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review article

Mechanisms of Disease

Cancer Stem Cells

Craig T. Jordan, Ph.D., Monica L. Guzman, Ph.D., and Mark Noble, Ph.D.

he deepening of our understanding of normal biology has made

it clear that stem cells have a critical role not only in the generation of complex multicellular organisms, but also in the development of tumors. Recent
findings support the concept that cells with the properties of stem cells are integral
to the development and perpetuation of several forms of human cancer.1-3 Eradication of the stem-cell compartment of a tumor also may be essential to achieve stable,
long-lasting remission, and even a cure, of cancer.4,5 Advances in our knowledge of
the properties of stem cells have made specific targeting and eradication of cancer
stem cells a topic of considerable interest. In this article, we discuss the properties
of cancer stem cells, outline initial therapeutic strategies against them, and present
challenges for the future.

From the James P. Wilmot Cancer Center

(C.T.J., M.L.G.) and the Department of
Biomedical Genetics (M.N.), University
of Rochester School of Medicine, Rochester, NY. Address reprint requests to Dr.
Jordan at the University of Rochester
School of Medicine, 601 Elmwood Ave.,
Box 703, Rochester, NY 14642, or at
[email protected].
N Engl J Med 2006;355:1253-61.
Copyright 2006 Massachusetts Medical Society.

B ackground a nd Defini t ions

Stem cells occur in many different somatic tissues and are important participants
in their physiology (Fig. 1). Populations of cells that derive from stem cells are organized in a hierarchical fashion, with the stem cell residing at the apex of the
developmental pathway (Fig. 2). Stem cells have three distinctive properties: selfrenewal (i.e., at cell division, one or both daughter cells retain the same biologic
properties as the parent cell), the capability to develop into multiple lineages, and
the potential to proliferate extensively. The combination of these three properties
makes stem cells unique. The attribute of self-renewal is especially notable, because
its subversion is highly relevant to oncogenesis and malignancy.6,7 Aberrantly increased self-renewal, in combination with the intrinsic growth potential of stem
cells, may account for much of what is considered a malignant phenotype.
Many studies performed over the past 30 to 40 years, when viewed collectively,
have shown that the characteristics of stem-cell systems, the specific stem-cell
properties described above, or both, are relevant to some forms of human cancer.3,4,8,9 Biologically distinct and relatively rare populations of tumor-initiating
cells have been identified in cancers of the hematopoietic system, brain, and
breast.10-13 Cells of this type have the capacity for self-renewal, the potential to
develop into any cell in the overall tumor population, and the proliferative ability
to drive continued expansion of the population of malignant cells. Accordingly,
the properties of tumor-initiating cells closely parallel the three features that define normal stem cells. Malignant cells with these functional properties have been
termed cancer stem cells (Fig. 2).
Given these features, it is possible that cancer stem cells arise by mutation from
normal stem cells. However, several lines of evidence indicate that cancer stem
cells can also arise from mutated progenitor cells.14-17 Such progenitors (also known
as transit-amplifying cells) can possess substantial replicative ability, but they do
not usually have the self-renewal capacity of stem cells. To become a cancer stem

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Neural
stem cells

Brain
tissue

of

Hematopoietic
stem cells

Mammary
stem cells

Breast
tissue

Bone
marrow

Brain

All types of
blood cells
Breast

Figure 1. Examples of Stem Cells Found in Adult Somatic Tissues.

Neural stem cells generate cells in the central nervous system (Panel A). Hematopoietic stem cells generate mature blood cells (Panel B).
Mammary stem cells generate breast tissue (Panel C).

cell, a progenitor cell must acquire mutations that

cause it to regain the property of self-renewal.
A detailed discussion of the origins of cancer
stem cells is beyond the scope of this review, but
it is important to acknowledge the possibility that
multiple pathways and processes can give rise to
cancer stem cells.
Although specific features of normal stem
cells may be preserved to greater or lesser degrees in cancer stem cells, the key issue for consideration with regard to tumor biology is that a
small subgroup of the cells in a tumor the
cancer stem cells are essential for its growth.
The concept of cancer stem cells can, however,

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vary in different contexts. For example, cancer

stem cells can be the source of all the malignant
cells in a primary tumor, they can compose the
small reservoir of drug-resistant cells that are
responsible for relapse after a chemotherapyinduced remission, or they can give rise to distant metastases (Fig. 3). The biologic features of
cancer stem cells in each of these instances may
differ, suggesting that the acquisition of features
associated with tumor progression, such as genetic instability and drug resistance, will also be
associated with cancer stem cells.
It is becoming evident that a cancer treatment
that fails to eliminate cancer stem cells may allow

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mechanisms of disease

regrowth of the tumor. In cases in which bulk

disease is eradicated and chemotherapy is given,
only to be followed by a relapse, a plausible explanation is that the cancer stem cells have not
been completely destroyed (Fig. 3B). Therapeutic
strategies that specifically target cancer stem
cells should eradicate tumors more effectively
than current treatments and reduce the risk of
relapse and metastasis.

Normal
stem cell

Mature
tissue

Cancer Stem Cells in the Hematopoietic

System

Mutations

The hematopoietic system is the best characterized somatic tissue with respect to stem-cell biology. Over the past several decades, many of the
physical, biologic, and developmental features of
normal hematopoietic stem cells have been defined18,19 and useful methods for studying stem
cells in almost any context have been established.
Hematopoietic-cell cancers such as leukemia are
clearly different from solid tumors, but certain aspects of hematopoietic stem-cell biology are relevant to our understanding of the broad principles
of cancer stem-cell biology.6 In various types of
leukemia, cancer stem cells have been unequivocally identified, and several biologic properties of
these stem cells have been found to have direct
implications for therapy.1,20-22
Cancer stem cells are readily evident in chronic myelogenous leukemia (CML)23 and acute myelogenous leukemia (AML),10,11 and they have
been implicated in acute lymphoblastic leukemia
(ALL).24-26 CML stem cells have a well-described
stem-cell phenotype and a quiescent cell-cycle
status. Similarly, AML stem cells are mostly quiescent,27-30 suggesting that conventional antiproliferative cytotoxic regimens are unlikely to be
effective against them. AML stem cells have surface markers, such as the interleukin-3receptor
chain, that are not present on normal stem cells.31
These markers may be useful for antibody-based32
or other related therapeutic regimens.33,34 Early
efforts have demonstrated the usefulness of antibodies against the CD33 antigen in the treatment of AML,35,36 and recent reports indicate
that CD33 is expressed on some leukemia stem
cells.37 Continued development of immunotherapy against stem-cellspecific antigens is warranted.
There has been extensive research on drugs
that specifically modulate pathways implicated in
leukemia-cell growth (i.e., targeted agents).38,39

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Progenitor or
transit-amplifying
cells

Bulk
tumor
Cancer
stem cell

Figure 2. Stem-Cell Systems.

Normal tissues arise from a central stem cell that grows and differentiates
to create progenitor and mature cell populations. Key properties of normal
stem cells are the ability to self-renew (indicated by curved arrow), multilineage potential (indicated by cells of different colors), and extensive proliferative capacity. Cancer stem cells arise by means of a mutation in normal stem cells or progenitor cells, and subsequently grow and differentiate
to create primary tumors (the broken arrow indicates that specific types of
progenitors involved in the generation of cancer stem cells are unclear).
Like normal stem cells, cancer stem cells can self-renew, give rise to heterogeneous populations of daughter cells, and proliferate extensively.

Use of the ABL kinase inhibitor imatinib mesylate (Gleevec) to treat CML has had particularly
interesting results.40 Despite the remarkable clinical responses achieved with imatinib, however,
residual disease persists in many patients. In vitro
studies indicate that inhibition of the CML translocation product BCR-ABL is sufficient to eradicate most or all leukemia cells, but the drug does
not appear to kill CML stem cells.41 Imatinib
primarily affects the progeny of cancer stem cells,
so CML usually recurs when therapy is discontinued.42 Furthermore, although the newly approved
CML agent dasatinib is effective for imatinibresistant disease, recent data suggest that it too
may fail to eradicate CML stem cells.43

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Mutations
Normal stem cell
or progenitor cell

New cancer
stem cell
Primary tumor

Chemotherapy
Refractory cancer
stem cell
Primary tumor

Relapsed tumor

Tumor
cell escape
Metastatic cancer
stem cell

Metastases

Primary tumor
Figure 3. Scenarios Involving Cancer Stem Cells.
For tumors in which cancer stem cells play a role, at least three scenarios are possible. First, mutation of a normal
stem cell or progenitor cell may create a cancer stem cell, which will then generate a primary tumor (Panel A). Second, during treatment with chemotherapy, the majority of cells in a primary tumor may be destroyed, but if the cancer stem cells are not eradicated, the tumor may regrow and cause a relapse (Panel B). Third, cancer stem cells arising from a primary tumor may emigrate to distal sites and create metastatic lesions (Panel C).

Unique molecular features of leukemia stem

cells may provide opportunities for therapeutic
intervention. For example, there is evidence of
constitutive activation of both the nuclear factorB (NF-B) and phosphatidylinositol 3 (PI3) kinase signaling pathways in AML stem cells.28,44
Neither NF-B nor PI3 kinase activity is detectable in resting, normal hematopoietic stem cells,
so both of these molecular factors could be tumorspecific targets. Two studies with different methods of pharmacological inhibition of NF-B have
reported specific eradication of AML stem cells
in vitro, without apparent harm to normal hematopoietic stem cells.45,46 A separate study demonstrated that inhibition of PI3 kinase reduced the
growth of AML stem cells.44 Similarly, inhibition
of the downstream PI3-kinase mammalian target
of rapamycin (mTOR) appears to enhance the
activity of the chemotherapeutic agent etoposide

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against AML stem cells.47 Inhibition of mTOR

also blocks the growth of leukemia-initiating
cells in a mouse model of AML.48 Taken together,
these findings indicate that leukemia stem-cell
specific therapies may be attainable.
Cancer Stem Cells in the Central Nervous
System

Isolation of cancer stem cells of the central nervous system (CNS) has been achieved by means
of antigenic markers and by exploiting in vitro
culture conditions developed for normal neural
stem cells. As was first observed in 1992,49,50 CNS
cells grown on nonadherent surfaces give rise to
balls of cells (neurospheres) that have the capacity for self-renewal and can generate all of the
principal cell types of the brain (i.e., neurons,
astrocytes, and oligodendrocytes). Neurospheres
in which the stem-cell compartment is maintained

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mechanisms of disease

can be repeatedly split apart into single cells; a

small fraction of these cells can generate a new
neurosphere (Fig. 4). This capacity for repeated
generation of neurospheres from single cells is
generally viewed as evidence of self-renewal.51,52
More recent studies have demonstrated that normal neural stem cells express a cell-surface protein that can be detected with an antibody against
the AC133 (CD133) epitope,53 a marker commonly
found on stem cells and progenitor cells in various tissues.54
Application of the strategies used to generate
neurospheres to specimens obtained from gliomas55 or purification of CD133-positive cells from
human gliomas56 allows for the isolation and
growth of tumor stem-cell populations. In both
cases, the cancer stem-cell population is essential for establishing a tumor in vivo. Transplantation of as few as 100 CD133-positive human
glioma cells into the brains of immunodeficient
mice initiates the development of a glioma,
whereas no tumors result from transplantation of
105 CD133-negative cells from the same tumors.12
Many studies have demonstrated that the expression of stem-celllike properties in CNS tumor
cells does not necessarily suggest that these cells
originated from stem cells. In experimental systems, the expression of cooperating oncogenes
in lineage-restricted progenitor cells of the CNS
can yield tumors with the cytopathological characteristics of the most malignant CNS tumor (i.e,
glioblastoma multiforme). For example, expression of the ras and myc oncogenes in oligodendrocyte progenitors yields cells that readily form tumors when transplanted in vivo.57 These studies
suggest that a cancer stem cell need not be derived from a bona fide tissue-specific stem cell,
but instead can arise from a committed progenitor cell that acquired stem-celllike properties
when it underwent oncogenic transformation.
From a therapeutic perspective, the development of treatments directed against cancer stem
cells in the brain is likely to progress substantially during the next several years. The state of
knowledge of the stem cells and progenitor cells
that build the CNS is sufficiently advanced to
permit side-by-side analysis of these populations
of cells with CNS tumor cells. Furthermore, a
powerful advantage of studies of the CNS is that
all of the major precursor (i.e., replicating) populations can be grown as purified populations
with the capacity for extended division of stem

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Figure 4. Primary Human Neurosphere.

cells and progenitor cells in vitro.58-61 Therefore,

it should be feasible to conduct high-throughput
in vitro analyses to search for compounds that
selectively kill cancer stem cells without killing
the normal cells of the CNS.
Cancer Stem Cells in the Breast

In addition to cancers of the hematopoietic system and the CNS, the third major human cancer
in which cancer stem cells have been definitively
identified is breast cancer. Studies by Al-Hajj et al.
of specimens from patients with advanced stages
of metastatic breast cancer demonstrated that
cells with a specific cell-surface antigen profile
(CD44-positive and CD24-negative) could successfully establish themselves as tumor xenografts.13
The experiments were conducted with immunodeficient mice, and the cells were transplanted
into the mammary fat pad to provide an environment similar to that in human breast cancer. As
observed for analogous studies in AML and gliomas, only the relatively rare subgroup of cancer
stem cells could successfully propagate the tumor
in vivo, whereas the majority of malignant cells
failed to recapitulate the tumor. Furthermore, the
purified CD44-positive and CD24-negative cells
could differentiate and give rise to cells similar
to those found in the bulk tumor population.
Definition of the characteristics of both normal cells and cancer stem cells in the breast has
advanced rapidly.62-67 Recent studies have provided detailed characterizations of normal breast

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stem cells in mice and have demonstrated the

functional potential of such cells by virtue of
their ability to completely regenerate a mammary
gland when transplanted into a suitable host environment.68,69 With the experimental tools developed for characterization of normal mammary
stem cells, further elucidation of the biologic
properties of breast-cancer stem cells should be
forthcoming.
Challenges for Therapy Targeted
against Cancer Stem Cells

The development of treatments that target cancer

stem cells is an important objective, but the challenges are formidable. First, to design treatments
that selectively eradicate cancer stem cells, it is
useful to have the cognate normal stem cell or
progenitor cell. This step requires the development
of assays to characterize the function of normal
stem cells and the means to define physical features (i.e., cell-surface antigen markers) that will
permit their isolation. Without this knowledge, it
is impossible to know whether a candidate drug
is also cytotoxic to normal stem cells. Second, we
need similar ways to describe cancer stem cells
and appropriate functional assays must be validated. Third, it is critical to understand how cancer stem cells differ from normal stem cells, particularly with regard to mechanisms controlling
cell survival and responses to injury. Ideally, a
therapy should target pathways uniquely used by
cancer stem cells to resist extrinsic insults or to
maintain steady-state viability. Fourth, we must
understand how therapies that effectively target
the bulk of tumor cells fail to eradicate cancer
stem cells. The reasons for this phenomenon may
provide important clues for developing more effective and comprehensive regimens to attack both
the tumor stem cells and the bulk of the disease.
An additional challenge in targeting cancer
stem cells is to understand how the properties
of stem cells make them particularly difficult to
kill. Leukemia cancer stem cells reside in a largely quiescent state with regard to cell-cycle activity,27,30 like their normal counterparts. Consequently, typical cytotoxic regimens that target
rapidly dividing cells are unlikely to eradicate such
cells. Selective targeting will therefore require
regimens that kill cells independently of the cell
cycle, or that selectively induce cycling of cancer
stem cells. Another common feature of stem cells
is expression of proteins associated with the ef-

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flux of xenobiotic toxins (e.g., multidrug-resistant

proteins and related members of the ATP-binding cassette [ABC] transporter family). A variety
of cancer cells, particularly during relapse, express
such proteins, thus providing resistance to many
chemotherapeutic agents.70-73 The extent to which
cancer stem cells can mobilize all of the measures
provided by evolutionary history to protect normal stem cells is not yet known, but this information is likely to be biologically and clinically
significant.
A further concern is that normal stem cells
and progenitor cells may prove to be more sensitive than cancer stem cells to the effects of chemotherapy. Normal colon stem cells, for example, can inhibit DNA repair mechanisms and
thereby undergo apoptosis in response to DNA
damage; this mechanism avoids the accumulation of harmful mutations.74 If, however, coloncancer cells evade this protective mechanism, then
chemotherapy could preferentially spare them.
Recent studies have demonstrated that normal
hematopoietic stem cells undergo premature senescence (i.e., cellular aging) when exposed to
ionizing radiation or busulfan.75,76 This process
impairs the growth and developmental potential
of hematopoietic stem cells. If leukemia stem
cells fail to undergo senescence, as predicted by
recent studies of the genesis of cancer,77,78 then
we would expect that malignant stem cells
would actually have a growth advantage after
treatment with certain agents. Furthermore, it is
plausible that successive cycles of chemotherapy
only exacerbate the situation by increasing harm
to the normal stem-cell pool (by inducing senescence) and concomitantly increasing the growth
advantage of cancer stem cells, which are resistant to senescence. Clearly, a better understanding of normal and tumor stem cells is of great
importance not only in designing new therapies, but also in understanding the biologic and
clinical consequences of existing regimens.
If a clinical remission is achieved, the presence
of residual drug-resistant cancer stem cells can
initiate a relapse. Hence, we must develop better
methods for detection and quantitation of cancer stem cells in patients receiving cancer therapy.
Intriguing findings in leukemia indicate that the
level of residual disease directly correlates with
the long-term outcome79,80: if the number of
primitive leukemia cells can be reduced below
critical threshold levels, it may not be necessary

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mechanisms of disease

to completely eradicate the malignant clone.

Whether such residual cells are truly cancer
stem cells remains to be determined, but the
findings nonetheless suggest that sensitive realtime methods of cancer stem-cell detection are
an important priority.
In designing specific regimens for cancer stem
cells, several strategies should be considered.
Given the likelihood that aberrant regulation of
self-renewal is central to cancer stem-cell pathology, targeting pathways that mediate self-renewal
is an attractive option. An important unknown
factor is the degree to which inhibition of selfrenewal mechanisms can be tolerated, because
the pathways controlling self-renewal are central
to a variety of biologic functions. However, even
if the targeting of self-renewal pathways is feasible, we do not know whether it would kill cancer stem cells or simply suppress them. For these
reasons, an alternative is to interfere with cancer
stem-cellspecific survival pathways. For example, strategies that inhibit survival mechanisms
or the oxidative state of the cell may be selectively cytotoxic to leukemia stem cells.21 Antibody-based or ligand-based therapy also appears
to be a promising way to destroy cancer stem
cells. A small number of target antigens on cancer stem cells have been described, and with further characterization of purified populations, additional targets are likely to become available. It
remains to be determined, however, whether these
and other targets will distinguish cancer stem
cells from normal tissues.

is relevant to all the major forms of human cancer.

For this reason, it is premature to overstate the
general role of stem cells in cancer. Nonetheless,
the eradication of cancer stem cells will be necessary to improve the outcome of treatment for
at least some cancers. An interesting question is
whether different types of cancer stem cells have
the same Achilles heel; it should be possible to
determine whether the same tumor-specific mechanisms of growth and survival are active across
multiple cancer types. Because certain features of
normal stem cells are conserved in different tissues,81 determining whether there is similar conservation among cancer stem cells will be useful
in the design of new therapies.
Another important issue to investigate is how
existing chemotherapy agents affect the evolution
of cancer stem cells during conventional treatment regimens. This question relates to both the
sensitivity of normal stem cells, as compared with
malignant ones, and the mechanisms by which
drug resistance may arise. Do current forms of
treatment provide a competitive advantage for
cancer stem cells, and if so, does that selective
pressure drive the emergence of drug resistance
in cancer stem cells?
Finally, it will be critical to evaluate the clinical end points by which treatment success should
be measured. The eradication of bulk disease is
not likely to predict the efficacy of drug regimens for rare cancer cells. Therefore, the development of assays that measure the survival of
cancer stem cells will be important for assessing
the potential of new targeted regimens.

Sum m a r y

Supported by grants from the National Institutes of Health

(RO-1NS44701, to Dr. Noble, and R01-CA90446, to Dr. Jordan)
and from the Department of Defense (DAMD17-03-1-0263, to Dr.
Jordan).
Dr. Jordan reports being a scholar of the Leukemia and Lymphoma Society. No other potential conflict of interest relevant to
this article was reported.
We are indebted to the Douglas Kroll Research Foundation
for support.

There is now abundant evidence that stem-cell

properties are highly relevant to the biology of
several human cancers. However, many key questions remain. At the most fundamental level, we
must determine to what extent stem-cell biology
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