Mikroba Kanker

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Nat Rev Cancer. Author manuscript; available in PMC 2014 April 14.
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Published in final edited form as:

Nat Rev Cancer. 2013 November ; 13(11): 800812. doi:10.1038/nrc3610.
The microbiome and cancer

Robert F. Schwabe and
Department of Medicine, and Institute of Human Nutrition, Columbia University, College of
Physicians and Surgeons, New York 10032, USA
Christian Jobin
Department of Medicine and Department of Infectious Diseases & Pathology, University of
Florida, Gainesville, Florida 32611, USA
Robert F. Schwabe: [email protected]; Christian Jobin: [email protected]
Abstract
Microbiota and host form a complex super-organism in which symbiotic relationships confer
benefits to the host in many key aspects of life. However, defects in the regulatory circuits of the
host that control bacterial sensing and homeostasis, or alterations of the microbiome, through
environmental changes (infection, diet or lifestyle), may disturb this symbiotic relationship and
promote disease. Increasing evidence indicates a key role for the bacterial microbiota in
carcinogenesis. In this Opinion article, we discuss links between the bacterial microbiota and
cancer, with a particular focus on immune responses, dysbiosis, genotoxicity, metabolism and
strategies to target the microbiome for cancer prevention.
Since the late nineteenth century, when Koch postulated that a pathogen must be isolated
from the diseased subject, grown in pure culture and cause disease when reintroduced into a
susceptible recipient1, research on microbial interactions with humans has focused on single
pathogenic organisms. On the basis of these principles, we have witnessed tremendous
progress in our understanding and in the treatment of infectious diseases over the past 100
years. Moreover, we have learned that chronic infections contribute to carcinogenesis with
approximately 18% of the global cancer burden being directly attributable to infectious
agents2,3. Many pathogens, particularly viruses, promote cancer through well-described
genetic mechanisms4. Other pathogens, such as Helicobacter pylori and hepatitis C virus,
promote the development of cancer through epithelial injury and inflammation, which as
postulated by Virchow5 150 years ago contributes to carcinogenesis2,3,6. However, recent
evidence suggests that human disease is attributable not only to single pathogens but also to
global changes in our microbiome7,8. Our microbiome often termed the forgotten organ
(REF. 9) contains a metagenome that exceeds our own genome by 100-fold (REFS
10,11) and exerts key functions that are relevant to human health12. Traditional culturebased methods capture only a small proportion, typically less than 30%, of our bacterial
microbiota13. Culture-independent analysis using next-generation sequencing has closed this
2013 Macmillan Publishers Limited. All rights reserved

Competing interests statement
The authors declare no competing financial interests.
Schwabe and Jobin
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gap and has been essential in defining and understanding the bacterial microbiome and
metagenome, and its key role in metabolism and inflammation12,14 two factors that
contribute to carcinogenesis in modern societies15,16. In this Opinion article, we discuss the
possible roles of the bacterial microbiome in carcinogenesis, focusing on hostmicrobiota
interactions and effector mechanisms. The contribution of viruses to carcinogenesis has been
reviewed elsewhere4.
Cancer-modulating effects of microbiota
Microbiota and host have co-evolved into a complex super-organism, the intricate
relationships of which benefit the host in many ways, such as through nutrition and
metabolism12,14. However, this close relationship also carries risks for disease development,
particularly when host regulatory pathways that guard homeostasis are perturbed. Of the
microbial mass, 99% is within the gastrointestinal tract, and it exerts both local and longdistance effects. For this reason, the gastrointestinal microbiome not only has the greatest
effect on overall health and metabolic status of all the microbiomes but it is also the bestinvestigated microbiome and serves as a model for understanding hostmicrobiota
interactions and disease. Other organs with a well-characterized microbiome include the
skin and the vagina14,17. The microbiome of each organ is distinct14, which suggests that
effects on inflammation and carcinogenesis are likely to be organ specific. Moreover, there
is an important and functionally relevant inter-individual variability of microbiomes14,
which renders them a potential determinant of disease (including cancer) development. In
addition, the microbial community and abundance vary in different locations within
organs14,17. These differences might be an explanation for the occurrence of diseases,
including cancer, in particular locations within an organ; for example, the higher rate of
cancer in the large intestine where microbial densities are much higher than in the small
intestine9. In the gastrointestinal tract, the bacterial community also varies between luminaland mucosa-associated communities18. Although many organs, for example, the liver, do
not contain a known microbiome, they may be exposed to microorganism-associated
molecular patterns (MAMPs) and bacterial metabolites through anatomical links with the
gut1922.
Studies in germ-free animals have revealed evidence for tumour-promoting effects of the
microbiota in spontaneous, genetically-induced and carcinogen-induced cancers in various
organs, including the skin, colon, liver, breast and lungs21,2333 (TABLE 1). Similarly,
depletion of the intestinal bacterial microbiota in mice, using antibiotics, reduces the
development of cancer in the liver and the colon21,22,3437, as does the eradication of
specific pathogens in humans and in mice3840 (TABLE 1). Although most of these studies
show tumour-promoting effects of the bacterial microbiota, antitumour effects have also
been observed. In the late nineteenth century antitumour effects were observed in patients
with sarcomas, after bacterial infections or after the injection of heat-killed bacteria (termed
Coleys toxin)41,42. Subsequent studies implicated specific bacterial components, which
were later identified as Toll-like receptor (TLR) agonists and NOD-like receptor (NLR)
agonists, as being responsible for many of these antitumour effects; this led to the concept
that potent activation of innate immunity may convert tumour tolerance into antitumour
immune responses4345. However, apart from life-threatening infections and TLR- and
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NLR-based therapeutic interventions44, the bacterial microbiota rarely triggers the degree of
innate immune activation that is required for antitumour immune responses, and instead it
often induces disease-promoting low-grade chronic inflammation. Indeed, there is increasing
evidence from patients and animal models that shows relevant cancer-promoting effects of
the microbiota in many organs, particularly in those that are exposed to the microbiota or to
MAMPs (TABLE 1). However, mechanisms of microbiota-driven carcinogenesis
substantially differ between organs (TABLE 2).
Carcinogenesis triggered by specific bacterial pathogens
Gastric cancer is the prime example for bacterially driven carcinogenesis that is caused by
infection with a specific bacterial pathogen30,46,47. Infection with H. pylori, which is
classified as a carcinogen by the International Agency for Research on Cancer (IARC), may
lead to the sequential development of gastritis, gastric ulcer, atrophy and finally gastric
cancer47. With a worldwide prevalence of ~50%, and with gastric cancer occurring in 13%
of chronically infected individuals, H. pylori infection substantially contributes to global
cancer mortality47. Although identified as a carcinogenic pathogen, H. pylori-induced
gastric cancer is promoted by the presence of a complex microbiota, as H. pylori monoassociated mice developed fewer tumours than their specific pathogen-free counterparts in a
hypergastrinaemic transgenic mouse model30. This may be explained by H. pylori-induced
gastric atrophy and hypochlorhydria, which renders the stomach susceptible to bacterial
overgrowth, and subsequently increased bacterial conversion of dietary nitrates into
carcinogens30. In contrast to its promotion of gastric carcinogenesis, H. pylori infection
lowers the risk of oesophageal adenocarcinoma in humans46,48, which emphasizes the
organ-specific effects of the bacterial microbiota in carcinogenesis.
Additional examples of carcinogenesis promoted by specific bacterial pathogens are

gallbladder cancer (that is associated with chronic Salmonella enterica subsp. enterica
serovar Typhi and Salmonella enterica subsp. enterica serovar Paratyphi infections49,50),
and mucosa-associated lymphoid tissue (MALT) lymphomas, both of which are examples of
tumours that are triggered by adaptive immune responses against specific pathogens. Gastric
MALT lymphoma is characterized by clonal expansion of B cells and T helper (TH) cells
that are reactive to H. pylori-derived antigens, and regression occurs after H. pylori
eradication51. Similarly, infections with Campylobacter jejuni, Borrelia burgdorferi and
Chlamydia psittaci are associated with certain lymphomas, and these commonly regress
after antibiotic treatment5254 (TABLES 1,2).
Cancers promoted by dysbiotic microbiomes
A wealth of studies in patients and mice has linked the microbiota to colorectal
carcinogenesis55. In contrast to gastric carcinogenesis, tumour-promoting effects of the
microbiota in colorectal cancer (CRC) seem to be caused by altered hostmicrobiota
interactions and by dysbiosis, rather than by infections with specific pathogens.
Accordingly, germ-free status and treatment with wide-spectrum antibiotics led to a
significant reduction of the numbers of tumours in chemical and genetic experimental
models of colorectal carcinogenesis25,27,3234,36,37. The liver does not contain a known
microbiome and it provides a prime example of cancer that is promoted by dysbiotic
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microbiota through long-distance mechanisms. Intestinal bacteria may promote liver cancer
through proinflammatory MAMPs and bacterial metabolites, both of which reach the liver
via the portal vein21,22,35. Notably, hepatic exposure to cancer-promoting MAMPs and
metabolites is increased in liver disease, and has been linked to intestinal dysbiosis1922.
Accordingly, germ-free status and non-absorbable antibiotics reduce hepatic inflammation,
fibrosis and hepatocellular carcinoma (HCC) development in mice2022,35, whereas
treatment with the TLR4 agonist lipopolysaccharide (LPS) increases HCC development21.
Similar to the liver, the pancreas does not have a known microbiome. Recent studies suggest
that inflammatory MAMPs, such as LPS and its receptor TLR4, promote pancreatic
cancer56. Moreover, there is an association of the oral microbiome and periodontitis with
pancreatic cancer57,58. However, the mechanisms by which the bacterial microbiota and
MAMPs promote pancreatic cancer remain elusive.
There are considerable gaps in our knowledge about the role of the microbiota in
carcinogenesis in many other organs that have a substantial bacterial microbiome, such as
the lungs, skin, oral cavity and female genital tract. Several findings indicate a possible role
for bacteria in the promotion of lung cancer, such as the increased bacterial colonization in
chronic obstructive pulmonary disease (COPD59,60; which is a known risk factor for lung
cancer development61), a lower incidence of lung cancer in germ-free male rats, and the
promotion of lung cancer by LPS or by chronic respiratory infections24,62. Similarly, the
reduced rate of skin cancer in germ-free rats23 and in mice lacking receptors or adaptor
molecules for pro-inflammatory bacterial MAMPs6365 also suggests a possible role for the
bacterial microbiota in skin carcinogenesis.
Hostmicrobiota interplay in cancer

Mechanisms controlling hostmicrobiota interactions in the super-organism
Millions of years of evolution have seen the host and its surrounding microbial environment
co-evolve into a complex super-organism in which numerous relationships such as
commensalism, mutualism and parasitism are established within the ecosystem66,67.
Microbial communities, which either benefit or do not harm the host, have an evolutionary
advantage at establishing a permanent niche and reside in a state of immune tolerance with
their host, whereas those that adopt a pathogenic relationship on entering the ecosystem
activate robust innate and adaptive immune responses68. A key principle that allows the
symbiotic coexistence between host and microbiota is the anatomical separation of microbial
entities from the host compartment by well-maintained, multi-level barriers. Perturbation of
these barriers promotes inflammation and diseases, including cancer. The barriers rely on an
intact epithelial lining, sensing systems that detect and eliminate invading bacteria, and in
some cases on additional features such as a mucous layer (in the gut), the stratum corneum
(in the skin) and a low pH (in the skin and the stomach). Furthermore, specific cell types,
such as Paneth and goblet cells in the gut and keratinocytes in the skin, monitor bacterial
number and location, and regulate the microbiota through the secretion of antibacterial
peptides69,70. Barriers are also enriched in specific subsets of immune cells, such as gutassociated lymphoid tissue (GALT), Langerhans cells in the skin and TH17 cells at mucosal
surfaces70,71. In the gut, secreted immunoglobulin A represents an additional mechanism by
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which the host controls the microbiota; this host mechanism limits the access of intestinal
antigens to the circulation and limits the invasiveness of potentially dangerous bacterial
species72. Besides host mechanisms, the microbiome itself represents a functional luminal
barrier73 by maintaining epithelial cell turnover, by mucin production and by competing for
resources, thereby suppressing the growth of pathobionts. A prime example for the
protective role of the commensal microbiota is infection with Clostridium difficile, which
only thrives and causes disease when the indigenous gut microbiota is suppressed by
antibiotics, and which can be cured by microbiota transplantation from healthy
individuals74. Similarly, germ-free mice have an increased susceptibility to infection with
pathogens75. In addition to resource competition with metabolically related strains75,
commensal bacteria also suppress pathobionts and pathogens using active interference
mechanisms such as the production of bacteriocins76.
Failure of these control mechanisms that is, barrier defects, immune defects and the loss
of eubiosis have been associated with microbially driven carcinogenesis. Importantly,
regulatory mechanisms are tightly linked, and failure of one control mechanism typically
perturbs the overall equilibrium (FIG. 1). As such, infection with H. pylori not only directly
injures host cells, but also changes the gastric environment and barrier, increasing
inflammation and altering the microbiota47. Another example of the interdependence
between the barrier, immunity and the microbiota is the finding that inactivating mutations,
or the absence of key components of inflammasomes nucleotide-binding oligomerization
domain-containing 2 (NOD2) and NOD-, LRR- and pyrin domain-containing 6 (NLRP6)
or of interleukin-10 (IL-10), not only affect host inflammatory responses but may also lead
to dysbiosis and to bacterial translocation7779.
Barrier failure in carcinogenesis
The most relevant pathomechanism for bacterially driven carcinogenesis is barrier failure,
which results in increased microbiotahost interactions. Barrier failure can result from
primary defects in genes that encode proteins that are essential to maintain a functional
barrier, or from secondary defects owing to infection, inflammation and carcinogenesis. The
relationship between barrier failure and carcinogenesis is complex: barrier failure may
trigger inflammation and carcinogenesis, but inflammation and carcinogenesis may also
promote barrier failure, thus suggesting the existence of forward-amplifying loops.
Clinically, the best known example of barrier failure is ulcerative colitis, in which defects in
the intestinal barrier not only contribute to disease development but also increase the risk of
cancer80. Accordingly, genome-wide association studies have found mutations in crucial
barrier proteins, such as laminins, in patients with ulcerative colitis81,82.
The promotion of cancer by a defective barrier is shown by mucin 2-knockout (Muc2/)
mice, which lack the most abundant gastrointestinal mucin and which spontaneously
develop CRC83. In experimental colorectal carcinogenesis, bacterial translocation was
detected at sites of tumour initiation, and eradication of the bacterial microbiota by
antibiotics reduced CRC development36. Another example of barrier defects contributing to
cancer development is HCC. Increased translocation of bacteria and of bacterial MAMPs,
which are a hallmark of advanced liver disease19, promotes HCC development and can be
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reduced by germ-free status or by antibiotics21,35. Although genetic defects in the keratinassociated protein filaggrin affect the barrier function in the skin and contribute to atopic
dermatitis84, they have not been associated with cancer development. Thus, barrier defects
may require organ-specific second hits to promote cancer development.
Bacterial dysbiosis in carcinogenesis
Longitudinal studies show considerable taxonomic (but little metagenomic) variation of the
normal human microbiota14,85,86. Perturbations may occur through changes in diet, innate
immune responses and inflammation, or infections, and may affect microbial composition,
richness and the metagenome77,87,88. Besides the well-established cancer-promoting role of
specific pathogens in certain cancers (TABLE 2), a contribution of specific bacteria to
human carcinogenesis generally remains elusive. Additional bacterial pathogens such as
Enterococcus faecalis, enterotoxigenic Bacteroides fragilis and Helicobacter hepaticus
promote cancer in animal models8994, but there is no clear epidemiological link to human
carcinogenesis.
However, direct manipulation of the microbial community using germfree, gnotobiotic,

antibiotic-treated and co-housed mice has revealed the essential role of commensal
microbiota in CRC and HCC21,22,35,36,78,79,95,96. Indeed, thought-provoking studies
involving Nod2/, Asc/ (also known as Pycard/) and Nlrp6/ mice, suggest that
dysbiosis is sufficient to promote cancer78,79. Obesity is one of the best-studied conditions
that leads to dysbiosis, with increased populations of Firmicutes and decreased populations
of Bacteroidetes observed in the gut of both humans and mice88,97, as well as a decrease in
microbial richness and the associated dysmetabolism in humans98,99. Notably, obesity is a
well-established risk factor for cancer development, contributing to ~1520% of cancer100.
In liver cancer, obesity causes cancer-promoting dysbiosis, with increased prevalence of
Clostridia that produce the secondary bile acid deoxycholic acid (DCA), which in turn
promotes HCC development22. However, direct evidence of the cancer-promoting effect of
specific Clostridia strains for example, through co-housing experiments or the use of
gnotobiotic mice is still lacking. In the colon, dietary fat increases taurocholic acid
production, which leads to the expansion of the pathobiont Bilophila wadsworthia and to
colitis in Il10/ mice101, but a direct link between obesity-induced dysbiosis and CRC also
remains to be established.
Microbial dysbiosis in the luminal or the mucosal compartment of patients with CRC has
been reported by numerous investigators102105, but these findings remain largely
correlative. However, from these data sets, Fusobacterium spp. particularly
Fusobacterium nucleatum emerge as a potential candidate for CRC susceptibility106109.
F. nucleatum is far less common in the gut microbiome of healthy individuals than it is in
the gut microbiome of patients with Crohns disease110. Notably, clinically isolated F.
nucleatum promotes intestinal carcinogenesis in adenomatous polyposis coli (Apc)Min/+
mice107. The F. nucleatum adhesin FadA binds to E-cadherin and activates -catenin in
CRC cells, thereby promoting inflammation and E-cadherin-mediated tumour cell
growth109. Importantly, fadA levels are significantly increased in human CRC tissue
samples109.
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As the bacterial microbiota has a high redundancy at the metagenomic level14, it is possible
that cancer-promoting effects are conferred by different classes of bacteria but through
similar pathways, and that alterations in microbial richness and function (rather than true
dysbiosis) affect carcinogenesis. Moreover, horizontal gene transfer occurs between
pathogens and commensal bacteria, particularly in the context of pathogen-induced
inflammation111, which suggests the possibility of cancer-promoting gene transfer between
bacteria.
The mechanisms that contribute to dysbiosis and to alterations in microbial richness are not
yet understood. Host-derived immune and inflammatory responses are an important driving
force that shape the microbial community composition and, when altered, that may
contribute to dysbiosis, as seen in Il10/, Nod2/, Asc/ and Nlrp6/ mice7779,112. In
addition to microbial regulation by innate immunity, inflammation (with its complex set of
mediators) may also contribute to a milieu that favours the outgrowth of specific bacteria.
Inflammation alters the production of specific metabolites, such as nitrate that is derived
from the activity of inducible nitric oxide synthase (iNOS; also known as NOS2). Nitrate
may provide a unique source of energy for facultative anaerobic bacteria (for example,
Enterobacteriaceae), allowing them to thrive within a community dominated by obligate
anaerobic bacteria that lack the proper electron transport chain to use nitrate113.
Accordingly, a bloom of Enterobacteriaceae has been observed across numerous
inflammatory disease models and in patients with chronic inflammation114116. Finally,
inflammation induces expression of stress-response genes in bacteria, which is an effect that
could promote bacterial fitness and adaptability117; for example, Escherichia coli from
Il10/ mice with intestinal inflammation show an increased expression of small heat shock
proteins IbpA and IbpB, which protects this bacterium from oxidative stress117.
Furthermore, it has been suggested that specific low-abundance microorganisms, termed
keystone pathogens or alpha-bugs, may further amplify dysbiosis in disease states by
exerting dominant effects on the bacterial composition118.
Mechanisms of carcinogenesis
The microbiota is sensed by multiple pattern recognition receptors (PRRs), which monitor
microbial status and barrier integrity, and which initiate regulatory responses. These PRRs
may not only control the microbiota through antibacterial mediators and thereby suppress
cancer, but may also promote resistance to cell death one of the hallmarks of cancers119
and may trigger cancer-promoting inflammation. In addition, the microbiota affects
carcinogenesis through the release of carcinogenic molecules, such as genotoxins, and
through the production of tumour-promoting metabolites.
Microbiota-induced activation of TLRs in carcinogenesis
Microbial pattern recognition by TLRs is a cornerstone of innate immunity and it represents
one of the most powerful pro-inflammatory stimuli120. Accumulating evidence indicates that
bacterial MAMPs and TLRs are contributors to carcinogenesis. TLR4, the receptor for the
Gram-negative bacterial cell wall component LPS, promotes carcinogenesis in the colon,
liver, pancreas and skin, as shown by reduced tumour development in Tlr4-deficient
mice21,56,64,121 and by increased tumour load in mice expressing constitutively activated
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epithelial-derived TLR4 (REF. 122). TLR2, which is the receptor for the bacterial cell wall
components peptidoglycan and lipoteichoic acid, promotes gastric cancer123. TLRs promote
epithelial carcinogenesis through epithelial cells, stromal fibroblasts and through bone
marrow-derived cells. A key cancer-promoting downstream effect of TLR signals is the
induction of survival pathways, which is mediated by activation of nuclear factor-B (NFB) and signal transducer and activator of transcription 3 (STAT3)21,121,123. Although there
is strong evidence that tumour cells express TLRs121,123, conditional ablation strategies are
required to determine whether activation of TLR signalling directly affects the survival of
tumour cells, or whether tumour cell survival is indirectly affected through TLRs that are
expressed in the tumour stroma. The pro-survival function of the TLRmyeloid
differentiation primary response 88 (MYD88) pathway is highlighted by the finding that
human lymphomas often contain an activating point mutation in MYD88 that triggers NF-B
and STAT3 activation124. In the intestine, microbiota-induced activation of TLRs on
myeloid cells triggers an IL-17 and IL-23 pro-carcinogenic pathway, as shown by their
decreased expression after antibiotic treatment or genetic inactivation of Myd88, Tlr2, Tlr4
or Tlr9 (REF. 36). Importantly, carcinogenesis is reduced by genetic or pharmacological
inhibition of IL-17 and IL-23 signalling36,92. TLRs may also promote tumour proliferation,
which is thought to be mediated through mitogens such as epiregulin, amphiregulin and
hepatocyte growth factor (HGF) that are released from TLR-expressing stromal fibroblasts;
this has been shown in the colon and in the liver21,121,125,126.
It should be emphasized that signalling pathways used by TLRs, such as MYD88, often
have multiple functions, and that complete ablation not only affects malignant cells but also
affects the function of normal epithelia. In the intestinal epithelium, MYD88 functions as a
gatekeeper of epithelial integrity. This may explain why MYD88 deficiency not only
suppresses the development of cancer127130 but also promotes carcinogenesis in models
with substantial epithelial damage, such as in the model of dextran sodium sulphate (DSS)promoted CRC56,131. The increased damage possibly masks potential tumour-suppressive
effects of reduced MYD-88-mediated inflammation in these models. MYD88 is also a
mediator of IL-18 signalling, and the absence of MYD88 may therefore promote
carcinogenesis by blocking the activity of an IL-18-dependent pathway that influences
microbial composition (discussed below).
Microbiota-induced activation of NLRs in carcinogenesis

NLRs are a family of PRRs that are characterized by a central NOD domain112. NOD2, a
muramyl dipeptide-sensing NLR, has been the focus of many studies because its loss of
activity is associated with Crohns disease80. Notably, inactivating polymorphisms in NOD2
have been associated with increased susceptibility to CRC in several cohorts132. Similar to
what is seen in patients with Crohns disease, Nod2 deficiency leads to increased CRC in
mice78. NOD2 exerts a key role in bacterial immunity, as shown by the increased
susceptibility of NOD2-deficient mice to bacterial infections, and by the decreased ability of
NOD2-deficient crypts to kill commensal bacteria133,134. Interestingly, Nod2/ mice, as
well as patients with NOD2 mutations, also have intestinal dysbiosis135. Indeed, a thoughtprovoking study has recently suggested that the increased cancer susceptibility in NOD2-
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deficient mice is a consequence of dysbiosis, as the increased cancer development was

transferable to wild-type mice by co-housing78.

A second NLR implicated in the hostmicrobiota interaction and in bacterially driven

carcinogenesis is NLRP6. NLRP6 is a component of inflammasomes and it contributes to
their activation, as shown by decreased levels of IL-18 in Nlrp6/ mice79. Similar to
Nod2/ mice, Nlrp6/ mice have dysbiosis that makes them more susceptible to colitis and
CRC development. The dysbiosis-driven carcinogenesis in Nlrp6/ mice is a result of
decreased inflammasome activation and IL-18 production, as shown by the increased
susceptibility of Asc/ and Il18/ mice to CRC, and by the ability of these mice to transmit
this disease to wild-type mice in co-housing studies79. IL-6 represents a common mediator
of the tumour-promoting effects of dysbiotic Nod2/ and Nlrp6/ mice, as shown by
reduced CRC development in mice that are treated with neutralizing IL-6 receptor (IL-6R)
antibodies and in mice with Il6r ablation78,79. NOD1 also has a role in intestinal defence
against bacteria, and NOD1 variants have been implicated in inflammatory bowel disease in
humans136. Notably, NOD1 deficiency negatively affects the intestinal barrier and it
promotes inflammation- and genetically-induced CRC, which can be suppressed by
depletion of the gut microbiota by antibiotic treatment34. Other NLRs such as NLRP3,
NLRP12 and NOD-, LRR- and CARD-containing 4 (NLRC4) also have a role in colitisassociated cancer137139, but the functional contribution of these innate sensors to
microbially driven carcinogenesis remains unclear.
Bacterial-derived genotoxins
Although the ability of some bacteria to induce chronic inflammation (and an associated
increase in reactive oxygen species (ROS)-mediated genotoxicity) clearly contributes to
their carcinogenic potential, microorganisms also have the capacity to directly modulate
tumorigenesis through specific toxins that induce DNA damage responses (FIG. 2). As
discussed above, alterations in barrier function may allow luminal bacteria (such as
adherent-invasive E. coli) access to the epithelium, where direct contact with host cells
enables the bacteria to transfer or to deliver specific toxins. Bacterial toxins, such as
cytolethal distending toxin (CDT), cytotoxic necrotizing factor 1, B. fragilis toxin and
colibactin, affect crucial cellular responses that are implicated in tumorigenesis, particularly
responses to DNA damage77,92,140142. However, only CDT and colibactin exert direct
DNA damage responses and genomic instability, and are therefore considered
genotoxic141,142. Both of these genotoxins trigger double-strand DNA damage responses,
including activation of the ataxia-telangiectasia mutated (ATM)CHK2 signalling pathway
and phosphorylation of histone H2AX, which lead to transient G2/M cell cycle arrest and to
cell swelling.
CDT is produced by Gram-negative bacteria and is by far the most wellcharacterized
genotoxin. Microorganisms relevant to colorectal, gastric and gallbladder cancer (such as E.
coli, Helicobacter spp. and S. Typhi) are all CDT producers143. Upon infection, the CdtA
and CdtC subunits form an anchor between the bacterium and the host cell to allow delivery
of the active subunit CdtB into the cytoplasm, from where it travels to the nucleus and
confers DNase activity-mediated DNA damage141. Mutation of residues in the active site of
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CdtB, which are highly homologous to those in mammalian DNase I sites, reduces DNA
damage responses in vitro, including cell cycle arrest141,144. CDT-mediated DNase activity
may also be important for the carcinogenic potential of CDT-carrying bacteria, such as C.
jejuni and Helicobacter cinaedi, because CdtB-mutant strains failed to elicit intestinal
hyperplasia in mice lacking NF-B subunits, p50 (also known as Nfkb1) and one allele of
p65 (also known as Rela), and failed to elicit dysplasia in Il10/ mice145,146.
Colibactin, which is encoded in the 54 kb polyketide synthase (pks) genotoxicity island, is

another important genotoxin that has attracted recent attention. pks-containing bacteria
mostly belong to the Enterobacteriaceae family, with E. coli from the B2 groups
representing the predominant carrier147. Recently, the murine isolate E. coli NC101 pks was
functionally linked to CRC development in gnotobiotic Il10/ mice77, and the pks island
was more prevalent in mucosa-associated E. coli clinical isolates obtained from patients with
CRC compared with those obtained from controls77,148. Interestingly, Proteus mirabilis and
Klebsiella pneumoniae, two microorganisms that can induce a maternally transmissible
colitis in immunodeficient mice that are deficient in both T-bet (also known as TBX21) and
recombination activating gene 2 (RAG2; Tbet/Rag2/ mice) 149, are also pks carriers150.
Whether P. mirabilis, K. pneumoniae and colibactin are functionally implicated in the
development of CRC observed in Tbet/Rag2/ mice95 remains to be determined.
Colibactin has not been isolated and purified, but it is known that eight of nine accessory
genes, and all the PkS and nonribosomal peptide synthetase (NRPS) subunits, are required to
generate active colibactin with DNA-damaging capacity147. At the molecular level, E. coli
pks-positive strains induce double-strand DNA breaks and associated DNA damage
responses (mediated by ATM), cell cycle arrest and genomic instability77,142. Colibactin
genotoxicity and carcinogenic effects might be mediated by DNase activity. This hypothesis
is supported by the finding that DNA integrity in cells infected with E. coli pks+ strains is
compromised compared with pks-defective isogenic mutants147. Whether this effect is the
direct result of colibactin, as is the case for CDT, or is due to an intermediate target, needs
further investigation.
Moreover, various bacterial-derived metabolites such as hydrogen sulphide and superoxide

radicals may cause genomic instability151,152. For example, Enterococcus faecalis can
generate large amounts of extracellular superoxide, which causes double-strand DNA breaks
and chromosome instability152,153; this leads to the development of CRC in Il10/
mice154,155. E. faecalis mutants that are defective in extracellular superoxide production (for
example, menB strain) fail to promote tumorigenesis in Il10/ mice compared with mice
colonized with the parental E. faecalis strain154,155. Sulphate-reducing bacteria which
mostly belong to the class of Fusobacteria (which has recently been linked to CRC106,156
and tumour development in preclinical models107) and to the class Deltaproteobacteria
promote the generation of hydrogen sulphide, which is a gas with genotoxic properties157.
Host-mediated detoxification and/or microbial-mediated elimination (or use) of these
genotoxic products are likely to have an effect on host cellular homeostasis and on
carcinogenesis.
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Bacterial virulence factors
Disease-promoting and cancer-promoting effects of pathogens often depend on virulence

factors. This is exemplified by increased inflammation and cancer rates in H. pylori strains
expressing the virulence factors cytotoxin-associated gene A (CagA) or vacuolating
cytotoxin A (VacA)47. Virulence factors may use specific host-derived signalling pathways
that result in the activation of tumour-promoting pathways, as demonstrated by the
activation of the tyrosine phosphatase SHP2 (also known as PTPN11) and by the
development of gastric cancers in transgenic mice expressing CagA, but not
phosphorylation-resistant CagA158. In addition, F. nucleatum uses the virulence factor FadA
to adhere to and invade cells159, and was recently shown to interact with E-cadherin to
activate -catenin signalling and to promote CRC development109. Virulence factors found
in other pathogens and commensal bacteria are likely to contribute to carcinogenesis, but
this requires further investigation.
Microbial-derived metabolism affecting carcinogenesis
Human metabolism represents a combination of microbial and human enzyme activities11.

The bacterial metagenome is functionally far more diverse than that of humans, and is
enriched for genes that are relevant for nutrient, bile acid and xenobiotic metabolism, as well
as for the biosynthesis of vitamins and isoprenoids11,160. These metabolic activities,
generated by the oral and intestinal microbiota, may affect carcinogenesis by regulating
obesity and obesity-induced inflammation, metabolic activation and inactivation of
carcinogens (which includes the generation of nitrosamines and the conversion of alcohol to
acetaldehyde), metabolic activation or inactivation of dietary phytochemicals, metabolism of
hormones and the generation of tumour-promoting secondary bile acids.
Gut bacteria regulate bile acid metabolism through various hydrolase activities, which
remove polar groups for example, taurine from conjugated bile acids, thereby
affecting bile acid composition and enterohepatic circulation, and allowing microorganisms
to use secondary bile acids as an energy source160. Recent studies suggest that a high-fat diet
alters the gut microbiome and increases the levels of the secondary bile acid DCA, which is
a metabolite that is solely produced by bacterial 7-dehydroxylation. Notably, in this highfat diet model, DCA supplementation increases HCC development, whereas reduction of
DCA-producing bacteria by antibiotics decreases it22. DCA is also known to promote colon
and oesophageal cancer, which suggests that the microbiome may also affect these cancers
through DCA production, particularly in the context of obesity22,161,162.
Microbial carbohydrate fermentation may benefit the host through the generation of shortchain fatty acids163, whereas protein fermentation may have negative consequences owing
to the generation of potentially toxic and cancer-promoting metabolites, such as ammonia,
amines, phenols, sulphides and nitrosamines151,164166. As protein fermentation mainly
occurs in the distal colon, this might contribute to the higher rate of cancers in the distal
(small) versus the proximal (large) intestine. High-protein, low-carbohydrate diets may
change intestinal fermentation, leading to increased levels of hazardous metabolites, such as
nitrosamines, and to decreased levels of cancer- protective metabolites, such as butyrate and
plant-derived phenolic compounds167. In particular, short-chain fatty acids incuding butyrate
Schwabe and Jobin
Page 12
have a known role in the regulation of inflammation and autophagy, and have been
implicated in protection from colon and liver cancer168171. Health-promoting, antioxidant
and cancer-preventing properties of plant-derived products are often attributed to
phytochemicals, including polyphenols such as theaflavins, thearubigins, epigallocatechin-3gallate and flavonoids172174. Through its large enzymatic capacity, the microbiota
synthesizes, bioconverts or degrades isoprenoids and polyphenols (including flavonoids),
thus controlling their local and systemic effects on health and cancer
development11,173,175178. The gut microbiota also modulates the biological activity of
lignans177,179, a class of phytooestrogens that reduces cancer incidence180, thereby affecting
cancer development. Although the microbiota is necessary for phytochemical-mediated
anticancer properties, the microbial entities and complex partnerships that contribute to
these beneficial effects remain unclear.
The intestinal microbiota also has a major role in the metabolism of xenobiotics181. As such,
it influences the activity and the side effects of drugs used for antitumour therapies. For
example, irinotecan is inactivated by the liver but reactivated by bacterial -glucoronidase,
which leads to severe treatment-limiting side effects such as diarrhoea182; notably, treatment
with antibiotics or inhibitors of bacterial -glucoronidase prevents these complications182.
The microbiota also contributes to the activation28,183,184 and the inactivation of

carcinogens185,186, thereby modulating carcinogenesis. Importantly, the bacterial microbiota
contributes to the metabolism of alcohol, which is responsible for ~3.6% of all cancers187,
including cancers of the oral cavity, pharynx, oesophagus, colon, rectum, female breast and
liver. Germ-free rats have significantly lower concentrations of acetaldehyde188, which
mediates many of the disease-promoting and genotoxic effects of alcohol187. The
contribution of bacterial acetaldehyde generation may be particularly important in cancers of
the oral cavity, where further metabolism of acetaldehyde is limited, leading to 10100-fold
higher acetaldehyde concentrations than in the blood187.
The bacterial microbiota may also have a role in the metabolism of hormones, including
oestrogens189 and testosterone190. In particular, the microbiota modulates the enterohepatic
circulation of oestrogens through their ability to deconjugate oestrogens, thus affecting
circulating and excreted oestrogen levels189, and the risk for development of oestrogendependent cancers189.
In summary, the intricate relationship between the microbiota and the host in respect to
tumour-promoting and tumour-suppressive components of our diets and lifestyles is only
starting to be appreciated. Consumption of unhealthy diets, obesity, alcohol and smoking are
all known to modulate microbiomes and to contribute to carcinogenesis. The relative
contribution of microbiomes and microbial metabolism to the carcinogenesis that is
promoted by these unhealthy lifestyles remains to be determined.
Open questions and crucial issues

Although the link between the microbiota and cancer has been recognized, several key
questions remain unanswered in this rapidly evolving field of research.
Schwabe and Jobin
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Evidence for a contribution of microbiomes in human carcinogenesis
The functional relevance of human microbiomes to cancer development has not been
established. Transferring human cancer microbiomes to preclinical models would help to
assess the tumorigenic potential of the cancer-associated microbiota. However, experiments
using cross-species transplantation need to take into account host-specific microbiota effects
on the immune system191, which are an important component of the carcinogenic process.
Multifaceted and large-scale approaches that integrate metagenomic, metatranscriptomic and

metabolomic analysis from large cohorts of patients and healthy controls will be essential in
establishing the role that microbiomes have in cancer development, in an organ- and cancerspecific manner, and will allow investigators to determine whether changes in microbial
composition or richness, in particular at the metagenomic level, affect cancer development.
Validation of the cancer-inducing potential of clinical bacterial isolates would require the
use of various animal models, combined with different housing conditions specific
pathogen-free (SPF) and germ-free conditions, as well as gnotobiotics to clearly establish
causeeffect relationships. Furthermore, testing clinical isolates in more than one model is
also important as, for example, F. nucleatum promotes colorectal cancer in ApcMin/+ mice
but not in Il10/ mice107.
The contribution of extra-intestinal microbiomes to carcinogenesis
Most current data on the microbiota and cancer focus on the gut microbiome. Although the
gut microbiome dominates in number, other microbiomes may also have relevance to
cancer; for example, the contribution of the lung microbiome to lung cancer is clearly
understudied, and understanding this possible link may be relevant. Similarly, further insight
into the roles of microbiomes of the skin and the urogenital tract could be highly relevant.
Identification of bacteria and bacterial mediators or metabolites that promote cancer
Identification of key contributors to microbiota-driven carcinogenesis is required to develop

therapeutic approaches. Innovative techniques, including novel cultivation media,
particularly for anaerobic conditions192, and novel culture techniques such as microfluidic
continuous cultures193 will be necessary to overcome the limited range of bacteria that can
currently be cultured and that can subsequently be characterized in vitro or in gnotobiotic
animal models. Although gnotobiotic models are a powerful tool to understand microbial
contributions to carcinogenesis, this experimental approach does not reflect the complex
composition of the microbiome that is found in humans; indeed, it may either
overemphasize effects owing to artificial abundance of a single species or of a group of
bacteria, or it may not reveal effects that are due to the requirement of a complex microbial
community for the induction of disease by some bacteria149. It will be important to identify
the environmental conditions that lead to under-representation and overrepresentation of
bacterial species that are associated with cancer, and to mimic these conditions in
experimental models.
In addition to identifying the specific bacteria that contribute to carcinogenesis, the
identification of the mediators through which these bacteria promote cancer is essential to
advance therapeutic interventions. The recent discovery of the roles of bacterial genotoxins
Schwabe and Jobin
Page 14
and secondary bile acid metabolites as key effectors in mouse carcinogenesis is a first step
towards understanding how bacteria may directly promote cancer. Large-scale and deepsequencing analyses, in combination with proteomics and metabolomics, are likely to
uncover additional genotoxic islands and cancer-promoting metabolites or other factors
present in clinical isolates.
The interplay between inflammation and the microbiome in carcinogenesis
Although inflammation is an important environmental trigger that shapes microbial

composition194,195, it is not clear whether dysbiosis is fostered by the progression of
inflammatory grades or whether other factors (such as host genetics or diet) imprint early
microbial dysbiosis, which then promotes inflammation. This causeeffect relationship will
need to be investigated in more detail using longitudinal microbiome analysis in conjunction
with the measurement of inflammatory markers. Similarly, the functional effect of innate
sensors such as TLR2, TLR4 and TLR5 on microbial composition has been questioned196;
for example, although the dysbiotic microbiota from Nod2/ mice transfers carcinogenesis
to wild-type mice78, several groups have found no evidence of dysbiosis in Nod2/
mice197,198. These findings do not negate the observation that the microbiota could transfer
a given disease phenotype, but they certainly do question the causative link between a
specific genotype (for example, Nod2/) and dysbiosis. This highlights the need to carry
out additional experiments in which familial transmission196 and stochastic changes199 are
carefully monitored and assessed before firm conclusions are reached about dysbiosis and
the host genotype. Moreover, many PRRs not only regulate innate immunity and
inflammation but also regulate barrier integrity. An alternative mechanistic explanation for
the effects of PRRs in carcinogenesis could be that a breach of barriers owing to insufficient
PRR activity constitutes the key trigger in microbially driven inflammation and
carcinogenesis. In this scenario, dysbiosis could be an epiphenomenon to the pathology.
Another important unanswered question is the relationship between the microbiome and
cancer therapeutic responses. Although the influence of the gut microbiota in shaping local
and systemic immune responses has been recognized195, the effect of this biological
function on the efficacy of antitumour agents is unknown.
Possible future therapeutic applications
The many mechanisms by which the microbiota modulates carcinogenesis, including

inflammation, metabolism and genotoxicity (FIG. 2), provide possibilities to target the
microbiome for cancer prevention strategies. Although additional data linking the
contribution of the microbiome to specific cancers, particularly in humans, need to be
generated, microbiota-based strategies for cancer prevention can be envisioned (FIG. 3).
Prebiotics, probiotics or microbiota transplants may restore eubiosis in chronic disease
states, thereby reducing microbially-induced genotoxicity and activation of inflammatory,
proliferative and antiapoptotic pathways. Limited-spectrum and non-absorbable antibiotics
may be used to target genotoxic, DCA-producing or translocating bacteria; for example, in
patients at a high risk of developing CRC or HCC. Genetically altered microbiota expressing
or lacking specific enzymes200 in combination with matched diets might be used to
achieve higher levels of tumour-suppressive phytochemicals or lower levels of tumour-
Schwabe and Jobin
Page 15
promoting substances, or to suppress tumour-promoting bacterial species. Pharmacological

targeting of inflammatory pathways that are activated by the bacterial microbiota may
reduce cancer-promoting inflammation, and pharmacological approaches may be used to
target bacterial genotoxins and enzymes that promote cancer.
Understanding the diverse contributions of the bacterial microbiota to carcinogenesis will
open new possibilities for diagnostic, preventative and therapeutic approaches. Although it
is likely that many of the underlying mechanisms are disease- or organspecific, mining the
microbiome holds much promise and clearly represents the next frontier of medical research.
Acknowledgments
R.F.S. was supported by grants from the US National Institutes of Health (NIH) U54CA163111, R01DK076920
and R01AA020211. C.J. acknowledges support from the NIH (RO1DK047700 and RO1DK073338). The authors
thank D. Dapito for critical reading of the manuscript.
Glossary
Adaptive immune
responses
As opposed to innate immunity, adaptive immune responses are

specific to the type of pathogen that is encountered, thereby
providing a tailored (albeit slower) immune response. This
acquired response is typically mediated by B and T cells with the
subsequent generation of memory cells
Bacteriocins
Antimicrobial peptides released by bacteria to inhibit growth of

similar or closely related microorganisms
Commensalism
A relationship between two organisms in which one organism

benefits, whereas the other does not
Dysbiosis
A state of microbial composition that is characterized by an

unbalanced proportion of bacteria compared with the proportion
in a healthy state
Eubiosis
A state of microbial composition in which population abundances

are found in normal proportions and typically associated with
healthy individuals
Facultative
anaerobic bacteria
Bacteria that are able to generate energy (ATP) through aerobic

respiration (electron transport chain) or through fermentation,
depending on the amount of oxygen or fermentable products
available
Germ-free animals
Animals born and raised in a sterile environment; they lack any

microorganisms (except endogenous viruses)
Gnotobiotic
Describes an animal with a defined microbial population. These

animals are born germ-free and then known microorganisms are
introduced; this requires that the animals are housed in isolation,
to maintain their defined microbial status
Schwabe and Jobin
Page 16

Horizontal gene
transfer
The movement of genetic material from one organism to another,

without the need for cell division
Innate immunity
An immune response that recognizes conserved microbial

structures, typically through the action of pattern recognition
receptors expressed on host cells
Metagenome
The collection of genomes from members of a specific microbiota
Microorganismassociated
molecular patterns
(MAMPs)
Conserved structural components such as lipopolysaccharide,

flagellin and nucleic acids derived from microorganisms that are
detected by the host innate immune system
Muramyl dipeptide
A peptidoglycan derivative that is common to both Gram-positive

and Gram-negative bacterial cell walls and that triggers an innate
immune response
Mutualism
A relationship between two organisms, in which both organisms

benefit
Obligate anaerobic
bacteria
Bacteria that grow without the need for oxygen
Parasitism
A relationship in which one organism (pathogen) benefits at the

expense of another organism
Pathobionts
Normally innocuous microorganisms that can behave like

pathogens if their abundance increases and/or their environmental
conditions change
Stratum corneum
The outermost layer of the epidermis that forms the protective

layer of the skin
Toll-like receptor
(TLR)
A family of evolutionarily conserved receptors that recognize

microorganism-associated molecular patterns such as flagellin,
lipopolysaccharide or nucleic acids. These receptors have an
essential role in innate immune responses
Tumour tolerance
A state of immune hyporesponsiveness, in which tumour antigens

induce T cell tolerance (a process that allows tumour immune
evasion)
Virulence factors
Molecules expressed by pathogenic microorganisms that help

them to gain a growth advantage in a specific ecosystem. These
molecules are often responsible for disease manifestation in the
host
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Figure 1. Mechanisms controlling hostmicrobiota interactions and associated failures

implicated in cancer development
A state of homeostasis and symbiotic relationships is maintained by the separation of

microbial entities from the host through a multi-level barrier, by a eubiotic microbiome that
actively suppresses pathobionts and that maintains a symbiotic relationship with the host,
and by a state of low inflammation in the host. Perturbation of this balance leads to chain
reactions that ultimately result in a cancer-promoting state with a failing barrier,
inflammation and dysbiosis. This state includes qualitative and sometimes quantitative
changes in the microbiota; failure of the barrier either physically (for example, at the level of
tight junctions or at the mucous layer), or at the level of antibacterial defence systems
either those of epithelial cells or those of cells from the gut-associated lymphoid tissue
(GALT); and increased inflammatory responses, which are often mediated by pattern
recognition receptors (PRRs) and downstream cytokines that promote epithelial cell
proliferation and survival. DCA, deoxycholic acid; EREG, epiregulin; IgA, immunoglobulin
A; IL-6, interleukin-6; MAMP, microorganism-associated molecular pattern; NF-B,
nuclear factor-B; TH17, T helper 17; TNF, tumour necrosis factor.
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Figure 2. Mechanisms by which the bacterial microbiome modulates carcinogenesis
The bacterial microbiome promotes carcinogenesis through several mechanisms. a |

Changes in the microbiome and host defences may favour increased bacterial translocation,
leading to increased inflammation, which is mediated by microorganism-associated
molecular patterns (MAMPs) that activate Toll-like receptors (TLRs) in several cell types,
including macrophages, myofibroblasts, epithelial cells and tumour cells. These effects may
occur locally or through long-distance effects in other organs. b | Genotoxic effects are
mediated by bacterial genotoxins such as colibactin and cytolethal distending toxin
(CDT) that, after being delivered to the nucleus of host cells, actively induce DNA
damage in organs that are in direct contact with the microbiome, such as the gastrointestinal
tract. Reactive oxygen species (ROS) and reactive nitrogen species (RNS) released from
inflammatory cells such as macrophages, as well as hydrogen sulphide (H2S) from the
bacterial microbiota, may also be genotoxic. c | Metabolic actions of the microbiome may
result in the activation of genotoxins such as acetaldehyde, dietary nitrosamine and other
carcinogens, in the metabolism of hormones such as oestrogen and testosterone, in the
metabolism of bile acids and in alterations of energy harvest. The microbiota also mediates
tumour suppressive effects (shown in green) through inactivation of carcinogens, through
the generation of short-chain fatty acids such as butyrate and through the biological
activation of cancer-preventing phytochemicals. Many of these tumorigenic and tumoursuppressive mediators exert both local and longdistance effects. AREG, amphiregulin; DCA,
deoxycholic acid; EREG, epiregulin; IL, interleukin; NF-B, nuclear factor-B; NLR,
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NOD-like receptor; STAT3, signal transducer and activator of transcription 3; TH17, T

helper 17; TNF, tumour necrosis factor.

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Figure 3. Targeting the bacterial microbiota for therapeutic modulation of carcinogenesis
On the basis of the known contribution of the bacterial microbiota in experimental

carcinogenesis, the approaches shown are conceivable for the prevention of human
carcinogenesis.

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Table 1
Evidence for tumour-promoting effects of the bacterial microbiota

Cancer type
Disease or model
Findings
Refs
Murine studies
Colorectal cancer
Gastric cancer
Liver cancer
Lung cancer
Breast cancer
Germ-free rats and spontaneous carcinogenesis
Fewer tumours in germ-free rats
23
Germ-free rats and DMH-induced
25
Germ-free rats and AOM-induced
More tumours in germ-free rats
28
Germ-free rats and MAM-GlcUA
28
Germ-free rats and AOM-induced
32
AOM in Il10/ gnotobiotic mice
Fewer tumours in germ-free mice
29
Germ-free ApcMin/+ mice
31
ApcMin/+ Cdx2Cre mice treated with antibiotic

cocktail
Fewer tumours in antibiotic-treated mice
36
Nod1/ mice treated with antibiotic cocktail
34
AOM plus DSS -treated mice treated with antibiotic

cocktail
37
Wild-type microbiota transplanted into Nod2/

mice
Fewer tumours after transplant
78
Helicobacter pylori-infected gnotobiotic INS-GAS

mice
30
H. pylori-infected INS-GAS mice, treated with

antibiotic
38
DEN plus CCl4-treated germ-free mice
21
DEN plus CCl4-treated mice, receiving antibiotic

cocktail
21
DEN plus CCl4-treated mice, receiving rifaximin
Fewer tumours in rifaximin-treated mice
21
DEN-treated rats, receiving neomycin
Fewer tumours in neomycin-treated rats
35
DMBA and high-fat-diet-treated mice, receiving

antibiotic cocktail
22
DMBA and high-fat-diet-treated mice, receiving

vancomycin
Fewer tumours in vancomycin-treated mice
22
NHMI-treated germ-free rats
DMAB-treated germ-free rats
Fewer tumours in male germ-free

rats
No change in female germ-free rats
24
Reduced tumours in germ-free rats
26
Human studies
Gastric cancer
H. pylori eradication by antibiotics
Reduced cancer in antibiotic-treated patients
Gastric MALT lymphoma
H. pylori eradication by antibiotics
Regression after eradication
39,40
51
Skin MALT lymphoma
Borrelia burgdorferi eradication by antibiotics
53
IPSID
Campylobacter jejuni eradication by antibiotics
52
Ocular adnexal lymphoma
Chlamydia psittaci eradication by doxycycline
54
AOM, azoxymethane; Apc, adenomatous polyposis coli; CCl4, carbon tetrachloride; Cdx2, caudal type homeobox 2; DEN, diethylnitrosamine;
DMAB, 3,2-dimethyl- 4-aminobiphenyl hydrochloride; DMH, dimethylhydrazine; DSS, dextran sodium sulphate; Il10, interleukin-10; IPSID,
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immunoproliferative small intestinal disease; MALT, mucosa-associated lymphoid tissue; MAM-GlcUA, methylazoxymethanol--Dglucosiduronic acid; NHMI, N-nitrosoheptamethyleneimine; Nod, nucleotide-binding oligomerization domain-containing.

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Table 2
Mechanisms by which the bacterial microbiota contribute to carcinogenesis

Cancer
Mechanism
Evidence
Refs
Cancers promoted or inhibited by specific bacterial pathogens

Gastric cancer
Epidemiology
Reduction by H. pylori
eradication
Uncontrolled adaptive immune responses in

patients with chronic infection with H.
pylori, Campylobacter jejuni, Borellia
burgdorferi or Chlamydia psittaci
Epidemiology
Antibiotic treatment
Gallbladder cancer
Chronic infection with Salmonella enterica

subsp. enterica serovar Typhi
Epidemiology
49,50
Oesophageal cancer
Reduced risk in patients with H. pylori

infection
Epidemiology
46,48
Gastric MALT
lymphoma
IPSID
Skin MALT
lymphoma
Ocular adnexal
lymphoma
Chronic infection with Helicobacter pylori
39,40, 46,47
5254
Cancers promoted by specific pathogens (in mice only)

Breast cancer
Increased inflammation, mediated by T

regulatory cells
Cancer promoted in Helicobacter hepaticusinfected ApcMin/+ mice
94
Liver cancer
Chronic hepatitis
Cancer promoted in H. hepaticus-infected

mice
89
Colorectal cancer
TNF-mediated and NO-mediated
Cancer promoted in H. hepaticus-infected

Rag2/ mice
90
Cancers suspected to be promoted by commensal bacteria or dysbiotic microbiomes

Colorectal cancer
Liver cancer
Lung cancer
Pancreatic cancer
Dysbiosis
Barrier failure
Chronic inflammation
Bacterial genotoxicity
Increased hepatic exposure to

TLR-activating MAMPs
Increased exposure to the

secondary bile acid DCA
Increased bacterial infection in COPD?
LPSTLR4-mediated increase of pancreatic

cancer
Cancer reduction by antibiotics and in germfree mice; transmission of dysbiotic

microbiota triggers cancer development
Cancer reduction by treatment

with antibiotics and in germfree mice
Cancer increased by treatment

with LPS and DCA
Decreased cancer in germ-free

animals
Promotion of cancer by LPS and

infections
LPS treatment increases cancer

development
25,27, 3234,36
21,22,35
24,5962
5658
Apc, adenomatous polyposis coli; COPD, chronic obstructive pulmonary disease; DCA, deoxycholic acid; IPSID, immunoproliferative small
intestinal disease; LPS, lipopolysaccharide; MALT, mucosa-associated lymphoid tissue; MAMPs, microorganism-associated molecular patterns;
NO, nitric oxide; Rag2, recombination activating gene 2; TLR, Toll-like receptor; TNF, tumour necrosis factor.

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The microbiome and cancer

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Schwabe and Jobin

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Cancer-modulating effects of microbiota

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Schwabe and Jobin

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Additional examples of carcinogenesis promoted by specific bacterial pathogens are

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Hostmicrobiota interplay in cancer

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Schwabe and Jobin

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However, direct manipulation of the microbial community using germfree, gnotobiotic,

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Schwabe and Jobin

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Microbiota-induced activation of NLRs in carcinogenesis

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deficient mice is a consequence of dysbiosis, as the increased cancer development was

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A second NLR implicated in the hostmicrobiota interaction and in bacterially driven

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Schwabe and Jobin

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Colibactin, which is encoded in the 54 kb polyketide synthase (pks) genotoxicity island, is

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Moreover, various bacterial-derived metabolites such as hydrogen sulphide and superoxide

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Bacterial virulence factors

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Disease-promoting and cancer-promoting effects of pathogens often depend on virulence

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Human metabolism represents a combination of microbial and human enzyme activities11.

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Schwabe and Jobin

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