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Table of Contents

    Topic review

    Susceptibility to Head and Neck Cancers

    Subjects: Biology
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    Definition

    HNC involves a series of tumors originating in the oropharynx, hypopharynx, oral cavity, lip, larynx, or nasopharynx. Smoking, alcohol consumption, and high-risk human papillomaviruses have been related to HNC. In connection with the role of genetics in HNC, several recent meta-analyses have reported the association of polymorphisms with the risk of HNCs.

    1. Introduction

    Cellular inflammation and immunity can play a significant role in various stages of carcinogenesis [1] such as head and neck cancers (HNCs). HNC mortality rates are elevating and disproportionately affect people in low- and middle-income countries and areas with restricted resources [2]. Global Burden of Disease Study (GBD) in 2016 estimated 512,492 deaths due to HNC (a minimum of 15,018 deaths in North Africa and the Middle East to a maximum of 199,280 in South Asia) and predicted the death count to reach 705,901 in 2030 [3][4]. HNC involves a series of tumors originating in the oropharynx, hypopharynx, oral cavity, lip, larynx, or nasopharynx [5]. Smoking, alcohol consumption, and high-risk human papillomaviruses have been related to HNC [5][6][7]. In connection with the role of genetics in HNC, several recent meta-analyses have reported the association of polymorphisms with the risk of HNCs [8][9][10][11].

    A number of heterocyclic and aromatic amines are the main carcinogenic compounds of tobacco smoke [12][13] that their metabolism in humans is complex and includes acetylation as a main pathway for DNA mutation and the onset of carcinogenesis [14]. In particular, two N-acetyltransferases, NAT1 and NAT2 perform a role in catalyzing the deactivation and activation of several carcinogenic amines through N- and O-acetylation, respectively [14][15]. Both NAT genes ( NAT1 and NAT2 ) have polymorphisms in humans and in accordance with slow and rapid acetylator phenotypes [16]. The NAT2 metabolized gene is located in region 10 of chromosome 8p21, which contains two exons with a long intron of about 8.6 kb [17]. Exon 1 is very short (100 bp) and the entire protein-coding region in Exon 2 is 870 bp [18]. Also, the NAT1 gene is located on the short arm of chromosome 8 (8p21) [19][20]. NAT1 accelerates acetylation specifically for arylamine receptor structures such as p-aminosalicylic and p-aminobenzoic acids [21] and NAT2 acetylates other arylamine-acceptor structures, such as isoniazid, sulfasalazine, procainamide, and caffeine [19].

    Evidence from the published articles on the relationship between NAT1 and NAT2 polymorphisms and HNC susceptibility is conflicting [22][23]. The association between the polymorphisms ( NAT1 and NAT2 ) and the HNC risk has been evaluated by one [24] and four [25][26][27][28] meta-analyses, respectively. However, these studies were published several years ago with the most recent one being published in 2015. Therefore, through this meta-analysis, we intend to update the evidence on the association between the polymorphisms and the HNC risk by including more studies. In addition, we aim to conduct trial sequential analysis (TSA) and meta-regression.

    2. Analysis on Results

    Twenty-eight studies included in the analysis were published between 1998 and 2014 ( Table 1 ). Fourteen articles [22][23][29][30][31][32][33][34][35][36][37][38][39][40] reported the results in Caucasians, nine [41][42][43][44][45][46][47][48][49] in Asians, and five [50][51][52][53][54] among participants of mixed ethnicity. The control source in eighteen articles [22][23][41][30][32][33][36][37][38][39][42][43][45][46][47][51][52][54] was hospitals and ten [29][31][34][35][40][44][48][49][50][53] recruited the controls from a general population. In total, the articles included 5154 HNC cases and 6194 controls. Age, gender distribution, sample size, tumor type, genotyping method, and the quality score are shown in Table 1 .

    Table 1. Characteristics of the articles included in the meta-analysis.
    The First Author, Publication Year Country Ethnicity Control Source Number Mean Year Male Percentage Type of Tumor Genotyping Method Quality Score
    Case Control Case Control Case Control
    Gonzalez, 1998 [34] Spain Caucasian PB 75 200 58.7 45 100 75 Oral, pharyngeal, laryngeal PCR-RFLP 7
    Katoh, 1998 [41] Japan Asian HB 62 122 61.7 62.4 64.5 61.5 Oral PCR-RFLP 7
    Henning, 1999 [23] Germany Caucasian HB 255 510 61.4 NA 90.6 NA Laryngeal PCR 7
    Jourenkova-Mironova, 1999 [37] France Caucasian HB 250 172 54.4 54.9 96 94.8 Oral, pharyngeal, laryngeal PCR-RFLP 7
    Morita, 1999 [48] Japan Asian PB 145 164 59.0 49.8 86.9 62.2 Oral, pharyngeal, laryngeal PCR 7
    Olshan, 2000 [54] USA Mixed HB 171 193 59.5 56.8 81.3 59.1 Oral, pharyngeal, laryngeal PCR 7
    Chen, 2001 [29] USA Caucasian PB 341 552 NA NA 70.4 71.6 Oral PCR-RFLP 9
    Fronhoffs, 2001 [32] Germany Caucasian HB 291 300 59.8 47.1 80.1 58 Oral, pharyngeal, laryngeal RT-PCR 6
    Hahn, 2002 [35] Germany Caucasian PB 94 92 61.5 45.1 65.9 51.1 Oral PCR-RFLP 7
    Lei, 2002 [45] China Asian HB 62 56 60.2 58.2 NA NA Laryngeal PCR-RFLP 7
    Varzim, 2002 [40] Portugal Caucasian PB 88 172 62.8 43.0 94.3 72.7 Laryngeal PCR-RFLP 7
    Cheng, 2003 [43] Taiwan Asian HB 279 325 NA NA NA NA Pharyngeal PCR-RFLP 6
    Gajecka, 2005 [33] Poland Caucasian HB 289 311 57.9 45.9 100 100 Laryngeal PCR-RFLP 8
    Rydzanicz, 2005 [38] Poland Caucasian HB 266 143 61.6 53.1 95.1 100 Oral, pharyngeal, laryngeal PCR-RFLP 8
    Unal, 2005 [39] Turkey Caucasian HB 45 104 53.5 50.0 93.3 65.4 Laryngeal PCR-RFLP 7
    Marques, 2006 [52] Brazil Mixed HB 231 212 56.6 55.3 83.5 79.2 Oral PCR-RFLP 8
    Gara, 2007 [51] Tunisia Mixed HB 64 160 50.7 53.6 65.6 45 Oral, pharyngeal, laryngeal PCR-RFLP 7
    Majumder, 2007 [47] India Asian HB 297 342 NA NA NA NA Oral PCR-RFLP 6
    Boccia, 2008 [22] Italy Caucasian HB 210 245 63.6 63.3 71.4 72.2 Oral, pharyngeal, laryngeal PCR-RFLP 8
    Buch, 2008 [50] USA Mixed PB 182 399 58.7 58.7 87.4 75.7 Oral PCR-RFLP 9
    Harth, 2008 [36] Germany Caucasian HB 312 300 59.7 47.2 80.4 58.7 Oral, pharyngeal, laryngeal PCR-RFLP 6
    Chatzimichalis, 2010 [30] Greece Caucasian HB 88 102 66.5 62.5 87.5 74.5 Laryngeal PCR-RFLP 8
    Demokan, 2010 [31] Turkey Caucasian PB 95 93 59.6 53.3 86.3 52.7 Oral, pharyngeal, laryngeal PCR 8
    Hou, 2011 [44] China Asian PB 172 170 49.6 49.6 100 100 Oral, pharyngeal PCR-RFLP and Taqman 9
    Balaji, 2012 [42] India Asian HB 157 132 53.1 55.1 54.8 34.8 Oral Taqman 7
    Majumder, 2012 [46] India Asian HB 299 381 NA NA NA NA Oral PCR 6
    Tian, 2013 [49] China Asian PB 233 102 60.0 60.0 NA NA Laryngeal PCR 8
    Marques, 2014 [53] Brazil Mixed PB 101 141 NA NA NA NA Oral, pharyngeal, laryngeal PCR-RFLP 7
    Abbreviations: HB, hospital-based; PB, Population-based; PCR, Polymerase Chain Reaction; RT, Real Time; RFLP, Restriction Fragment Length Polymorphism; NA, Not Available. Taqman: The 5′ Nuclease Assay.

    Table 2 shows the prevalence of slow and rapid acetylators of NAT1 and NAT2 polymorphisms. Eight studies [23][41][31][32][37][40][46][54] included NAT1 polymorphism with 1509 HNC cases and 1829 controls and twenty-five studies [22][23][41][29][30][31][33][34][35][36][37][38][39][40][42][43][44][45][47][48][49][50][51][52][53] included NAT2 polymorphism with 4393 HNC cases and 5321 controls.

    Table 2. Prevalence of the polymorphisms of N-acetyltransferases 1 and 2 (NAT1 and NAT2), (slow vs. rapid acetylators).
    Author, Year NAT1
    Case Control
    Slow Rapid Slow Rapid
    Katoh, 1998 [41] 9 53 46 76
    Henning, 1999 [23] 144 109 232 164
    Jourenkova-Mironova, 1999 [37] 141 109 98 74
    Olshan, 2000 [54] 83 88 108 85
    Fronhoffs, 2001 [32] 195 96 206 94
    Varzim, 2002 [40] 48 40 107 65
    Demokan, 2010 [31] 53 42 42 51
    Majumder, 2012 [46] 128 171 168 213
    Author, Year NAT2
    Case Control
    Slow Rapid Slow Rapid
    Gonzalez, 1998 [34] 28 47 37 163
    Katoh, 1998 [41] 7 55 7 115
    Henning, 1999 [23] 138 117 286 224
    Jourenkova-Mironova, 1999 [37] 142 108 91 81
    Morita, 1999 [48] 18 127 17 147
    Chen, 2001 [29] 198 143 302 250
    Hahn, 2002 [35] 59 35 57 35
    Lei, 2002 [45] 50 12 34 22
    Varzim, 2002 [40] 47 41 76 96
    Cheng, 2003 [43] 39 240 54 271
    Gajecka, 2005 [33] 127 162 165 146
    Rydzanicz, 2005 [38] 131 135 72 71
    Unal, 2005 [39] 15 30 7 97
    Marques, 2006 [52] 29 202 38 174
    Gara, 2007 [51] 33 31 59 101
    Majumder, 2007 [47] 190 107 205 137
    Boccia, 2008 [22] 109 101 128 117
    Buch, 2008 [50] 84 98 224 175
    Harth, 2008 [36] 189 123 181 119
    Chatzimichalis, 2010 [30] 39 49 65 37
    Demokan, 2010 [31] 50 45 45 48
    Hou, 2011 [44] 46 126 33 137
    Balaji, 2012 [42] 100 57 67 65
    Tian, 2013 [49] 189 44 56 46
    Marques, 2014 [53] 48 53 51 90

    When there was one study for a subgroup, we could delete it [55]. Subgroup analyses were performed based on ethnicity, sample size, control source, genotyping method, and tumor type ( Table 3 ). With regards to NAT1 polymorphism, no subgroup differences were observed. For NAT2 polymorphism, significant subgroup effects were observed for ethnicity and the control source. Slow acetylators among Asians and also the population-based studies could be effective factors on the pooled result of the association between NAT2 polymorphism and the HNC risk.

    Table 3. Subgroup analyses of association between N-acetyltransferases 1 and 2 (NAT1 and NAT2) polymorphisms and the risk of head and neck cancer (slow vs. rapid acetylators).
    Polymorphism Variable (N) OR 95% CI p-Value I2 Pheterogeneity
    NAT1 Overall (8) 0.89 0.77, 1.02 0.09 48% 0.06
    Ethnicity          
    Caucasian (5) 0.96 0.80, 1.15 0.64 0% 0.45
    Asian (2) 0.55 0.17, 1.80 0.32 87% 0.005
    Control source          
    Hospital-based (6) 0.87 0.74, 1.01 0.06 46% 0.10
    Population-based (2) 1.05 0.51, 2.17 0.90 72% 0.06
    Sample size          
    ≥200 (6) 0.90 0.77, 1.04 0.15 0% 0.87
    <200 (2) 0.67 0.13, 3.56 0.64 91% 0.0007
    Genotyping method          
    PCR (4) 0.94 0.79, 1.14 0.54 26% 0.26
    PCR-RFLP (3) 0.64 0.34, 1.18 0.15 74% 0.02
    Tumor type          
    Oral (2) 0.55 0.17, 1.80 0.32 87% 0.005
    Laryngeal (2) 0.87 0.67, 1.15 0.33 0% 0.43
    NAT2 Overall (25) 1.22 1.02, 1.46 0.03 74% <0.00001
    Ethnicity          
    Caucasian (13) 1.10 0.89, 1.37 0.38 71% <0.0001
    Asian (8) 1.60 1.13, 2.26 0.008 69% 0.002
    Mixed (4) 1.04 0.61, 1.77 0.89 79% 0.003
    Control source          
    Hospital-based (15) 1.10 0.88, 1.37 0.39 71% <0.0001
    Population-based (10) 1.41 1.04, 1.92 0.03 75% <0.0001
    Sample size          
    ≥200 (20) 1.19 1.00, 1.42 0.05 70% <0.00001
    <200 (5) 1.49 0.68, 3.29 0.32 85% <0.0001
    Genotyping method          
    PCR (4) 1.47 0.77, 2.78 0.24 85% 0.0002
    PCR-RFLP (19) 1.14 0.93, 1.39 0.21 72% <0.00001
    Tumor type          
    Oral (7) 1.05 0.80,1.38 0.72 62% 0.01
    Pharyngeal (2) 0.82 0.54, 1.24 0.35 0% 0.96
    Laryngeal (8) 1.48 0.88, 2.51 0.14 88% <0.00001
    Abbreviations: PCR, Polymerase Chain Reaction; RFLP, Restriction Fragment Length Polymorphism.

    The meta-regression analyses assessing the effect of publication year, the sample size, and the mean age and gender distribution of cases and controls on the risk of HNC in NAT1 and NAT2 polymorphisms are shown in Table 4 . Sample size, the mean age of cases, and the percentage of males in the controls were confounding factors for the pooled result of the association between NAT2 polymorphism and the HNC susceptibility. With an increase in sample size, age of the cases, and percentage of males in the controls, the OR decreased.

    Table 4. Meta-regression analysis of association between N-acetyltransferases 1 and 2 (NAT1 and NAT2) polymorphisms and the risk of head and neck cancer (slow vs. rapid acetylators).
    Polymorphism Variable   Point Estimate Standard Error Lower Limit Upper Limit Z-Value p-Value
    NAT1 Publication year Slope 0.01830 0.01361 −0.00837 0.04497 1.34462 0.17875
    Intercept −36.77098 27.26207 −90.20365 16.66169 −1.34880 0.17740
    Sample size Slope 0.00027 0.00045 −0.00060 0.00115 0.61240 0.54027
    Intercept −0.25993 0.24912 −0.74819 0.22833 −1.04340 0.29676
    Mean age of cases Slope −0.01179 0.03248 −0.07546 0.05186 −0.36300 0.71660
    Intercept 0.57037 1.93376 −3.21972 4.36047 0.29496 0.76803
    Mean age of controls Slope −0.02263 0.03624 −0.09365 0.04839 −0.62459 0.53224
    Intercept 1.17938 2.13386 −3.00290 5.36167 0.55270 0.58047
    Male percentage of cases Slope −0.01131 0.01256 −0.03593 0.01331 −0.90074 0.36773
    Intercept 0.86738 1.11137 −1.31087 3.04562 0.78046 0.43512
    Male percentage of controls Slope −0.00268 0.00617 −0.01478 0.00942 −0.43474 0.066375
    Intercept 0.03230 0.43459 −0.81948 0.88409 0.07433 0.94074
    NAT2 Publication year Slope 0.00944 0.01016 −0.01047 0.02934 0.092942 0.35267
    Intercept −18.82284 20.36308 −58.73373 21.08806 −0.92436 0.35530
    Sample size Slope −0.00080 0.00020 −0.00120 −0.00040 −3.91239 0.00009
    Intercept 0.50882 0.11300 0.28733 0.73030 4.50265 0.00001
    Mean age of cases Slope −0.04050 0.01356 −0.06706 −0.01393 −2.098776 0.00281
    Intercept 2.47888 0.80007 0.91077 4.04699 3.09832 0.00195
    Mean age of controls Slope −0.00438 0.00889 −0.02180 0.01305 −0.49203 0.62270
    Intercept 0.34691 0.47403 −0.58217 1.27600 0.73184 0.46427
    Male percentage of cases Slope −0.0629 0.00393 −0.01399 0.00141 −1.60201 0.10915
    Intercept 0.57366 0.33428 −0.08152 1.22884 1.71610 0.08614
    Male percentage of controls Slope −0.00785 0.00289 −0.01351 −0.00219 −2.71989 0.00653
    Intercept 0.64373 0.22152 0.20956 1.07790 2.90598 0.00366

    3. Current Insights

    This meta-analysis showed a significant relationship between NAT2 polymorphisms and the HNC susceptibility with slow acetylators being at higher risk for HNC than rapid acetylators. For NAT2 polymorphism, the ethnicity, the control source, and genotyping methods could modify the association of this polymorphism and the HNC risk. In addition, TSA showed the amount of information for the association between the polymorphisms (NAT1 and NAT2) and the HNC risk was not large enough.
    The findings from studies exploring the association of NAT1 polymorphism with other cancers and HNC are different. One meta-analysis [24] found NAT1 polymorphism to be related to the risk of lung, colorectal, head and neck, bladder, and gastric carcinomas, but not with prostate, breast, and pancreatic carcinomas and non-Hodgkin’s lymphoma. Varzim et al. [40] checked the association between NAT1 polymorphism and the laryngeal cancer risk and found that the association depends on tumor location. Among the eight studies included in our meta-analyses [23][41][31][32][37][40][46][54] which evaluated the association between NAT1 polymorphism and the HNC risk, just one study [41] reported a protective role of NAT1 slow acetylators in the HNC patients while the rest of the studies did not find any association.
    Comparing the individual studies included in the meta-analysis, differences were observed between the studies. For example, five studies [34][39][42][49] found an elevated risk of HNC for NAT2 slow acetylators, one found a protective role of these acetylators in HNC patients, and three did not find any association between NAT2 polymorphism and the HNC risk [23][38][43].
    Effective factors on the association between NAT polymorphisms and the risk of HNC were not included in our analysis due to low numbers of studies, including smoking, gene combination, and the linkage disequilibrium. One study [34] found an elevated frequency of the NAT2 slow acetylator genotypes among HNC patients who smoked less than those who smoked more frequently. Another study reported an association in cases with a smoking history ≤30 years in duration [41]. These contradictory results [41][34][39] suggest the need to evaluate the effect of NAT polymorphisms independent of the history of smoking. In addition, assessing the frequencies of gene-gene combination (NAT2 with GSTM1, XPD, and CYP1A1) between cases with laryngeal cancer and the controls, the frequency of combinations was superior to cases than in controls where the numbers of combinations had an increased risk of laryngeal cancer and the numbers of other combinations had a protective role [33]. The linkage disequilibrium between the genes of NAT1 and NAT2 has been observed in HNC [23][31][56] and other cancers [57][58][59]. Research [60] showed the highest level of carcinogen-DNA adducts formation in cases with acetylation activity of NAT1 rapid and NAT2 slow. Therefore, future studies should consider the linkage between these polymorphisms.

    4. Conclusions

    There was no association between NAT1 polymorphism and susceptibility to HNC, whereas an association between and NAT2 polymorphism and the HNC risk was found. Slow acetylators of NAT2 polymorphism were at greater risk for HNC than the rapid acetylators. Despite the stability of the results, the presence of high heterogeneity, publication bias, and confounding factors warrant the need for more studies to confirm the results of the present meta-analysis as well as TSA.

    This entry is adapted from 10.3390/medicina57101095

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