Cell Death and Differentiation (2018) 25, 104–113

& 2018 ADMC Associazione Differenziamento e Morte Cellulare All rights reserved 1350-9047/18
www.nature.com/cdd

REVIEW

How does p53 induce apoptosis and how does this

relate to p53-mediated tumour suppression?
Brandon J Aubrey1,2, Gemma L Kelly1,2, Ana Janic1,2, Marco J Herold1,2 and Andreas Strasser*,1,2

The tumour suppressor gene TP53 is mutated in ~ 50% of human cancers. In addition to its function in tumour suppression, p53
also plays a major role in the response of malignant as well as nontransformed cells to many anticancer therapeutics, particularly
those that cause DNA damage. P53 forms a homotetrameric transcription factor that is reported to directly regulate ~ 500 target
genes, thereby controlling a broad range of cellular processes, including cell cycle arrest, cell senescence, DNA repair, metabolic
adaptation and cell death. For a long time, induction of apoptotic death in nascent neoplastic cells was regarded as the principal
mechanism by which p53 prevents tumour development. This concept has, however, recently been challenged by the findings that
in striking contrast to Trp53-deficient mice, gene-targeted mice that lack the critical effectors of p53-induced apoptosis do not
develop tumours spontaneously. Remarkably, even mice lacking all mediators critical for p53-induced apoptosis, G1/S boundary
cell cycle arrest and cell senescence do not develop any tumours spontaneously. In this review we discuss current understanding
of the mechanisms by which p53 induces cell death and how this affects p53-mediated tumour suppression and the response of
malignant cells to anticancer therapy.
Cell Death and Differentiation (2018) 25, 104–113; doi:10.1038/cdd.2017.169; published online 17 November 2017

unstressed state
* *  Combined loss of the p53 effectors of apoptosis (PUMA
* *
cellular stress * * 2) p53 protein
and damage * stabilization plus NOXA) and cell cycle arrest/cell senescence (p21)
* *
* * * *
does not cause spontaneous tumour development.
1) p53 protein  Apoptosis induction via PUMA and NOXA is critical for the
at low levels
killing of malignant cells by anticancer drugs that activate
3) transcriptional
TP53 but other effectors contribute also.
PUMA activation Open Questions
tumour
apoptosis NOXA p53 p53
suppression
other effector p53 p53  Which processes and target genes activated by p53 are
processes ???
critical for the prevention of cancer?
 Loss of which p53-induced processes cooperate with loss
Graphical Abstract of p53-induced apoptosis to cause cancer?
 Why do certain malignant as well as nontransformed cells
Facts undergo apoptosis upon TP53 activation, whereas others
do not die, but instead undergo cell cycle arrest and/or
 TP53 is a critical tumour suppressor that is mutated in senescence?
~ 50% of human cancers.  What are the differences in p53-induced apoptosis between
 In unstressed cells p53 protein levels are very low because nontransformed and malignant cells?
it is targeted for proteasomal degradation by the E3  How do the hot spot p53 mutant proteins inhibit wild-type
ubiquitin ligase MDM2. p53-induced apoptosis in nascent neoplastic as well as
 TP53 is activated in response to many stress stimuli, malignant cells?
including activation of oncogenes and DNA damage.
 Upon activation, p53 directly regulates the transcription of
Discovery of p53 and Discovery of Mutations in the TP53
~ 500 genes and indirectly regulates many additional genes
Gene in Human Cancer
and thereby controls diverse cellular processes.
 P53 induces apoptosis in nontransformed cells mostly by The p53 protein (also called TP53) was discovered as a
direct transcriptional activation of the pro-apoptotic BH3- protein bound to the SV40 large T antigen in transformed cells
only proteins PUMA and (to a lesser extent) NOXA. (reviewed in Levine et al.1 and Lane and Benchimol2).

1
The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia and 2Department of Medical Biology, University of Melbourne, Parkville, Victoria,
Australia
*Corresponding author: A Strasser, The Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052 Victoria, Australia. Tel: +61 3 9345 2555;
Fax: +61 3 9347 0852; E-mail: [email protected]
Received 29.5.17; revised 05.9.17; accepted 08.9.17; Edited by F Pentimalli; published online 17.11.17
 Mechanisms by which p53 induces cell death
BJ Aubrey et al
105

Inadvertently, some of the first experiments in which p53 was sustained growth of a cancer, and it appears likely that this
overexpressed in cell lines used constructs encoding cancer- may vary depending on both the cell of origin undergoing
derived mutant TP53. Such enforced mutant p53 expression transformation and the nature of the cooperating oncogenic
enhanced cell growth, and it was therefore concluded that p53 lesions that drive the neoplastic transformation of these cells.
functions as an oncoprotein (reviewed in Levine et al.1 and
Lane and Benchimol2). Subsequent studies found, however,
Control of TP53 Activation and Cellular Responses
that enforced expression of wild-type (WT) TP53 actually
Activated by p53
impaired the growth of transformed cells in culture, providing
the first evidence that TP53 can function as a tumour Unstressed, nontransformed cells contain very low (often
suppressor.3,4 At about the same time, it was discovered that undetectable) levels of WT p53 protein despite readily
many sporadic human cancers of diverse origins carried detectable mRNA expression.11 The main reason for this is
mutations in TP53, usually a point mutation in one allele that that p53 is targeted for proteasomal degradation by the E3
permitted expression of mutant p53 protein (often at abnor- ligase, MDM2 (Figure 1).12–14 In response to diverse stress
mally high levels; see below) accompanied by a deletion that stimuli, including activation of oncogenes, DNA damage or
removed the other allele, including adjoining regions.5,6 nutrient deprivation, the levels of p53 protein rise substantially
Moreover, individuals with the Li–Fraumeni syndrome, who because several signalling pathways that are activated in
carry germline heterozygous mutations in TP53, usually response to the aforementioned stressors converge upon the
develop multiple cancers over their lifetime, often from a young inhibition of MDM2, whereas some lead to modifications (e.g.,
age.7,8 acetylation, phosphorylation) in the p53 protein itself (Figure 1)
Most of the mutations in TP53 detected in cancer cells are (see reviews9,10,15). Upon activation, p53 binds as a homo-
point mutations in the DNA-binding domain. These mutant p53 tetramer to specific sequences in the regulatory regions of its
proteins are thought to be unable to regulate the transcription target genes (~500).16–20 Studies using enforced expression
of WT p53 target genes (loss of function (LOF)) (reviewed in or conditional activation (e.g., using temperature-sensitive
Vousden and Lane9 and Freed-Pastor and Prives10). Interest- mutants) of p53 in cell lines revealed that p53 can activate
ingly, many mutant p53 proteins are detected at high levels in diverse cellular effector processes, including cell cycle arrest,
malignant cells. Therefore, by forming mixed tetramers with cellular senescence, coordination of various DNA damage
WT p53, mutant p53 proteins can exert dominant negative repair pathways, metabolic adaptation and apoptotic cell
effects (DNEs) that are likely to play critical roles early during death (reviewed in Vousden and Lane9 and Freed-Pastor and
transformation when nascent neoplastic cells still retain their Prives10). Gene expression studies and functional assays
WT TP53 allele (reviewed in Vousden and Lane9 and Freed- using gene-targeted mice soon identified genes that are
Pastor and Prives10). In addition, certain p53 mutants have essential for certain p53-activated cellular responses. For
been reported to exert gain-of-function (GOF) effects by example, the cyclin-dependent kinase inhibitor (CDKi) p21 is
binding to and thereby modulating the functions of other critical for p53-mediated G1/S boundary cell cycle arrest and
tumour suppressors and transcriptional regulators (reviewed cell senescence21 (although additional p53 target genes also
in Vousden and Lane9 and Freed-Pastor and Prives10). It play a role in the latter process). Moreover, several genes
remains unclear which of the LOF, the DNE or the GOF effects implicated in various DNA repair processes were found to be
of mutant p53 are most important during the development and either direct targets of p53 or indirectly regulated by p53.22

unstressed state stressed state

oncogene DNA damage metabolic

MDM2 expression dysfunction

proteasome ubiquitination

ub
ub
ub
ub p14/ARF
p53 hypoxia
ATM ATR oxidative stress
nutrient deprivation
CHK1 CHK2
p53 protein maintained MDM2 MDM4
at very low levels

MDM4
MDM2 basal state Ac post-translational
P
transcriptional modifications
p53 p53 control p53 p53
p53 p53 p53 stabilisation
p53 p53
P and
Ac
transcriptional
activation

Figure 1 Regulation of p53 protein level and activity in unstressed versus stressed cells. Models depicting the mechanisms that regulate p53 protein levels and activity
in unstressed cells and in cells undergoing stress, for example, due to the activation of oncogenes or DNA lesions that they have sustained. (Ub, ubiquitin; P, phosphorylation; Ac,
acetylation)

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 Mechanisms by which p53 induces cell death
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106

Finally, direct transcriptional induction of Mdm2 by p53 was apoptosis.51–53 Notably, the cells rescued from p53-induced
recognised as a major negative feedback loop in p53 death by expression of BCL-2 still underwent cell cycle
signalling.23 This is most spectacularly demonstrated by the arrest,52 demonstrating that p53 was fully functional (i.e.,
finding that loss of MDM2 causes excess p53 activation, BCL-2 does not directly block all p53 functions). Thus, p53
resulting in early embryonic lethality in mice, and that this must induce cell cycle arrest and apoptosis through distinct
lethality can be prevented by concomitant loss of Trp53.24,25 pathways, and BCL-2 (or other pro-survival BCL-2 family
members) inhibit p53-induced apoptosis at a downstream
point in apoptosis signalling (Figure 2).
P53-Mediated Induction of Apoptosis
The caveat with the aforementioned experiments is that the
The first clue that p53 can induce apoptotic cell death came levels of p53 used to induce apoptosis were abnormally high.
from studies using a myeloid leukaemia cell line expressing a Hence, it was not yet proven that p53 could induce apoptosis
temperature-sensitive conditionally active mutant of p53 (i.e., under physiological conditions, that is, when expressed at
at 37 °C this protein behaves as mutant p53 but at 32 °C it normal levels. This was established when it was shown that
assumes WT p53 structure and function).26 The observation thymocytes and other lymphoid cell subsets from Trp53
that p53 can induce apoptosis was confirmed and extended by knockout mice are completely resistant to apoptosis induced
similar experiments in which a temperature-sensitive p53 or by γ-radiation and treatment with chemotherapeutic drugs that
WT p53 was also enforcibly expressed in erythroleukaemia induce DNA damage (e.g., etoposide, cyclophosphamide,
cells,27 a colon cancer cell line28 and a Burkitt lymphoma cisplatin).52,54,55
line.29
There are two distinct, although ultimately converging,
Discovery of the p53-Activated Inducers of the BCL-2-
pathways to apoptosis in mammalian cells:30 the so-called
Regulated Apoptotic Pathway
BCL-2-regulated (also called intrinsic, mitochondrial or stress)
pathway that is activated by stress conditions, such as The demonstration that p53-induced apoptosis can be
cytokine deprivation, ER stress or DNA damage, and the so- blocked by BCL-2 overexpression launched the hunt to identify
called death receptor (also called extrinsic) pathway that is the p53-activated initiators of the cell death pathway that is
activated by ligation of members of the tumour necrosis factor regulated by BCL-2. Many candidates were identified by
receptor (TNFR) family bearing an intracellular death searching for genes that were upregulated in response to
domain.31–33 In the BCL-2-regulated apoptotic pathway, cell overexpression of p53 at highly nonphysiological levels.
death is initiated by the transcriptional and/or post- Perhaps predictably, most of these candidates have still not
transcriptional upregulation of the so-called pro-apoptotic been proven to have roles in apoptosis. The two notable
BH3-only members of the BCL-2 protein family (BIM, PUMA, exceptions are Puma/Bbc3 and Noxa/Pmaip: both of these
BID, BMF, BAD, BIK, NOXA, HRK). The BH3-only proteins genes are direct p53 targets and encode pro-apoptotic BH3-
bind and inhibit the pro-survival BCL-2 proteins (BCL-2, BCL- only proteins.56–59 These genes are directly upregulated by
XL, MCL-1, BCL-W and A1/BFL1), thereby unleashing the cell p53 and their enforced expression causes rapid apoptosis in
death effectors BAX and BAK (the pro-apoptotic multi-BH cell lines, whereas their knockdown protects cells against
domain members of the BCL-2 family that may also include cytotoxic stimuli that trigger apoptosis in a p53-dependent
BOK34–37). Certain BH3-only proteins were reported to also manner.56–59 Studies with gene-targeted mice revealed that
activate BAX/BAK directly (see reviews32,38). Activation of PUMA and to a lesser extent NOXA are critical for p53-
BAX/BAK causes mitochondrial outer membrane permeabi- mediated apoptosis (e.g., apoptosis induced by γ-radiation or
lisation (MOMP), the point of no return in apoptosis signalling, chemotherapeutic drugs that cause DNA damage) in a broad
with consequent activation of the cascade of aspartate- range of cell types, including lymphoid as well as myeloid cells,
specific cysteine proteases (caspases; in this pathway fibroblasts and skin keratinocytes, both in culture and
initiated by caspase-939–41 and its activator APAF-142,43) that in vivo.60–63 Remarkably, thymocytes from Puma/Noxa double
dismantle the cell (Figure 2) (reviewed in Green32). Con- knockout mice are as resistant to γ-radiation in vivo as those
versely, the death receptor pathway activates apoptosis by from Trp53 knockout mice (Figure 2).64 Loss of PUMA
recruitment and activation of the pro-form of caspase-8 via the generally affords many cell types with much greater protection
adaptors FADD, and in some cases also TRADD, at the ligated against cytotoxic agents that trigger apoptosis via p53
death receptors at the plasma membrane.44,45 In so-called activation (e.g., γ-radiation in lymphoid cells) than loss of
type 1 cells (e.g., thymocytes), such caspase-8 activation with NOXA.61,64 Curiously, however, in certain cell types and under
consequent activation of the effector caspases (caspase-3 certain conditions the impact of loss of NOXA is more
and -7) is sufficient for effective induction of apoptosis. In pronounced. For example, NOXA deficiency protects skin
contrast, in the so-called type 2 cells (e.g., hepatocytes), keratinocytes and fibroblasts more potently against UV
efficient cell killing requires amplification of the caspase radiation (a p53-dependent apoptotic stimulus) than loss of
cascade by crossover activation of the BCL-2-regulated PUMA.63 This suggests that the relative contributions of
apoptotic pathway that is achieved by caspase-8-mediated PUMA versus NOXA to the induction of apoptosis may vary
proteolytic activation of the otherwise inert BH3-only protein depending on the cytotoxic insult, the nature of the responding
BID.46–50 cell or both. Of note, NOXA preferentially inhibits MCL-1 and
Studies using cell lines with enforced expression of WT p53 (in contrast to other BH3-only proteins that can bind to MCL-1)
or temperature-sensitive p53 revealed that overexpression promotes the degradation of this pro-survival protein.65,66 The
of anti-apoptotic BCL-2 could prevent p53-induced prominent role of NOXA in UV radiation-induced apoptosis

Cell Death and Differentiation

 Mechanisms by which p53 induces cell death
BJ Aubrey et al
107

1) induction of the intrinsic apoptotic pathway

activated caspase 9

cytochrome C
release
BCL-XL APAF-1
BIM
BAX
p53 PUMA MCL-1
BAK MOMP apoptosome formation
NOXA BCL-2

induction of inhibition of derepression effector caspase

BH3-only pro-survival of apoptosis activation
proteins BCL2 family effectors
members cell demolition

2) modification of the apoptotic response

sensitisation
FAS/DR5 to the death
receptor pathway
ZMAT3 ??
p53 modifiers
miR-34a BCL-2 of apoptosis

BTG2/PLK2 pro-survival
functions

Figure 2 Mechanisms of p53-induced apoptosis. Model depicting the mechanism by which activated p53 induces apoptosis through the BCL-2-regulated pathway. Fat arrows
indicate p53-induced targets that are essential for p53-induced apoptosis. Thin arrows indicate p53-induced targets that are constituents of the BCL-2-regulated apoptotic
pathway but are still expressed at levels sufficient for apoptosis induction in the complete absence of p53; that is, their induction by p53 may make the pathway work more
efficiently, but this induction is not a sine qua non for p53-induced apoptosis, at least in haematopoietic cells. The broken arrow indicates that p53 may also activate BIM
expression indirectly. The possible scenario that activation of targets that are not constituents of the apoptosis machinery per se can impact on apoptosis indirectly is also depicted

may therefore be explained if MCL-1 is the critical pro-survival BAX and APAF-1 (the scaffold protein for caspase-9 activa-
protein protecting skin keratinocytes and fibroblasts against tion) have been convincingly shown to be transcriptionally
UV radiation. regulated by p53.75–77 However, p53 is not a sine qua non
Even though in non-transformed cells combined loss of for BAX and APAF-1 expression. This is best demonstrated
PUMA and NOXA provides full protection (i.e., as potent as by the observations that Trp53-deficient haematopoietic
loss of TP53 itself) against apoptosis induced by γ-radiation or cells express normal levels of BAX and APAF-1 and undergo
chemotherapeutic drugs that induce DNA damage,64 this is apoptosis as readily as control (wild-type) cells after exposure
not the case in malignant lymphoma and leukaemia cells. For to cytotoxic insults that induce BAX/BAK-dependent
example, mouse Eμ-Myc lymphoma cells lacking both PUMA apoptosis,78 involving APAF-1,42,43,79 in a p53-independent
and NOXA are much less resistant to cyclophosphamide, manner (e.g., cytokine deprivation, treatment with glucocorti-
etoposide or nutlin-3a (that activates p53 in a nongenotoxic coids).52 Accordingly, we conclude that p53-mediated tran-
manner by blocking its major inhibitor, the MDM2 E3 ubiquitin scriptional induction of BAX and APAF-1 is not essential for
ligase67) than loss of p53 or overexpression of anti-apoptotic induction of apoptosis, at least in haematopoietic cells, but
BCL-2.68,69 Interestingly, additional loss of the BH3-only may serve in certain other cell types, as a mechanism to make
protein BIM70,71 (i.e., combined loss of PUMA, NOXA plus the system work more efficiently or even allow this pathway to
BIM) provided as potent protection against nutlin-3a and operate. This may relate to the observation that the levels of
etoposide as loss of p53 (Figure 2).68,69 After treatment with BAX, APAF-1 and other constituents of the apoptosis
etoposide or nutlin-3a, BIM expression was upregulated in Eμ- machinery are much lower in many tissues (e.g., heart,
Myc lymphoma cells at a considerably later time compared kidney, brain) in adult mice and humans compared with
with the induction of PUMA and NOXA.68,69 Therefore, p53 newborns. This may account for the reduced sensitivity to
may indirectly regulate BIM expression, perhaps through apoptotic stimuli of cells from these tissues in adults compared
repression of a microRNA that regulates BIM. However, with newborns.80
evidence for direct activation of Bim transcription by p53 has
also been reported.72–74 Collectively, these findings reveal that
Mechanisms of Induction of Apoptosis by p53-Related
p53-induced apoptosis is likely to be more complex in
Proteins
malignant cancer cells compared with nontransformed cells
(Figure 2). For many years p53 was thought to have no relatives, but then
It is also noteworthy that two additional constituents of the within a short time frame, two closely related proteins, called
BCL-2-regulated apoptotic pathway, the pro-apoptotic effector p6381 and p73,82 were discovered. P63 and p73 share

Cell Death and Differentiation

 Mechanisms by which p53 induces cell death
BJ Aubrey et al
108

similarity with p53 in their DNA-binding and transactivation cytotoxic T cells or NK cells and such a process may contribute
domains and it is therefore widely assumed that many to the effectiveness of cancer therapy in certain cancers.
recognised p53 target genes, and hence the cellular pro-
cesses they control, can also be regulated by p63 and p73.83
Indirect Effects of p53 on Apoptosis Signalling
Some early studies showed that overexpression (although at
clearly nonphysiological levels) of p63 or p73 can cause cell To further add to the complexity of p53-mediated control of
death with morphological and biochemical features of apoptosis, p53 also drives the expression of several genes
apoptosis.81,84 The first demonstration that p63 can induce whose functions do not lie within the two apoptotic pathways
apoptosis under physiological conditions came from elegant per se but may modulate the cellular response to cell death-
studies in the mouse ovary. Even very low dose (0.5 Gy) inducing insults. For example, p53 drives expression of a
γ-radiation kills all primordial follicles in 5-day-old female mice number of microRNA species, including miR-34,94 that is
and renders these animals permanently infertile. This cell known to target the pro-survival Bcl-2 gene.95 Thus, p53-
death is completely prevented by loss of p63, but loss of p53 induced miR34a expression may sensitise cells to apoptotic
has no protective effect.85 Combined loss of PUMA and NOXA stimuli by reducing the levels of BCL-2. Another well-
protected the primary follicles in the ovary from γ-radiation to characterised transcriptional target of TP53 is Zmat396 that
the same extent as loss of p63.86 This demonstrates that p63 has a poorly defined function but has been shown to impact on
induces apoptosis in the same way as p53. Remarkably, the response of cells to apoptotic stimuli.97 Of note, p53 can
PUMA/NOXA double knockout and even PUMA single knock- also drive the expression of various genes that may serve pro-
out females, when irradiated either as pups or as adults, survival functions, such as BTG2 and PLK2.96 Thus, p53
retained normal fertility. Of note, among several hundred signalling should not be viewed as exclusively inducing
offspring of such irradiated Puma-/-Noxa-/- or Puma-/- mothers, apoptosis, but in certain situations p53 activation may
none were found to exhibit developmental abnormalities or preferentially activate processes that enhance cell survival
cancer predisposition.86 This means that primordial follicles and cell growth. This may well be pertinent to tumour
that are protected from γ-radiation-induced apoptosis due to development and cancer therapy.
the absence of PUMA or PUMA plus NOXA must be able to
repair their DNA lesions highly efficiently.
Reported Roles of p53 in Other Forms of Cell Death
Of note, the nematode C. elegans homologue of p53/p63/
p73 also has a function in DNA damage-induced killing of Although the role of p53 (and p63) in the induction of apoptosis
female germ cells and it induces a pathway to apoptosis that is is widely accepted, there are also reports that p53 can regulate
initiated by the pro-apoptotic BH3-only protein, EGL-1, and additional non-apoptotic cell death pathways. For example,
can be inhibited by the pro-survival BCL-2 homologue, p53 was reported to open the mitochondrial permeability
CED-9.87 This demonstrates that DNA damage-induced, transition pore to thereby induce necrotic cell death.98 More-
p63-induced apoptosis via the BCL-2-regulated pathway in over, p53 has also been reported to sensitise cells to
female germ cells is evolutionarily highly conserved and is ferroptosis, a non-apoptotic form of cell death,99 by repressing
likely to play a critical role in safeguarding genomic stability in expression of SLC7A11, a key component of the cystine/
the germline.88 glutamate antiporter.100 However, the relevance of these
processes to normal physiology (e.g., the death of nontrans-
formed cells with DNA lesions) or cancer therapy-induced
Impact of p53 on the Death Receptor Apoptotic Pathway
killing of tumour cells has not been established.
Importantly, p53 can also regulate the expression of compo-
nents of the extrinsic apoptotic pathway. The p53 can
Future Directions in Research on p53-Induced Cell Death
transcriptionally induce the genes encoding FAS (also called
APO-1 and CD95) and possibly other genes encoding related A ‘holy grail’ in research on p53 is to understand the
death receptors.89 Some studies have reported that cytotoxic mechanistic basis determining the strongly context-
drugs that cause activation of p53 (e.g., etoposide, cyclopho- dependent functional output following p53 activation. For
sphamide) and γ-radiation can induce apoptosis in leukaemic example, p53 activation by nutlin-3a results in apoptosis in
cells through the death receptor pathway.90 However, experi- some cells but cell cycle arrest and senescence in others (both
ments using a panel of transgenic and gene knockout mice malignant and nontransformed).67 Moreover, restoration of
demonstrated beyond doubt that DNA damage-inducing wild-type p53 in cancers driven by loss of p53 (plus additional
anticancer drugs and γ-radiation kill normal as well as oncogenic lesions) causes apoptosis in lymphoma cells but
transformed cells by activating the BCL-2-regulated apoptotic cell senescence and cell cycle arrest in solid organ
pathway91,92 in a p53-dependent manner. In striking contrast, cancers.101–104 Importantly, there is evidence that p53
complete loss of the death receptor apoptotic pathway (e.g., activation and expression may occur without necessarily
due to loss of function of caspase-8 or its activator FADD) does resulting in apoptosis or senescence, as has been observed
not protect these cells from these agents.44,93 Although we in stem cells, where p53 activation may drive differentiation
would conclude that p53-mediated upregulation of death rather than exerting antiproliferative effects.105 Finally, dra-
receptors is not essential for cell killing, it may serve to matic differences are seen in the sensitivity of different cell
sensitise cells to so-called death ligands (e.g., FASL, TNF; the types to p53 activation. For example, cells within the gastro-
ligands for the death receptors FAS and TNFR1) expressed on intestinal tract106 and the haematopoietic system54,55,91 are
neighbouring cells. This would allow for paracrine killing by particularly vulnerable to p53-induced apoptosis that

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 Mechanisms by which p53 induces cell death
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tumour suppressor
functions of the TIGAR
MDM2 p53 pathway SLC7A11
SESTRIN1/2
p53 feedback
metabolism
PUMA/BBC3
NOXA/PMAIP1 ERCC5
APAF1 transcription
MGMT
BAX factor POLK
ZMAT3
DNA damage
miR-34a
CDKN1A/p21 CDKN1A/p21 repair
apoptosis PML CAV1
E2F7 CDKN1A/p21 BTG2
GADD45
senescence G1 cell
G2/M cell
cycle arrest
cycle arrest

Figure 3 P53 activates a multitude of cellular effector processes. Model showing a selected cellular effector processes that can be activated by p53. Some, but not all, of the
p53 target genes that are critical for the execution of these processes are indicated. The challenge remains to understand of which of these processes are critical for tumour
suppression in which setting; that is, cell of origin undergoing neoplastic transformation and nature of the oncogenic lesions driving their transformation

underlies their prominent involvement in toxicity associated monitored over a long time period.64,107 Induction of G1/S
with DNA damage-inducing chemotherapy. We can speculate boundary cell cycle arrest and cell senescence are also
on factors that may differentiate the p53 response: post- thought to be processes that could be critical for p53 tumour
translational modifications on the p53 protein (e.g., acetyla- suppression (Figure 3). The CDK inhibitor p21 is essential for
tion, phosphorylation) that alter the function of p53 as a cell cycle arrest and also a major contributor to cellular
transcription factor, functional interaction between p53 and senescence.108 It is therefore remarkable that mice with
other transcription factors that may vary according to cell type, mutations in Trp53 that impair its ability to transcriptionally
context-dependent regulation of specific target genes (e.g., induce Puma, Noxa and p21 and even mice completely
altered regulation in the setting of oncogene expression), deficient for these genes (i.e., Puma-/-Noxa-/-p21-/- mice) do
epigenetic regulation of p53 target genes (e.g., p53 regulation not spontaneously develop any tumours (Figure 4).107,109,110
may vary depending on whether certain target genes are Notably, the cells from all of these mutant mice are unable to
epigenetically silenced) as well as post-transcriptional and undergo apoptosis, cell cycle arrest or senescence upon p53
post-translational regulation of p53 target genes or their activation. This demonstrates that p53 is capable of preventing
protein products (e.g., a role for p53-independent microRNA- spontaneous development of cancer in the complete absence
mediated regulation). These are all fascinating possibilities of its ability to induce apoptosis, G1/S cell cycle arrest and cell
that require much further investigation. senescence. Moreover, combined loss of PUMA and p21 or
mutations in the two transactivation domains of p53 that
are critical for the transcriptional induction of Puma, Noxa and
The Role of p53-Induced Apoptosis in p53-Mediated
p21 accelerate c-MYC-driven lymphoma development and
Tumour Suppression
mutant RAS-driven lung cancer development to a much lesser
The finding that p53 can induce apoptosis led to the widely extent than loss of p53 (Figure 4).111,112 The observation
accepted assumption that out of all the cellular effector that loss of PUMA (or combined loss of PUMA and NOXA or
processes activated by p53 (Figure 3) this is the most critical, PUMA and p21) can accelerate c-MYC-driven lymphoma
possibly even the sole, process by which p53 suppresses development112,113 does, however, show that p53-mediated
tumour development (reviewed in Vousden and Lane9). This apoptosis (via PUMA and NOXA) can exert significant tumour
made sense: after all, if cells during the early stages of suppressive function. The relative importance of the induction
neoplastic transformation are killed through p53-induced of apoptosis to overall TP53-mediated tumour suppression is
apoptosis, no fully transformed malignant cells will emerge likely to vary depending on the type of cell undergoing
from this clone. However, matters are not that simple. If neoplastic transformation and the nature of the oncogenic
apoptosis is the critical process for p53-mediated tumour lesions that drive tumorigenesis.
suppression, it would be predicted that Puma-/-Noxa-/- mice Important insight into the mechanisms that are critical for TP53-
should be as prone to spontaneous or oncogene-driven mediated tumour suppression also came from experiments using
tumour development as Trp53-/- mice themselves, as com- an elegant genetically engineered mouse model in which p53
bined loss of PUMA and NOXA abrogates p53-induced activity can be turned on or off at will.114 These studies used the γ-
apoptosis in many (possibly all) cell types.64 Contrary to this radiation-induced thymic T-cell lymphoma model and showed that
prediction, no spontaneous tumour development was the presence of p53 during the acute response to DNA damage
observed in a large cohort of Puma-/-Noxa-/- mice that were (characterised by extensive apoptosis of many haematopoietic

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 Mechanisms by which p53 induces cell death
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110

1) defective p53-induced apoptosis with no oncogenic stimulus

no spontaneous
tumour development

Puma-/-Noxa-/-

2) defective p53-induced apoptosis with oncogenic stimulus

accelerated
tumour development

Eи-Myc;Puma-/-Noxa-/-

3) defective p53-induced apoptosis obviating the need for stem/progenitor cell mobilisation

γ-irradiation-induced
tumour development

wild-type thymus

delayed
tumour development

Puma-/- thymus
non-transformed cell
transformed cell
γ-irradiation

Figure 4 Impact of p53-induced apoptosis on tumour development. Models showing the impact of loss of p53-induced apoptosis on tumour development in different cancer
models/settings

cell types) was not needed for tumour suppression. Instead, p53 lymphoma/leukaemia-initiating cancer stem cells in this model.117
function was required during the later recovery phase. Accordingly, This concept may extend to many additional cancers, including
p53-mediated tumour suppression was not activated through the epithelial ones, as overexpression of pro-survival BCL-2 para-
DNA damage sensing process but instead through p19/ARF114 doxically delays liver cancer development,118 whereas, conver-
that is activated in response to the expression of oncogenes (e.g., sely, loss of pro-survival MCL-1 promotes its development.119
deregulated c-MYC expression). P19/ARF inhibits MDM2, the
major negative regulator of p53. This indicates that in this model,
thymic T-cell lymphomas emerge from the stem/progenitor cells Impact of Mutant p53 on WT p53-Induced Apoptosis and
that have sustained potentially oncogenic DNA lesions and are on WT p53-Mediated Tumour Suppression
mobilised to replenish the haematopoietic system that was The p53 is unusual among tumour suppressors. In tumours
depleted by γ-radiation. The very rapid proliferation of progenitor that are driven by mutations in the tumour suppressors PTEN
cells bearing oncogenic lesions, which is likely to also be the basis or RB, the expression of these proteins is usually lost
of the development of many other cancers, may facilitate the completely because of the nature of the mutations selected
acquisition of mutations in oncogenes or suppressor genes that for during tumorigenesis (reviewed in Knudsen and
further drive neoplastic transformation. Some initially paradoxical Knudsen120 and Yin and Shen121). In contrast, many tumours
findings are consistent with this. In the aforementioned γ-radiation- that are driven by mutations in TP53 express high levels of the
induced thymic T-cell lymphoma development mouse model, loss mutant p53 protein and show a loss of the other allele of TP53
of pro-apoptotic PUMA or overexpression of pro-survival BCL-2 (reviewed in Vousden and Lane9 and Freed-Pastor and
completely prevented tumour development (Figure 4).115,116 The Prives10). In fact, the high-level mutant p53 protein expression
explanation for this is that loss of pro-apoptotic PUMA or pro- can be used as a diagnostic marker for cancers driven by
survival BCL-2 overexpression prevented the γ-radiation-induced mutations in the TP53 gene (reviewed in Liu and Gelmann122).
death of diverse leukocyte populations and this obviated the need The highly expressed mutant p53 protein can promote
for mobilisation and excess proliferation of haematopoietic stem/ tumorigenesis in three ways: (1) loss of the WT p53 activity,
progenitor cells in the bone marrow that are thought to be the (2) DNEs over the WT p53 protein early in transformation

Cell Death and Differentiation

 Mechanisms by which p53 induces cell death
BJ Aubrey et al
111

reducing the toxicities associated with chemotherapy and

loss of wild-type p53
radiotherapy and improving haematopoietic stem cell trans-
transcriptional function
plant conditioning regimens and perhaps also in nonmalignant
settings where abnormal induction of cell death pathways (that
may in part be driven by p53) contributes to tissue damage,
neomorphic such as myocardial infarction and cerebral ischaemia.
dominant negative mutant gain-of-function
effects
p53 activities

Conflict of Interest
Figure 5 Impact of mutant p53 proteins on tumour development. Model depicting The authors declare no conflict of interest.
the mechanisms by which mutant p53 proteins, which are frequently highly
overexpressed (compared with the wild-type p53 protein), on tumour development
Acknowledgements. We thank all of our current and past colleagues at The
Walter and Eliza Hall Institute and elsewhere. Our work is supported by the Australian
National Health and Medical Research Council (Program Grant 1016701 to AS and
before loss of the WT TP53 allele, through the formation of
Fellowship 1020136 1020363 to AS), the Leukemia and Lymphoma Society of
mixed tetramers containing both wild-type and mutant p53 America (LLS SCOR 7001-13 to AS), the Cancer Council of Victoria (1052309 to AS)
proteins and (3) de novo GOFs that are mediated through as well as operational infrastructure grants through the Australian Government
interactions of mutant p53 protein with other transcription Independent Research Institute Infrastructure Support Scheme (9000220) and the
factors and tumour suppressors (e.g., p63, p73) (Figure 5) Victorian State Government Operational Infrastructure Support Program.
(reviewed in Vousden and Lane9 and Freed-Pastor and
Prives10). As early in transformation, mutant p53 levels are
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Cell Death and Differentiation