Ijms 23 12844 v2
Ijms 23 12844 v2
Ijms 23 12844 v2
Molecular Sciences
Review
The Role of Telomerase in Breast Cancer’s Response to Therapy
Eliza Judasz 1 , Natalia Lisiak 1 , Przemysław Kopczyński 2 , Magdalena Taube 1 and Błażej Rubiś 1, *
1 Department of Clinical Chemistry and Molecular Diagnostics, Poznan University of Medical Sciences,
60-806 Poznan, Poland
2 Centre for Orthodontic Mini-Implants at the Department and Clinic of Maxillofacial Orthopedics and
Orthodontics, Poznan University of Medical Sciences, 60-812 Poznan, Poland
* Correspondence: blazejr@ump.edu.pl; Tel.: +48-616418304
Abstract: Currently, breast cancer appears to be the most widespread cancer in the world and the
most common cause of cancer deaths. This specific type of cancer affects women in both developed
and developing countries. Prevention and early diagnosis are very important factors for good
prognosis. A characteristic feature of cancer cells is the ability of unlimited cell division, which makes
them immortal. Telomeres, which are shortened with each cell division in normal cells, are rebuilt
in cancer cells by the enzyme telomerase, which is expressed in more than 85% of cancers (up to
100% of adenocarcinomas, including breast cancer). Telomerase may have different functions that are
related to telomeres or unrelated. It has been shown that high activity of the enzyme in cancer cells
is associated with poor cell sensitivity to therapies. Therefore, telomerase has become a potential
target for cancer therapies. The low efficacy of therapies has resulted in the search for new combined
and more effective therapeutic methods, including the involvement of telomerase inhibitors and
telomerase-targeted immunotherapy.
acquire a very dynamic characteristic that is associated with tumor cells’ ability to induce
the epithelial–mesenchymal transition (EMT) and, conversely, the mesenchymal–epithelial
transition (MET) [7]. Consequently, by changing their phenotype, cells are able to escape the
bulk, enter the cardiovascular system, and metastasize to lymph nodes and distant organs
such as bones, the liver, or the brain [7,8]. The ability of breast cancer cells to metastasize
is the main cause for treatment failure and patient deaths. However, the mechanisms that
contribute to this phenomenon are not yet fully understood. Different metabolic phenotypes
of breast cancer cells are modulated by both intrinsic (such as MYC amplification, PIK3CA,
and TP53 mutations) and extrinsic factors (such as hypoxia, oxidative stress, and acidosis) [9].
The pathways involved in the modulation of breast cancer cell mobility are associated with
the metalloproteinases MMP1 and ADAMTS1, which drive metastasis to bones. In turn, when
metastasis to the lungs is reported, the combinatorial effects of COX2, EREG (cyclooxygenase-2
and epiregulin, respectively), and MMP1 and 2 are raised [10]. Importantly, the pharmacologi-
cal inhibition of pathways mediated by these factors was shown to diminish the aggressiveness
of the metastatic phenotypes [11]. Thus, as the EMT accounts for a broad spectrum of tran-
sitional stages between the epithelial and mesenchymal phenotypes, it is critical to find a
common feature of all these stages. Apart from the modulation of the mentioned pathways,
some specific genes and proteins are directly involved in adhesion and cell-to-cell interactions,
including α1 and β1 integrins, cadherins, selectins, focal adhesion kinase (FAK), Akt, and
other cell adhesion molecules as well as epigenetic factors, including miRNA [12]. Importantly,
one of the most characteristic features of the vast majority of adenocarcinomas, including
breast cancer, is the restoration of the telomerase expression (specifically the key catalytic
telomerase subunit hTERT) and activity that provide tumor cell immortality. Telomerase
is also postulated to modulate cancer cells’ responses to drugs as well as their metastatic
potential via affecting adhesion pathways [13]. For these reasons, telomerase seems to be a
good therapeutic target in breast cancer.
One of the most important features of cancer cells is their ability to undergo an
unlimited number of cell divisions, which provides them with immortality. This is due to
the autocrine secretion of growth factors, which results from the cancer cells’ independence
from external factors. In addition, cancer cells can interact with the surrounding normal
cells, creating a specific microenvironment as well as stimulating nearby normal cells to
produce growth factors [20]. Cancer resistance to apoptosis results from various defense
mechanisms, but the most common cause is mutations leading to the loss of p53 protein
function [18]. It is also characteristic for cancer cells to increase the expression of telomerase,
whose role is, among others, to restore telomeres, which allows cells to divide in an
unlimited way and avoid replicative senescence [18].
Figure 1. Association between hTERT, key signaling pathways, and senescence (acc. [21,22,39],
Figure 1. Association
modified). Thebetween hTERT,ofkey
hTERT subunit signalingcan
telomerase pathways, andinsenescence
be involved (acc. [21,22,39],
various metabolic pathways (e.g.,
modified).
NFκB, Wnt/β-catenin, and adhesion as well as senescence) and affect thepathways
The hTERT subunit of telomerase can be involved in various metabolic (e.g.,
expression of various
NFκB, Wnt/β‐catenin, and adhesion as well as senescence) and affect the expression of various
genes. Under the influence of stress, hTERT is translocated to mitochondria, where hTERT protects
genes. Under the influence of stress, hTERT is translocated to mitochondria, where hTERT protects
mitochondrial metabolism by lowering the level of ROS and binding to mtDNA.
mitochondrial metabolism by lowering the level of ROS and binding to mtDNA.
It was shown that hTERT is not the only subunit that exhibits extratelomeric functions.
7. Therapeutic Potential
The hTERC of Telomerase
subunit Subunits
is also able to control the expression of other genes, as was demon-
7.1. Telomerase
strated as A Target
during for Cancer
studies Therapymelanoma cell line. In this study, the suppression of
on a mouse
mTERC (mouse TERC) resulted in the inhibition
In most somatic cells, telomerase activity is below ofthethe expression
detection limitof[3,45].
more than 100 genes.
The ex‐
Some of them were involved in the glycolytic pathway, indicating a possible
ceptions are embryonic stem cells, marrow stem cells, intestinal crypts, hair capsules, tes‐ relationship
between
ticular cells, and hTERC
ovarian and
cellscancer
[46–48].metabolism [42]. Studies
Most fetal tissues, in human
apart from cell lines
brain cells, showsuggest
high that
the upregulation
telomerase of hTERC
activity at 16–20 weeks ofcould lead to the
development inhibition
[49]. However,of it
angiogenesis and the
was not detected in down-
cells from a 2‐month‐old baby, with the exception of reproductive cells [49,50]. High te‐
lomerase activity is characteristic of most cancers, especially advanced and metastatic can‐
cers [45]. Normal breast tissue has been shown to lack telomerase activity [48]. In the case
of noninvasive ductal carcinoma, telomerase activity was demonstrated in 75% of exam‐
Int. J. Mol. Sci. 2022, 23, 12844 5 of 13
regulation of metastasis-related gene expression [43]. It has also been shown that hTERC
is involved in the transcription of genes mediated by the telomerase-dependent NFκB
signaling pathway [32,44].
Telomerase subunits may have many different nontelomeric functions. Many discrep-
ancies can be seen in the results of studies on their noncanonical functions. This is probably
a result of the diversity of research models and the lack of appropriate experimental tools
to gain a thorough understanding of the mechanisms involved in cells. Moreover, in cancer
cells hTERT is a weakly expressed protein, and the existence of alternative splice variants
of hTERT complicates the interpretation of the results [35].
Importantly, breast cancer has a very low frequency of TERT promoter mutation, which
implies epigenetic regulation in this type of cancer and possibly a wider systemic effect,
especially in HER2-positive breast cancer [88].
7.4. Immunotherapy
A novel approach is to use telomerase as a target for the development of immunother-
apy, and two main strategies have been adopted. The first is based on direct in vivo immune
activation with a vaccine directed against hTERT, which sensitizes cells of the immune sys-
tem to tumor cells [4,51]. Telomerase is degraded by proteasomes, leading to the formation
and presentation of hTERT-derived peptides as antigens on the cell surface [4,51,89]. This
induces an antitumor response of CD8+ or CD4+ cytotoxic T lymphocytes [51]. Promising
vaccines include GV1001 and Vx-001 (Geron, Foster City, CA, USA), both of which effec-
tively stimulate the immune system while inducing minimal side effects, as demonstrated
in clinical trials [4,53,90,91]. Another strategy is the ex vivo activation and expansion
of immune cells using the GRNVAC1 vaccine. The patient’s isolated dendritic cells are
transfected ex vivo and then administered to the patient via intradermal injection. This
induces a strong immune response with only grade 1 toxicity [4,51,91]. Importantly, these
studies have already progressed to in vivo experiments, which makes this strategy less
elusive and more realistic [92–94].
Another peptide-based cancer vaccine consisted of two human leukocyte antigens.
The subcutaneous injection of the TERT (572Y) peptide followed by the subcutaneous
administration of the TERT (572) peptide was aimed to elicit a specific and possibly optimal
cytotoxic T-cell (CTL) response against hTERT-expressing tumor cells [95]. The new trend in
cancer immunology is based on nucleic acids and an adjuvant approach. As shown in 2007,
chemokine adjuvant strategies might enhance the tumor-antigen-specific (hTERT-targeted)
immunity induced by vaccines. The hTERT DNA vaccine consisted of a plasmid containing
the carboxyl terminal end of the TERT (cTERT) gene encapsulated in multilayered liposomes
with a hemagglutinating virus of Japan coating. The study demonstrated that CCL21
administration before cTERT DNA vaccination significantly augmented tumor-antigen-
specific immunity against breast cancer [96].
Other studies on hTERT-based immunotherapy (three phase I/IIa clinical trials covering
malignant melanoma, non-small-cell lung cancer, and prostate cancer) showed that UV1, a
second-generation telomerase-targeting therapeutic cancer vaccine, triggered highly dynamic
and persistent telomerase-peptide-specific immune responses that lasted up to 7.5 years after
the initial vaccination. The superior immune response kinetics were observed in the melanoma
study [97].
conditions in humans is a mouse breast tumor model based on 4T1 tumor cells. The 4T1
mammary carcinoma is a transplantable tumor cell line that is highly tumorigenic, invasive,
and, unlike most tumor models, can spontaneously metastasize from the primary tumor
in the mammary gland to multiple distant sites, including the lymph nodes, blood, liver,
lung, brain, and bone. Moreover, the progressive spread of 4T1 metastases to the draining
lymph nodes and other organs is very similar to that of human mammary cancer. Another
advantage of 4T1 is its resistance to 6-thioguanine, which enables the precise quantitation
of metastatic cells [100].
Despite being considered a promising antitumor strategy, to date, cancer vaccination
has not been shown to be a clinically useful approach in patients with severe disease [101].
This overall negative result is at least in part due to the poor effectiveness of gene transfer
with the currently employed strategies and, particularly, the frequent onset of a neu-
tralizing antibody response against the viral vectors, which limits the use of repeated
vaccinations [102,103]. Therefore, new immunization regimens that are able to reduce the
neutralizing antibody response and maintain an active immune response over time are
needed to assess the actual potential of cancer vaccination in clinical practice. The results
of a recent study suggested the safety and feasibility of V934/V935 hTERT vaccination (an
adenoviral type 6 vector vaccine expressing a modified version of hTERT, administered
alone or in combination with V934, a DNA plasmid that also expresses the same antigen) in
cancer patients with solid tumors. Further investigation is needed for a proper evaluation
of the efficacy of this strategy and its potential impact on clinical practice [103].
8. Summary
Intensive research on the regulation of telomerase in cancer cells in recent years has
allowed for the understanding of the mechanisms accompanying tumor proliferation,
telomere elongation, and noncanonical enzyme functions. All of these make it possible
to develop new, effective anticancer drugs. Unfortunately, there are still many unsolved
questions concerning telomeres and telomerase, such as whether telomerase expression has
oncogenic properties [51]. It is also important to note that it has still not been possible to
develop an effective telomerase-based drug that would be approved for clinical use. This
shows the need for further research. However, it is undeniable that the study of telomerase
has contributed to a deeper understanding of cancer biology and has opened up promising
new therapeutic avenues [4,51,104]. Research conducted in recent years has led to the
development of many structurally diverse compounds with different mechanisms of action.
Therapies based on targeting telomerase and telomeres or combination therapies may
prove to have high efficacy against telomerase-positive tumors while sparing neighboring
normal cells [45,105]. In addition, the use of molecularly targeted therapy makes it possible
to bypass the side effects characteristic of conventional therapies [45,73]. Hopefully, the
knowledge accumulated so far will soon allow researchers to improve the therapeutic
efficacy and eliminate the side effects of previously known drugs targeting telomeres and
telomerase or will allow the development of new and effective drugs. However, further
research is needed to make this possible [105].
Author Contributions: Conceptualization, E.J. and B.R.; writing—original draft preparation, E.J. and
B.R.; writing—review and editing, N.L. and P.K.; visualization, E.J.; supervision, B.R.; immunotherapy
supplementation, M.T. All authors have read and agreed to the published version of the manuscript.
Funding: This work was funded by Poznan University of Medical Sciences.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: This work was supported by Poznan University of Medical Sciences.
Conflicts of Interest: The authors declare no conflict of interest.
Int. J. Mol. Sci. 2022, 23, 12844 9 of 13
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