Exposed: Anna Lee Exposed Volume 2

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However, neither EMu nor NMF provides a statistical hypothesis test of the presence or absence of a particular signature in a given tumor. Indeed, both EMu and NMF often attribute at least a small number of mutations to every available signature, which for many exposures does not correspond to a biologically plausible level of exposure. Therefore, we developed statistical tests for likely AA exposure based on two characteristics of AA mutagenesis.

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We calculated FDRs across the P -values of all tumors, adopting a threshold of 0. Seven bladder cancers including the two from patients in Taiwan met this threshold, with the highest FDR being 0. These tumors included three muscle-invasive tumors two from Taiwan and one from the United States and four non-muscle-invasive tumors one from Singapore and three from China.

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This dissimilarity was reflected by a cosine similarity of only 0. Clinical history that would indicate whether this patient used herbal remedies was unavailable. We have presented evidence of AA mutagenesis in the genomes of bladder cancers in patients known to have been exposed to AA, as well as evidence of AA exposure in a subset of bladder cancers from three patient populations. First, we found evidence of AA exposure in 3 of 99 bladder cancers treated in China.

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This is consistent with the fact that plants containing AA are components of traditional Chinese medicine [ 46 ]. Indeed, AA-containing herbal remedies are still readily available in China [ 47 ]. We also observed one likely AA-exposed case of bladder cancer from Singapore where traditional Chinese medicine is also widely used. Because the patient was 80 years old, he may have been exposed to AA before its use was prohibited in Singapore.

Our data demonstrating a molecular link between AA and bladder cancer are consistent with previous work showing the presence of AA adducts in the bladders of AA-exposed mice [ 34 , 35 ], with the role of AA in UTUCs [ 14 , 23 , 24 ], and with previously reported elevated risk of bladder cancer in patients with AA-induced kidney failure [ 31 - 33 ]. However, to our knowledge, the present research is the first to connect AA mutagenesis with bladder cancer in patients from the general population without a history of AA-induced kidney failure.

At present, no such mutagen is known, but the mutation signatures of most mutagens remain unstudied.


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Nevertheless, the reasonable prior possibility of AA exposure through herbal remedies in the tumors from Singapore and China would argue that the mutagen in these tumors was in fact AA. Associations between exposures and disease are often difficult to establish based on epidemiological data alone [ 48 , 49 ]. Various 'omics' approaches, such as transcriptomics, metabolomics, proteomics, and genomics, are now being evaluated as tools for assessing environmental exposures and cancer risk [ 50 ].

This was possible because the AA signature has been established in cell culture [ 14 , 25 ] and because previous epidemiological data have linked AA to UTUCs [ 24 , 28 , 51 ].

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The medicinal use of AA-containing plants has a long and geographically diverse history and likely remains widespread despite efforts at regulation in some countries [ 51 - 54 ]. In addition, there is evidence that AA-containing plants are also used in Central and South America [ 53 ]. Although use of these plants does not appear to be widespread in the US, their sale or use as botanical products without claims of health benefits are not restricted there.

Under the Dietary Supplement Health and Education Act of , the US Food and Drug Administration has little ability to regulate botanical products, although it has urged manufacturers and distributors to ensure that botanical products are free of AA and advised consumers to not use products that might contain AA [ 55 - 57 ].

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Large populations are using traditional herbal medicines that prescribe AA-containing plants, and there is new, rapidly emerging molecular epidemiological evidence of AA exposure in several types of cancer, including bladder cancer, not previously linked to AA. There is also additional exposure to AA due to unintended contamination of food with AA-containing plants.

Thus, multiple lines of evidence point to AA exposure as a worldwide public health issue that should be addressed by further investigation and by primary prevention through regulation and public education. Global cancer statistics. CA Cancer J Clin. Int J Cancer.


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  • Tobacco use, occupation, coffee, various nutrients, and bladder cancer. J Natl Cancer Inst. Arsenic ingestion and internal cancers: a review. Am J Epidemiol. Bladder cancer mortality associated with arsenic in drinking water in Argentina. Excess number of bladder cancers in workers exposed to ortho-toluidine and aniline. Monitoring of aromatic amine exposures in workers at a chemical plant with a known bladder cancer excess.

    Carcinogenicity of some aromatic amines, organic dyes, and related exposures. Lancet Oncol. International Agency for Research on Cancer. Meta-analysis of studies on individual consumption of chlorinated drinking water and bladder cancer. J Epidemiol Community Health. Mutation signatures of carcinogen exposure: genome-wide detection and new opportunities for cancer prevention.

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    Mechanisms underlying mutational signatures in human cancers. Nat Rev Genet. Mutational signatures: the patterns of somatic mutations hidden in cancer genomes. Curr Opin Genet Dev. Genome-wide mutational signatures of aristolochic acid and its application as a screening tool. Sci Transl Med. Mutational processes molding the genomes of 21 breast cancers.

    Signatures of mutational processes in human cancer. Mutational heterogeneity in cancer and the search for new cancer-associated genes. Deciphering signatures of mutational processes operative in human cancer. Cell Rep.

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    EMu: probabilistic inference of mutational processes and their localization in the cancer genome. Genome Biol. Mutational context and diverse clonal development in early and late bladder cancer.


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    • Mutation signatures implicate aristolochic acid in bladder cancer development?
    • Nat Genet. Mutational signature of aristolochic acid exposure as revealed by whole-exome sequencing. Aristolochic acid-associated urothelial cancer in Taiwan. Modelling mutational landscapes of human cancers in vitro. Sci Rep. TP53 Mutational signature for aristolochic acid: an environmental carcinogen. Analysis of TP53 mutation spectra reveals the fingerprint of the potent environmental carcinogen, aristolochic acid. Mutat Res. Aristolochic acid-induced upper tract urothelial carcinoma in Taiwan: clinical characteristics and outcomes. Renal cell carcinomas of chronic kidney disease patients harbor the mutational signature of carcinogenic aristolochic acid.

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