diol epoxide, 4-nitroquinoline 1-oxide, and
g-radiation) were also evaluated. A pedigree-based maximum
likelihood method (15, 16) was used to quantify the influences
of genetic and environmental contributions to the trait. The null
hypothesis that there is no genetic contribution to mutagen sen-
sitivity was rejected for all the four mutagen-sensitive traits
because the restricted model (assuming no genetic influence) fitted
the data significantly worse than the full model (including all
covariates and variance components), indicating that the genetic
component contributed significantly to all four markers. The
model generated a heritability estimate of 40.7%, 48.0%, 62.5%, and
58.8% for bleomycin, benzo[a]pyrene diol epoxide, g-radiation,
and 4-nitroquinoline 1-oxide sensitivity, respectively (Table 1).
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Table 1. Contribution of genetic and environmental
variance components to mutagen sensitivity
Variance components Mutagen
Bleomycin BPDE g-Radiaton 4NQO
Genetic contribution (%) 40.7 48.0 62.5 58.8
Nonshared environment (%) 33.3 31.8 37.5 39.7
Shared environment (%) 26.0 20.2 0 1.5
Abbreviations: BPDE, benzo[a]pyrene diol epoxide; 4NQO, 4-nitro-
quinoline 1-oxide.
It is apparent that whereas heritability varies different agents,
it plays the most prominent role in determining mutagen sensi-
tivity for any mutagen evaluated. The nonshared and shared
environment also contributes to mutagen sensitivity but to a
lesser degree (Table 1). g-Radiation seems to have the highest
heritability (62.5%) and the least contribution from shared envi-
ronment (0%) among these four mutagens, consistent with the
high heritability of radiation sensitivity in PBLs observed by
the aforementioned breast cancer family study (3). Bleomycin
sensitivity has lower heritability in this twin study (40.7%).
Cloos et al. (17) recently carried out microarray analysis in
lymphoblastoid cells from bleomycin-sensitive and bleomycin-
insensitive individuals to search for genes and pathways involved in
bleomycin sensitivity. The profile of altered gene expression after
in vitro bleomycin exposure involved genes in many biological
pathways, including cell growth and proliferation, cell cycle regu-
lation, and DNA repair, but no specific pathway could be singled
out to explain the difference in bleomycin sensitivity. These results
suggest that there may not be a single major gene or a limited
number of major genes determining bleomycin sensitivity. More
likely, a group of low-penetrance genes may determine bleomycin
sensitivity.
Assay Reliability and Technical Considerations
The mutagen sensitivity assay requires some level of cytogenetic
expertise to score, but it is reliable and comparable across different
labs. In a multicenter case-control analysis of bleomycin sensitivity,
Cloos et al. (7) reported no differences across institutions in the
distribution of bleomycin sensitivity in patients and controls. Erdei
et al. (18) recently conducted an interlaboratory comparison of
mutagen sensitivity to address the concerns of intraobserver,
interobserver, and interlaboratory variations. The correlation was
high for all tests, suggesting a good concordance rate between
different laboratories. One technical issue is that the definition of
a mutagen-sensitive phenotype is quite heterogeneous in the
literature. Some studies use a cutoff point based on a certain
percentile value (e.g., median, 25, or 75 percentile) of chromatid
breaks per cell in controls, whereas others use a specific
dichotomous chromatid break level (e.g., b/c > 1.0) to distinguish
sensitive from nonsensitive individuals. The level of b/c also varies
from mutagen to mutagen and between studies. Future efforts
should be directed at setting up a standardized assay procedure,
consistent scoring criteria, and a uniform b/c level for each
mutagen to facilitate interstudy comparisons and potential pooled
analyses.
3494 www.aacrjournals.org
 Mutagen Sensitivity and Cancer Risk

Perspectives and Conclusions
Over the past nearly two decades, mutagen sensitivity has been
a commonly used phenotypic assay in cancer epidemiology. The
epidemiologic evidence supporting its association with cancer
risk is strong and consistent. More importantly, it is the only DNA
repair assay whose heritability has been estimated by classic
twin studies. Therefore, mutagen sensitivity is one of the best-
established phenotypic susceptibility markers for cancer risk.
There remain some questions and issues to be addressed. The
use of PBLs is only a surrogate for the target organ, and the
correlation between surrogate and target tissue measurements has
not been established. Epidemiologic analyses on the modulation
of mutagen sensitivity by environmental factors (e.g., smoking,
alcohol, and diet) have been inconsistent. The twin study showed
that nonshared environmental factors exhibit considerable effects
on mutagen sensitivity. Further studies are warranted to evaluate
what environmental factors and to what degree such factors affect
the mutagen sensitivity phenotype. The more interesting and
important question awaiting study is to search for genes that are
responsible for the mutagen sensitivity trait. There have been some
reports of individual genotypes and genotype combinations in DNA
repair genes and cell cycle checkpoint genes modulating the
mutagen sensitivity phenotype (19). However, common polymor-
phisms in DNA repair genes that have been widely studied probably
explain only a small amount of the variability in DNA repair
capacity (20). The real genes that are responsible for the sensitivity
to each mutagen are still elusive. The identification of such genes
will not only improve our understanding of the mechanism of
mutagen sensitivity phenotype and the origin of heritability but
also provide novel candidate genetic markers for cancer risk
assessment, clinical prevention, and treatment.
Acknowledgments
Received 11/8/2006; revised 2/16/2007; accepted 2/26/2007.
Grant support: National Cancer Institute grants CA085576 (X. Wu), CA098897
(X. Wu), CA055769 (M.R. Spitz), and CA070907 (M.R. Spitz).

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Mutagen Sensitivity: A Genetic Predisposition Factor for
Cancer
Xifeng Wu, Jian Gu and Margaret R. Spitz

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