The interplay between driver mutation and oxidative stress in colorectal cancer: from pathogenesis to therapeutics

Abstract

Colorectal cancer (CRC) is a multifaceted disease influenced by genetic mutations and environmental factors, especially oxidative stress. Driver mutations are pivotal in CRC initiation and progression and alter key signaling pathways involved in cell proliferation, apoptosis, and genomic stability. Concurrently, oxidative stress, characterized by an imbalance between reactive oxygen species (ROS) production and antioxidant defenses, plays a crucial role in CRC development by promoting DNA damage, lipid peroxidation, and redox signaling dysregulation. The molecular mechanisms linking driver mutations and oxidative stress pathways underscore their collective or antagonistic impact on CRC heterogeneity, therapeutic responses, and clinical outcomes. Insights into mutation-specific vulnerabilities and redox modulation offer promising avenues for targeted therapies and personalized medicine approaches in CRC treatment. Here, we discuss the intricate interplay between driver mutations and oxidative stress, highlight emerging trends, and propose future research directions to advance our understanding of CRC pathogenesis and optimize therapeutic interventions.

Introduction

Colorectal cancer (CRC) remains a significant global health challenge and is responsible for substantial morbidity and mortality worldwide [1, 2]. CRC arises from a complex interplay of genetic mutations, environmental factors, and lifestyle influences, highlighting its heterogeneous and multifaceted nature [3]. Understanding the intricate mechanisms driving CRC pathogenesis is essential for developing effective therapeutic strategies that can improve patient outcomes.

Central to CRC pathogenesis are driver mutations in key oncogenes and tumor suppressor genes, which orchestrate dysregulated cellular pathways pivotal in tumorigenesis [4, 5]. Among the most frequently mutated genes in CRC are adenomatous polyposis coli (APC), Kirsten rat sarcoma viral oncogene homolog (KRAS), TP53 (tumor protein p53), BRAF (v-Raf murine sarcoma viral oncogene homolog B) and other novel driver genes [6–9]. These mutations collectively contribute to CRC initiation, progression, and therapeutic resistance. While these driver mutations are pivotal in CRC development, recent research has increasingly recognized the role of oxidative stress as a critical mediator in cancer pathogenesis [10, 11]. Oxidative stress arises from an imbalance between the production of reactive oxygen species (ROS) and antioxidant defense mechanisms [12, 13]. ROS are chemically reactive molecules containing oxygen that play a pivotal role in cellular signaling and homeostasis. In the context of cancer, ROS have a dual function [14]. At moderate levels, they act as signaling molecules that promote cell proliferation and survival. However, excessive ROS can cause oxidative damage to DNA, proteins, and lipids, leading to mutations and genomic instability that drive tumor initiation. Furthermore, elevated ROS levels contribute to tumor progression by facilitating processes such as epithelial–mesenchymal transition (EMT), invasion, and angiogenesis [15] (Fig. 1).

Fig. 1.

ROS function as critical mediators in tumor development and progression. Excessive ROS levels lead to oxidative damage of cellular components, including DNA, proteins, and lipids, resulting in genetic mutations and genomic instability that initiate tumorigenesis. Moreover, ROS influence tumor progression by promoting epithelial–mesenchymal transition (EMT), enhancing cancer cell migration and invasion, and stimulating angiogenesis through the activation of signaling pathways such as MAPK and PI3 K/Akt. This figure was created specifically for this article with BioRender

In CRC, oxidative stress plays a dual role—both as a driver of tumorigenesis and as a modulator of therapeutic responses [16]. ROS-induced DNA damage promotes genetic instability and mutagenesis, facilitating the acquisition of driver mutations such as APC, KRAS, TP53, and BRAF mutations [17–19]. Additionally, oxidative stress contributes to the activation of redox-sensitive signaling pathways that promote cell survival, proliferation, and angiogenesis in the tumor microenvironment [20–22]. Consequently, oxidative stress influences CRC phenotype heterogeneity, treatment response, and patient prognosis, highlighting its clinical relevance. For instance, at physiological levels, ROS function as signaling molecules that can inhibit the Wnt/β-catenin pathway, maintaining normal epithelial cell homeostasis. However, in the presence of APC mutations, elevated ROS levels can activate Wnt/β-catenin signaling and promote EMT, facilitating tumor initiation and progression (Fig. 2).

Fig. 2.

Oxidative stress plays a dual role in CRC development. The limited oxidative stress levels are crucial for maintaining normal colonic epithelium by inhibiting the Wnt/β-catenin signaling pathway, thereby preventing uncontrolled cell proliferation. Under conditions of APC mutation, elevated oxidative stress can promote cancer stemness and EMT, contributing to cancer progression and drug resistance. The figure highlights how disruption of the balance between ROS production and antioxidant defenses can lead to pathological outcomes. This figure was created specifically for this article with BioRender

This review aims to comprehensively explore the intricate interplay between driver mutations—specifically those in APC, KRAS, BRAF and TP53—and oxidative stress in CRC. By elucidating the molecular mechanisms and biological consequences of this interplay, we seek to provide insights into CRC pathogenesis, identify potential therapeutic targets, and discuss emerging strategies for personalized medical approaches in CRC treatment.

Driver mutations in CRC

CRC is a complex and heterogeneous disease driven by various genetic mutations. These mutations can be classified into"classic"driver mutations, which have been well studied and are commonly associated with CRC, and"novel"driver mutations, which have been more recently discovered and are still being investigated for their roles in CRC pathogenesis (Table 1).

Table 1.

Key driver gene mutations in CRC

Gene	Frequency in CRC	Function	Impact on CRC	Refs
APC	~ 80%	Tumor suppressor	Activates Wnt signaling pathway, leading to uncontrolled cell proliferation	[6]
TP53	~ 50–60%	Tumor suppressor	Loss of cell cycle control, evasion of apoptosis, and increased genetic instability	[57]
KRAS	~ 40%	Oncogene	Activates RAS/RAF/MEK/ERK signaling pathway, promoting cell proliferation and survival	[27]
TGFBR2	~ 20%	Tumor suppressor	Mutations lead to impaired TGF-β signaling, promoting tumor progression	[58]
PIK3 CA	~ 10–20%	Oncogene	Activates PI3 K/AKT signaling pathway, promoting cell survival and growth	[59, 60]
SMAD4	~ 10–15%	Tumor suppressor	Involved in TGF-β signaling, loss of function leads to increased proliferation and invasion	[61]
BRAF	~ 10–15%	Oncogene	Activates MAPK/ERK signaling pathway, associated with poor prognosis	[9]
MLH1	~ 10–15%	DNA mismatch repair	Mutations lead to microsatellite instability (MSI), promoting mutagenesis	[62]
MSH2	~ 10–15%	DNA mismatch repair	Mutations lead to MSI, similar to MLH1	[63]
MSH6	~ 10–15%	DNA mismatch repair	Mutations lead to MSI, similar to MLH1 and MSH2	[64]
PMS2	~ 10–15%	DNA mismatch repair	Mutations lead to MSI, similar to MLH1, MSH2, and MSH6	[64]
FBXW7	~ 10%	Tumor suppressor	Involved in ubiquitination and degradation of oncoproteins, mutations lead to stabilization of oncoproteins	[40]
PTEN	~ 5–10%	Tumor suppressor	Negatively regulates PI3 K/AKT signaling, loss of function promotes survival and growth	[65]
ARID1 A	~ 5–10%	Chromatin remodeling	Involved in chromatin remodeling, mutations lead to genomic instability	[66]
SOX9	~ 5–10%	Transcription factor	Involved in differentiation and proliferation, mutations can disrupt these processes	[67]
NRAS	~ 5%	Oncogene	Activates RAS/RAF/MEK/ERK signaling pathway, similar to KRAS	[68]
CTNNB1	~ 5%	Oncogene	Encodes β-catenin, involved in Wnt signaling, mutations lead to increased cell proliferation	[69]
RPL22	~ 5%	Ribosomal protein	Involved in protein synthesis, mutations associated with poor prognosis	[70]
SPOP	~ 5%	Ubiquitin ligase	Involved in protein degradation, mutations can lead to accumulation of oncoproteins	[71]
ERBB2	~ 3%	Oncogene	Encodes HER2, involved in cell growth and differentiation, overexpression promotes tumor progression	[72]
FGFR2	~ 2–3%	Oncogene	Encodes fibroblast growth factor receptor, involved in cell growth and angiogenesis	[73]
POLE	~ 1–2%	DNA polymerase	Involved in DNA replication and repair, mutations lead to hypermutated phenotype	[74]

Classic driver mutations

The APC gene, located on chromosome 5q21–22, is mutated in approximately 80% of sporadic CRC cases [6]. APC mutations typically occur early in colorectal tumorigenesis, disrupting the intricate balance of the Wnt signaling pathway by preventing the phosphorylation and degradation of β-catenin, a key downstream effector [23]. This results in the accumulation of β-catenin in the nucleus, where it interacts with transcription factors of the TCF/LEF family to drive the expression of genes involved in cell proliferation, survival, and differentiation [24]. Early mutations in APC are often seen in precursor lesions, such as adenomas, and their presence is considered a critical step in the adenoma-carcinoma sequence, which underpins much of CRC pathogenesis [25]. Clinically, APC mutations are associated with poor prognosis, as they contribute to tumor heterogeneity and resistance to certain therapeutic approaches, particularly those targeting the Wnt/β-catenin pathway [26]. Mutations in KRAS, which occur in approximately 40% of CRC cases, predominantly affect codons 12 and 13 of the KRAS gene [27]. KRAS mutations lead to constitutive activation of downstream signaling pathways such as RAF-MEK-ERK, promoting uncontrolled cell growth, survival, and metastasis [28]. Moreover, KRAS mutations are associated with resistance to targeted therapies, including anti-epidermal growth factor receptor (EGFR) monoclonal antibodies, which are standard treatments for metastatic CRC [29, 30]. BRAF mutations, particularly the V600E mutation, occur in approximately 10% of CRC cases and are associated with a distinct molecular phenotype characterized by hypermethylation of CpG islands and microsatellite instability [9]. BRAF V600E mutations activate the MAPK/ERK signaling pathway independently of upstream RAS activation, promoting cell proliferation, survival, and resistance to apoptosis [31]. Like KRAS mutations, BRAF mutations confer resistance to anti-EGFR therapies in CRC, influencing treatment outcomes and patient prognosis [32]. TP53, located on chromosome 17p13.1, is mutated in nearly 50% of CRC cases. TP53 is known as the"guardian of the genome"because of its critical role in regulating cell cycle arrest, DNA repair, apoptosis, and senescence in response to cellular stress [33]. It’s mutations typically occur later, resulting in the loss of critical tumor-suppressive functions and the emergence of a more aggressive tumor phenotype compared to early events like APC mutation [34].

These classic mutations, while well characterized, exhibit a layered temporal pattern in CRC evolution. Their differential impact on signaling pathways—such as the reliance on EGFR signaling in KRAS versus the early tumor-initiating effects of APC—highlights the necessity for mutation-specific therapeutic strategies.

Novel driver mutations

ZFP36L2 (zinc finger protein 36, C3H1-type-like 2) is a member of the tristetraprolin family of RNA-binding proteins, which regulate mRNA stability and degradation [35]. Unlike classic mutations that primarily affect protein signaling pathways, ZFP36L2 influences posttranscriptional regulation, suggesting potential for anti-inflammatory interventions [36]. It is involved in the posttranscriptional regulation of inflammation and cell proliferation. Loss-of-function mutations in ZFP36L2 result in the stabilization of proinflammatory and oncogenic mRNAs, leading to enhanced inflammatory responses and uncontrolled cell proliferation [37]. This can contribute to tumorigenesis and cancer progression in the colon. ZFP36L2 mutations are relatively rare in CRC but represent an important mechanism by which inflammation can drive cancer development [38]. Understanding the role of ZFP36L2 in CRC could lead to new therapeutic strategies that target mRNA stability and inflammatory pathways. ZFP36L2 status might also be used to identify patients who could benefit from anti-inflammatory treatments. FBXW7 (F-Box and WD Repeat Domain Containing 7) is a component of the SCF (SKP1-CUL1-F-box protein) ubiquitin ligase complex, which targets various oncoproteins for proteasomal degradation [39]. These targets include cyclin E, c-Myc, Notch, and mTOR. FBXW7 mutations are found in approximately 10% of CRC cases [40]. Loss-of-function mutations in FBXW7 lead to the accumulation of its target oncoproteins, resulting in uncontrolled cell proliferation and survival [41]. FBXW7 mutations are associated with chromosomal instability and poor prognosis in CRC, contributing more to tumor progression than initiation—complementing the profile of APC loss [42]. FBXW7 mutations can serve as prognostic markers for CRC [43]. Therapies targeting the downstream effects of FBXW7 loss, such as inhibitors of mTOR or Notch signaling, may be effective in treating CRC with FBXW7 mutations. The POLE (DNA polymerase epsilon, catalytic subunit) encodes the catalytic subunit of DNA polymerase epsilon, which is essential for DNA replication and repair [44]. The exonuclease domain of POLE has proofreading activity that ensures high fidelity during DNA replication, mutations in the exonuclease domain of POLE lead to defective proofreading, resulting in a high mutation rate (ultramutation phenotype) [45]. These hypermutated tumors are often associated with microsatellite instability (MSI) and a high neoantigen load, which can enhance immune recognition [46]. POLE mutations are found in a small subset of CRC cases, particularly those with a hypermutated phenotype [47]. In contrast to KRAS or BRAF mutations, POLE-mutant tumors may be more responsive to immune checkpoint inhibitors, given their high mutational burden and neoantigen load [48]. The SRY-related HMG-box (SOX) family of transcription factors plays critical roles in developmental processes, cell differentiation, and maintenance of stem cell pluripotency [49]. These proteins are involved in various signaling pathways, including the Wnt, Hedgehog, and Notch pathways. Alterations in SOX family proteins, such as SOX2, SOX4, and SOX9, have been implicated in CRC [50–52]. These mutations or dysregulated expression can disrupt normal differentiation processes, promote cell proliferation, and contribute to the maintenance of a stem-like phenotype in CRC cells. For example, overexpression of SOX9 has been linked to increased Wnt signaling, driving tumor growth and progression [53]. Mutations and aberrant expression in SOX family members are observed in a subset of CRC cases and are often associated with aggressive tumor behavior and poor prognosis [49, 54]. Targeting dysregulated SOX family proteins and their associated pathways could lead to novel therapeutic approaches for CRC [55]. Additionally, SOX proteins can serve as biomarkers for identifying aggressive CRC subtypes and tailoring personalized treatment strategies. Their broad regulatory roles differ from the more linear signaling disruptions seen in classic mutations, highlighting the complexity of tumor biology and the need for multi-targeted approaches [56].

Compared with classic drivers, novel mutations such as those in ZFP36L2, FBXW7, POLE, and SOX family proteins introduce additional layers of regulatory disruption. These mutations not only expand the spectrum of oncogenic mechanisms in CRC but also suggest alternative therapeutic avenues—especially where classic drivers offer limited treatment options. It’s crucial for improving the diagnosis, prognosis, and treatment of CRC patients. Future studies should focus on further elucidating the functional roles of these mutations and developing targeted therapies to improve patient outcomes.

The interplay between driver mutation and oxidative stress

The intricate interplay between driver mutations and oxidative stress is central to the pathogenesis of CRC [75]. Oxidative stress can induce driver mutations through direct DNA damage and epigenetic modifications, contributing to cancer initiation and progression [76, 77]. Conversely, driver mutations can regulate oxidative stress levels by altering metabolic pathways, mitochondrial function, and antioxidant defenses [78]. Recent research highlights a bidirectional relationship in which oxidative stress can regulate driver mutations and, conversely, driver mutations can also influence oxidative stress levels. For example, wild-type p53 safeguards against tumor development under conditions of moderate oxidative stress, by promoting processes such as mitochondrial permeability transition pore (mPTP) opening and necroptosis [79]. However, when p53 is mutated, its loss of function—and acquisition of novel oncogenic properties—leads to the activation of pro-oxidant pathways, metabolic alterations, and suppression of antioxidant defenses [80] (Fig. 3).

Fig. 3.

Differential regulation of oxidative stress and cell death by wild-type and mutant p53. This schematic diagram illustrates two distinct pathways by which oxidative stress influences cell fate in CRC depending on p53 status. In cells expressing wild-type p53, elevated ROS trigger mitochondrial translocation of p53, where it binds to cyclophilin D (CypD) to facilitate the opening of the mitochondrial permeability transition pore (mPTP). The subsequent mitochondrial dysfunction leads to necroptotic cell death, serving as a tumor-suppressive mechanism. In contrast, in cells harboring mutant p53, the normal protective functions are lost. Instead, mutant p53 actively promotes ROS production through activating pro-oxidant enzyme, metabolic rewiring and the induction of inflammatory signaling. Moreover, mutant p53 suppresses antioxidant transcription factors and catabolic processes that help mitigate ROS, resulting in sustained ROS production and further oncogenic stress. This figure was created specifically for this article with BioRender

Oxidative stress-induced driver mutations in CRC

Oxidative stress plays a pivotal role in the development and progression of CRC by inducing driver mutations in direct or direct ways. ROS directly interact with DNA bases, resulting in various oxidative lesions [81]. A notable example is 8-oxo-2'-deoxyguanosine (8-oxo-dG), which is formed by the oxidation of guanine [82]. This lesion is highly mutagenic because it can pair with adenine instead of cytosine during DNA replication, causing G-to-T transversions [83]. These mutations in critical genes, including tumor suppressors and oncogenes, can drive carcinogenesis [84]. Certain genomic regions, known as mutational hotspots, are more prone to oxidative damage. CpG islands, which are rich in cytosine and guanine nucleotides and are often sites of methylation, constitute one such region [85]. Methylated cytosines are susceptible to oxidative deamination, transforming them into thymine and leading to C-to-T transitions [86]. These transitions, particularly in regulatory regions or coding sequences of tumor suppressor genes such as TP53, can inactivate these genes, promoting cancer development [87, 88]. ROS can cause single-strand breaks (SSBs) and double-strand breaks (DSBs) in DNA. SSBs occur when ROS attack the sugar-phosphate backbone of DNA, whereas DSBs can result from closely spaced SSBs on opposite strands [81]. DSBs are especially damaging, as they can lead to chromosomal rearrangements, deletions, or translocations if not properly repaired [89]. The repair of SSBs and DSBs involves complex cellular machinery. SSBs are repaired mainly by base excision repair (BER), whereas DSBs are repaired through homologous recombination (HR) or nonhomologous end joining (NHEJ) [90]. Errors in these repair processes can introduce mutations. For example, NHEJ is an error-prone mechanism that can cause insertions or deletions (indels) at the break site [91]. These mutations in oncogenes or tumor suppressor genes could drive cancer progression. ROS can create cross-links between DNA strands or between DNA and proteins [92, 93]. Interstrand cross-links prevent the separation of DNA strands, obstructing replication and transcription [94]. If these cross-links are not efficiently repaired, they can lead to cell death or mutation. ROS can react with DNA bases to form adducts, which are covalent modifications that distort the DNA helix [95]. An example is malondialdehyde, a product of lipid peroxidation, which forms adducts with deoxyguanosine, resulting in mutagenic lesions [96]. These adducts can mispair during replication, leading to point mutations in essential genes.

In addition to direct mechanisms, indirect mechanisms also play essential roles in oxidative stress-induced driver mutations. Inflammatory cells, such as neutrophils and macrophages, produce ROS as part of the immune response [97, 98]. Chronic inflammation in the colorectal epithelium, which is observed in conditions such as inflammatory bowel disease (IBD), leads to sustained ROS production [99]. This persistent oxidative environment increases the likelihood of DNA damage and subsequent mutations. Proinflammatory cytokines, including TNF-α and IL-6, activate signaling pathways that increase ROS production [100]. These cytokines can also upregulate enzymes such as NADPH oxidase, which generates ROS [101]. The resulting oxidative stress causes genomic instability, promoting mutagenesis and cancer development. Moreover, epigenetic modification is also an indirect mechanism of oxidative stress-induced driver mutations. For example, oxidative stress can influence DNA methylation patterns, leading to epigenetic changes that affect gene expression [102]. Oxidative stress can cause hypermethylation of promoter regions of tumor suppressor genes, resulting in their silencing. This epigenetic silencing can contribute to the loss of tumor suppressive functions and cancer progression [103]. ROS can also induce modifications in histone proteins, such as acetylation, methylation, and phosphorylation. These histone modifications can alter chromatin structure and gene expression. For example, oxidative stress-induced acetylation of histone H3 at specific lysine residues can increase the expression of oncogenes, promoting tumor growth [104].

Oxidative stress can activate the Wnt/β-catenin signaling pathway, which is crucial for cell proliferation and differentiation. Mutations in the APC gene, often induced by oxidative stress, lead to the accumulation of β-catenin in the nucleus, where it activates the transcription of oncogenes [105]. This aberrant signaling promotes uncontrolled cell proliferation and tumorigenesis. The MAPK/ERK pathway is another critical signaling cascade influenced by oxidative stress. Mutations in the KRAS gene, which are frequently found in CRC, can be driven by ROS [106]. Activated KRAS triggers the MAPK/ERK pathway, leading to increased cell division and survival. This pathway is often constitutively active in CRC, contributing to cancer progression. ROS can also activate the PI3 K/AKT signaling pathway, which regulates cell growth, survival, and metabolism [107]. Mutations in the PIK3 CA gene, encoding the p110α subunit of PI3 K, can be induced by oxidative stress [108]. These mutations increase PI3 K activity, leading to AKT activation and promoting cell survival and proliferation. This pathway is frequently altered in CRC, supporting tumor development [109]. Mitochondria are a major source of ROS, particularly during oxidative phosphorylation. Dysfunctional mitochondria can produce excessive ROS, contributing to oxidative stress [110]. Mutations in mitochondrial DNA (mtDNA), often induced by ROS, can impair mitochondrial function and exacerbate ROS production, creating a vicious cycle of oxidative damage [111]. Cancer cells undergo metabolic reprogramming to support rapid growth and proliferation. Oxidative stress can drive this metabolic shift by activating oncogenic pathways such as the PI3 K/AKT and HIF-1α pathways [112]. These pathways enhance glycolysis and other metabolic processes, providing the energy and biosynthetic precursors needed for tumor growth [113]. Additionally, the Warburg effect, characterized by increased aerobic glycolysis, is often observed in cancer cells and is associated with elevated ROS levels [114]. Oxidative stress can induce cellular senescence, a state of permanent cell cycle arrest. Senescent cells secrete a variety of proinflammatory cytokines, growth factors, and proteases, collectively known as the senescence-associated secretory phenotype (SASP) [115]. The SASP can create a protumorigenic microenvironment by promoting inflammation, angiogenesis, and tissue remodeling, thereby supporting cancer progression. Tumor microenvironment (TME) is composed of cancer cells, stromal cells, immune cells, and the extracellular matrix, is influenced by oxidative stress [116]. ROS can modulate the TME by affecting the behavior of stromal and immune cells. For example, oxidative stress can activate cancer-associated fibroblasts (CAFs), which secrete factors that increase tumor growth and invasion [117]. Additionally, ROS can suppress antitumor immune responses by affecting the function of immune cells such as T cells and macrophages, promoting immune evasion [118].

Driver mutations regulate oxidative stress in CRC

Driver mutations play crucial roles in regulating oxidative stress in CRC [119]. These mutations impact various molecular pathways involved in ROS production, antioxidant defense, and redox signaling, contributing to tumor initiation, progression, and therapy resistance [120]. Mutations in the APC gene are among the earliest and most common events in CRC. APC mutations lead to the accumulation of β-catenin in the nucleus, where it activates the transcription of target genes involved in cell proliferation and survival [121]. Additionally, APC plays a role in regulating oxidative stress by modulating the expression of antioxidant enzymes, such as superoxide dismutase (SOD), catalase, glutathione peroxidase (GPx), thioredoxin reductase (TrxR), and peroxiredoxins [122]. Loss of APC function results in reduced expression of these enzymes, leading to increased ROS levels and oxidative damage [123]. This oxidative stress further drives mutagenesis and tumor progression in CRC. Mutant KRAS enhances ROS production by upregulating the expression of NADPH oxidases, enzymes that generate ROS [124]. This increased ROS production can lead to oxidative damage and contribute to cancer cell proliferation and survival [125]. Moreover, KRAS mutations can activate the Nrf2 pathway, a key regulator of antioxidant responses. However, this activation is often insufficient to counteract elevated ROS levels, resulting in persistent oxidative stress that promotes tumorigenesis [126]. Wild-type p53 plays a crucial role in maintaining redox balance by regulating the expression of antioxidant enzymes. TP53 mutations lead to the loss of this regulatory function, resulting in increased oxidative stress [127]. Mutant p53 can also gain new functions (gain-of-function mutations) that increase ROS production and promote tumor progression [128]. Additionally, the loss of p53 function impairs the ability of cells to respond to oxidative DNA damage, further contributing to genomic instability and cancer development [129]. PIK3 CA mutations are found in a significant subset of CRC cases. PIK3 CA encodes the p110α catalytic subunit of PI3K, which is involved in the PI3K/AKT signaling pathway [130]. PIK3 CA mutations lead to the activation of the PI3 K/AKT pathway, which promotes cell growth, survival, and metabolism. This pathway also plays a role in regulating oxidative stress [131]. Mutant PIK3 CA enhances glycolysis, leading to increased ROS production [132]. The activation of AKT can also inhibit FOXO transcription factors, which are involved in the expression of antioxidant enzymes [133]. This inhibition results in reduced antioxidant capacity and elevated oxidative stress, contributing to CRC progression. SMAD4 plays a role in regulating the expression of genes involved in oxidative stress responses. Mutations in SMAD4 can disrupt this regulation, leading to increased ROS levels and oxidative damage [134]. Additionally, the loss of SMAD4 function can enhance the proinflammatory environment in the tumor microenvironment, further contributing to oxidative stress and tumor progression [135].

NADPH oxidases are a family of enzymes that produce ROS by transferring electrons from NADPH to oxygen. NOX enzymes are upregulated in various cancers, including CRC, and are involved in ROS-mediated signaling pathways that promote tumorigenesis [136]. Driver mutations such as those in KRAS and PIK3 CA can upregulate NOX enzymes, leading to increased ROS production [137]. This upregulation creates a pro-oxidant environment that promotes DNA damage, genomic instability, and cancer cell survival. NRF2 is a key transcription factor that regulates the expression of antioxidant enzymes, including SOD, catalase, and glutathione peroxidase [138]. NRF2 activation is a critical cellular response to oxidative stress. Mutations in genes such as APC and TP53 can impair the activation of NRF2 and reduce the expression of antioxidant enzymes, leading to elevated oxidative stress [139, 140]. Additionally, some driver mutations can result in aberrant activation of NRF2, which may contribute to cancer cell survival by increasing antioxidant capacity and promoting resistance to oxidative damage [141]. Mitochondrial dysfunction can lead to increased ROS production and contribute to oxidative stress. Driver mutations such as those in KRAS and PIK3 CA can impact mitochondrial function and increase ROS production. For example, mutant KRAS can alter mitochondrial metabolism, leading to increased electron transport chain activity and ROS generation [142]. Similarly, PIK3 CA mutations can promote glycolysis and reduce oxidative phosphorylation, leading to mitochondrial dysfunction and oxidative stress [143]. Chronic inflammation is a hallmark of CRC and is associated with increased ROS production. Inflammatory cells such as neutrophils and macrophages produce ROS as part of the immune response, contributing to the oxidative environment in tumors. Driver mutations can modulate the inflammatory response and influence the TME. For example, TP53 mutations can increase the production of proinflammatory cytokines, leading to increased ROS levels and oxidative stress [144]. Additionally, the MAPK/ERK pathway is involved in cell proliferation, differentiation, and survival. This pathway can be activated by oxidative stress and plays a role in redox signaling. Mutations in genes such as KRAS can constitutively lead to continuous activation of downstream signaling MAPK/ERK pathway pathways, leading to increased oxidative stress and tumorigenesis [145]. In contrast, the BRAF V600E mutation is associated with aggressive tumor behavior, such as lung metastasis and liver metastasis (Fig. 4).

Fig. 4.

Oncogenic roles of KRAS and BRAF mutations in CRC development, malignant transformation, and metastasis. KRAS mutation activates downstream signaling pathways such as the MAPK/ERK and PI3 K/AKT pathways, leading to increased cell proliferation, survival, and transformation of normal colorectal epithelial cells into cancerous cells. The mutation also affects cellular metabolism and promotes an altered redox state, contributing to malignant progression. BRAF mutation is particularly important in CRC metastasis, particularly in cells with high levels of glutathione (GSH), cells with elevated GSH levels exhibit enhanced resistance to oxidative damage, facilitating the metastatic potential of BRAF V600E-mutant CRC cells. This figure was created specifically for this article with BioRender

Overall, exploring this bidirectional relationship provides valuable insights into CRC pathogenesis and highlights potential therapeutic targets. Strategies aimed at modulating oxidative stress, either by targeting ROS production or enhancing antioxidant defenses, could complement existing therapies and improve cancer treatment outcomes. Further research is needed to elucidate the precise mechanisms involved and to translate these findings into clinical practice.

The role of driver mutation and oxidative stress in CRC

Oxidative stress can induce driver mutations and promote tumor progression while also activating protective antioxidant responses and imposing selective pressures that limit cancer growth. Therefore, the interplay between driver mutations and oxidative stress in CRC is complex and involves both cooperative and antagonistic effects (Fig. 4).

Cooperative effects: how driver mutations and oxidative stress promote CRC

Oxidative stress, by generating ROS, contributes significantly to genomic instability through various forms of DNA damage. The cell has developed several repair mechanisms, such as BER, NHEJ, and HR, to counteract this damage, but excessive oxidative stress can overwhelm these systems. If not properly repaired, it can result in mutations that activate oncogenes or inactivate tumor suppressor genes, leading to carcinogenesis and cancer progression [146].

The DNA damage induced by ROS can result in mutations if not properly repaired. These mutations occur during DNA replication and are often perpetuated in subsequent cell divisions [81]. Several mechanisms contribute to the mutagenic potential of oxidative DNA damage. Oxidative DNA damage can cause replication stress by stalling replication forks [147]. This stress leads to the activation of error-prone repair pathways such as translesion synthesis, which allows DNA replication to continue past damaged sites but often introduces mutations [147, 148]. In addition, persistent oxidative DNA damage can lead to genomic instability, characterized by an increased rate of mutations, chromosomal rearrangements, and aneuploidy [149]. Genomic instability is a hallmark of cancer and contributes to the accumulation of driver mutations that confer selective growth advantages to cancer cells [150, 151].

Driver mutations often lead to metabolic reprogramming, which increases ROS production and oxidative stress, creating a feedback loop that supports tumor growth [152]. CRC cells exhibit the Warburg effect, which is characterized by increased glycolysis and lactate production even in the presence of oxygen [153]. This metabolic shift, driven by mutations in genes such as MYC and HIF1 A, results in elevated ROS levels owing to altered mitochondrial function and increased glycolytic flux [154]. Mutations in mitochondrial DNA or nuclear-encoded mitochondrial genes can impair the electron transport chain, leading to increased ROS production and further oxidative stress [111]. This oxidative stress can, in turn, drive additional mutations in nuclear genes, promoting tumorigenesis [75]. Oxidative stress can also lead to epigenetic changes that cooperate with driver mutations to promote CRC development. For example, ROS can inhibit DNA methyltransferases, leading to abnormal DNA methylation patterns. This can result in hypomethylation of oncogenes and hypermethylation of tumor suppressor genes, driving CRC progression [155]. Moreover, ROS can affect enzymes that modify histones, leading to changes in chromatin structure and gene expression [156]. These changes can impact genes involved in cell proliferation, survival, and DNA repair, further promoting tumorigenesis [104]. Mutations in APC not only activate Wnt signaling but also increase cellular oxidative stress by disrupting mitochondrial function. This creates a feedback loop in which oxidative stress further promotes genomic instability and tumor progression [157]. Oncogenic KRAS mutations enhance ROS production through increased metabolic activity and mitochondrial dysfunction [158, 159]. Elevated ROS levels, in turn, promote additional mutations and oncogenic signaling, creating a vicious cycle of tumor promotion [119].

Overall, oxidative stress plays a pivotal role in the induction of driver mutations in CRC by causing various types of DNA damage, including base modifications, SSB, DSB, and crosslinking. The accumulation of oxidative DNA damage, coupled with impaired DNA repair mechanisms, leads to mutations in key genes such as APC, KRAS, TP53, and PIK3 CA. These driver mutations disrupt normal cellular processes, promote genomic instability, and drive the initiation and progression of CRC.

Antagonistic effects: balancing the impact of driver mutations and oxidative stress

Cells have evolved sophisticated antioxidant defense systems to counteract the damaging effects of ROS. These systems include enzymatic and nonenzymatic antioxidants that neutralize ROS and repair oxidative damage [14]. While oxidative stress can promote tumorigenesis, it can also activate antioxidant responses that counteract ROS and protect cells from damage [160, 161]. Driver mutations can influence these responses, sometimes leading to antagonistic effects.

The activation of these antioxidant defense mechanisms can mitigate the impact of oxidative stress, thereby reducing the likelihood of oxidative DNA damage and the subsequent accumulation of driver mutations [162]. In addition, cells possess several DNA repair pathways that detect and repair oxidative DNA damage, thereby preventing the propagation of mutations. For example, BER is the primary pathway for repairing oxidative DNA damage. It involves the recognition and removal of damaged bases by DNA glycosylases, followed by the insertion of the correct base and ligation of the DNA strand [163]. Efficient functioning of these repair pathways can prevent the accumulation of mutations induced by oxidative stress, thereby reducing the risk of cancer development [164]. Moreover, tumor suppressor genes and cell cycle checkpoints play critical roles in maintaining genomic integrity by preventing the proliferation of cells with DNA damage. In response to DNA damage, p53 can induce cell cycle arrest to allow for DNA repair or trigger apoptosis to eliminate damaged cells [165]. The loss of p53 function due to mutations can impair these protective mechanisms, leading to increased genomic instability [160]. The RB1 protein regulates the G1/S checkpoint of the cell cycle. In response to DNA damage, RB1 can inhibit cell cycle progression, allowing time for repair. Mutations in RB1 can disrupt this checkpoint, leading to uncontrolled cell proliferation [166]. The ATM (Ataxia-Telangiectasia Mutated) and ATR (ATM and Rad3-Related) proteins are involved in the DNA damage response. They activate signaling cascades that lead to cell cycle arrest and DNA repair [167]. Mutations in these genes can compromise the ability of the cell to respond to DNA damage. The proper functioning of these tumor suppressor genes and cell cycle checkpoints is essential for preventing the accumulation of driver mutations and the progression of CRC.

Oncogenes and tumor suppressors can directly regulate oxidative stress by modulating ROS production and antioxidant defenses. For example, the MYC oncogene can increase ROS production by upregulating metabolic processes such as glycolysis and mitochondrial respiration [168]. However, MYC also induces the expression of antioxidant genes, creating a balance between ROS production and detoxification [169]. NRF2 is activated in response to oxidative stress and plays a crucial role in maintaining redox balance [170]. NRF2 can be modulated by various oncogenes and tumor suppressors, influencing its activity and the cellular response to oxidative stress [171]. The BCL-2 family of proteins regulates apoptosis and can also influence ROS levels. The overexpression of antiapoptotic BCL-2 can protect cells from oxidative stress-induced apoptosis, contributing to cancer cell survival [172]. These regulatory mechanisms highlight that the antagonistic effects between driver mutations and oxidative stress involve a complex interplay of molecular mechanisms that maintain cellular homeostasis and prevent tumor progression. Understanding these mechanisms provides valuable insights into the pathogenesis of CRC and highlights potential therapeutic targets. By targeting the interactions between driver mutations and oxidative stress, strategies that increase treatment efficacy, reduce resistance, and improve patient outcomes in CRC can be developed.

Therapeutic implications

The interplay between driver mutations and oxidative stress opens new avenues for therapeutic interventions in CRC. Combination therapies that target driver mutations and oxidative stress represent promising approaches for CRC treatment [173, 174]. By addressing multiple pathways simultaneously, these therapies can enhance efficacy, overcome resistance, and potentially provide durable responses (Table 2).

Table 2.

Therapeutic implications of targeting ROS and driver mutations in CRC

	Therapeutic strategy	Biological target or pathway	Mechanism of action	Illustrative agents	Clinical stage and implications	Notes	Refs
Driver mutation targeting	Direct KRAS inhibition	KRAS G12 C mutation	Covalent binding to mutant KRAS to block downstream signaling	Sotorasib, adagrasib	FDA-approved for NSCLC; early-phase trials in CRCremains under evaluation;	Efficacy in CRC beyond benefits outside NSCLC are still uncertain	[195]
	BRAF inhibition	BRAF V600E mutation	Inhibition of mutant BRAF to disrupt the MAPK pathway	Encorafenib + cetuximab	FDA-approved for BRAF V600E-mutated CRC	It is limited to BRAF-mutant subsets; ongoing studies are clarifying long-term outcomes	[196]
	PI3 K/AKT/mTOR pathway inhibition	PIK3 CA mutation/PI3 K pathway	Inhibition of cell growth and survival signaling cascades	Alpelisib, everolimus	Approved for breast cancer; investigational in CRC	Benefit in CRC remains exploratory with ongoing studies to define efficacy and safety	[197]
	Wnt Signaling modulation	APC mutation/β-Catenin	Inhibition of aberrant Wnt signaling to reduce tumor cell proliferation	Tankyrase inhibitors, porcupine inhibitors	Preclinical to early-phase clinical trials	Clinical efficacy and optimal dosing regimens in CRC are not yet established	[198]
	FBXW7 signaling modulation	FBXW7 mutation	Loss of FBXW7 increases oncoproteins and chromosomal instability, promoting tumorigenesis	mTOR inhibitors, Notch inhibitors	Preclinical stage; combination with mTOR inhibitors shows potential	Inhibition of mTOR pathway can reduce tumor growth in FBXW7-deficient tumors	[199]
	SOX pathway inhibition	SOX family proteins (SOX2, SOX4, SOX9)	Dysregulation of SOX proteins promotes stem cell-like behavior and tumor progression	SOX inhibitors (preclinical)	Emerging, targeting SOX proteins in CRC; preclinical validation is required	Inhibiting SOX proteins could reduce aggressive CRC characteristics	[49]
	POLE inhibition	POLE mutation	POLE mutations result in ultramutated tumors with high neoantigen load, providing an opportunity for immunotherapy	Pembrolizumab (immune checkpoint inhibitor)	Effective in POLE-ultramutated CRC; under investigation for its potential in immunotherapy	High mutational burden in POLE-mutant CRC may enhance response to immune checkpoint therapy	[200]
ROS Modulation	Antioxidant therapy	ROS	Scavenges free radicals to lower oxidative stress, protecting normal cells	NAC, Vitamins C & E, polyphenols	Investigational; various early-phase clinical studies	Balancing efficacy and toxicity to normal tissues remains challenging; further studies required	[201]
	Pro-oxidant therapy	ROS	Increases oxidative stress to lethal levels in cancer cells	High-dose ascorbate, menadione	Primarily in preclinical studies; early-phase clinical investigations	Applicability across a broader CRC population is under ongoing clinical investigation	[202, 203]
Combination Therapies	Wnt signaling & redox rodulation	APC mutation/β-Catenin; ROS	Inhibition of aberrant Wnt signaling combined with modulation of oxidative stress	Tankyrase inhibitors + Nrf2 activators	Preclinical/early-phase clinical trials	Synergistic benefits are promising; larger-scale studies are needed to validate the strategy	[204]
	TP53 restoration & ROS induction	TP53 Mutation/p53 Pathway	Restoring wild-type p53 function paired with pro-oxidant therapy to enhance cell death	APR-246 with pro-oxidants	Early-phase clinical trials in various cancers; application in CRC under evaluation	Optimal combination ratios and dosing strategies are still under investigation	[205]
	PI3 K/AKT/mTOR inhibition & metabolic Stress	PIK3 CA Mutation/PI3 K Pathway	Blocking survival signaling and increasing metabolic stress to promote ROS-induced cell death	Alpelisib + glycolytic inhibitors	Preclinical/early-phase clinical trials	Early results are promising; further clinical validation and toxicity assessments are needed in CRC	[206]

Targeting ROS levels, either by increasing oxidative stress to lethal levels or by reducing ROS to prevent DNA damage, can be a promising strategy [175]. Agents that modulate ROS, such as pro-oxidants or antioxidants, can be used in combination with conventional treatment. For instance, antioxidants such as N-acetylcysteine (NAC) are being explored in clinical trials to restore the balance between ROS production and detoxification, with the goal of preventing DNA damage and protecting normal cells from oxidative damage [176]. Clinical trials, such as those evaluating NAC in combination with chemotherapy agents like 5-fluorouracil (5-FU), have provided insight into its potential as a chemoprotective agent, although results have been mixed in terms of efficacy in CRC [NCT04009876]. Moreover, the use of apocynin, an antioxidant and NADPH oxidase inhibitor, is under investigation in CRC, as it may modulate ROS levels and enhance the efficacy of chemotherapy in APC-mutant tumors [177]. While promising, these approaches are still in the early stages, and more robust clinical evidence is needed to establish their therapeutic potential and safety in CRC patients.

Targeting oncogenes and tumor suppressors that regulate oxidative stress can provide a therapeutic advantage. KRAS mutations are common in CRC and are associated with increased ROS production. The development of direct KRAS inhibitors, such as sotorasib and adagrasib, offers new opportunities for combination therapies [178]. Combining KRAS inhibitors with antioxidants or pro-oxidants can target the altered redox balance in KRAS-mutant CRC cells. For example, preclinical studies indicate that combining KRAS inhibitors with drugs such as ascorbate, which induces ROS production, can sensitize KRAS-mutant tumors to oxidative stress-induced cell death by overwhelming their antioxidant defenses [179]. These combinations are largely in the preclinical phase with initial early-phase clinical investigations underway. APC mutations result in dysregulated oxidative stress responses. Tankyrase inhibitors, which stabilize AXIN and promote β-catenin degradation, can be combined with redox modulators. Approaches that combine tankyrase inhibitors with Nrf2 activators are promising in preclinical studies. These combinations aim to modulate the redox environment and sensitize CRC cells to pro-oxidant therapies [180]. In TP53-mutant CRC, the loss of p53 function is associated with increased oxidative damage and altered cell cycle regulation. Small molecules that target mutant p53, such as APR-246, which restores wild-type p53 function, can be combined with pro-oxidants to increase ROS levels [181, 182]. Preclinical data support the idea that this combination can lead to enhanced cancer cell death, particularly in cells with compromised antioxidant defenses. PIK3 CA mutations activate the PI3 K/AKT/mTOR pathway, promoting cell growth and survival. Drugs such as alpelisib are already approved for other cancers (e.g., PIK3 CA-mutated breast cancer), and their use in CRC is being investigated in early-phase trials or in preclinical models combined with agents that disrupt metabolic or redox homeostasis [183, 184].

Inhibitors of specific driver oncogenes can also increase the effectiveness of conventional therapies such as chemotherapy and radiotherapy by preventing the repair of therapy-induced DNA damage. Poly (ADP-ribose) polymerase (PARP) inhibitors target the BER pathway, increasing the susceptibility of cancer cells to DNA damage [185, 186]. These inhibitors are particularly effective in cancers with deficiencies in HR, such as those with BRCA1/2 mutations [187]. Moreover, inhibitors of checkpoint kinases (e.g., Chk1 and Chk2) can disrupt cell cycle checkpoints, enhancing the cytotoxic effects of DNA-damaging agents [188]. PARP inhibitors have shown success in cancers with HR deficiencies and are in clinical use for those indications, but combinations of PARP inhibitors and ROS-modulating agents are still being evaluated in preclinical studies [189]. Similarly, inhibitors of checkpoint kinases are under early-phase clinical trials as adjuncts to DNA-damaging therapies [190]. In addition, inhibitors of the MYC oncogene can reduce ROS production and mitigate oxidative stress [191, 192]. While still in the preclinical phase, MYC inhibitors have demonstrated potential in combining with other therapies to increase their effectiveness. Compounds that activate Nrf2 may enhance antioxidant defenses and protect against oxidative damage. These activators are largely preclinical, with ongoing research to determine their viability in preventing driver mutation accumulation and cancer progression [193].

Collectively, recent advances in CRC treatment have explored the potential of targeting both driver mutations and oxidative stress. Combination therapies aim to simultaneously target distinct pathways that are critical for cancer cell survival and proliferation. By modulating both driver mutation and oxidative stress mechanisms, these therapies can induce synergistic effects, enhancing antitumor activity and reducing the likelihood of resistance. Although KRAS inhibitors and NAC combination therapies, have already progressed to clinical trials; many others, particularly those involving complex redox modulation, remain in preclinical or early-phase clinical stages [194]. Continued research and clinical trials will be essential for refining these strategies and improving patient outcomes.

Conclusion and perspective

The interplay between driver mutations and oxidative stress plays a crucial role in the pathogenesis and progression of CRC. Understanding the cooperative and antagonistic effects of these factors provides valuable insights into CRC biology and opens new avenues for therapeutic interventions. By targeting the intricate balance between driver mutations and oxidative stress, we can develop more effective and personalized treatment strategies for CRC patients. Future research should focus on several key areas to advance this therapeutic approach. Additional studies are needed to better understand the precise mechanisms by which driver mutations, such as those in KRAS, APC, and TP53, modulate cellular redox balance and how these mutations influence the tumor microenvironment's ROS levels. Longitudinal clinical trials evaluating the efficacy of combination therapies using pro-oxidants or antioxidants in CRC patients will be critical for validating the therapeutic potential of ROS modulation. Moreover, investigating biomarkers of oxidative stress could help identify patients who are most likely to benefit from ROS-targeted therapies. Another promising area is the exploration of novel compounds or small molecules that can selectively modulate ROS production in cancer cells without affecting normal tissues. Lastly, research into overcoming resistance mechanisms to ROS-based therapies, such as adaptive antioxidant responses, will be necessary to optimize treatment outcomes in CRC patients.

Author contributions

Conceptualization, J.C., J.F. and L.L.; writing—original draft preparation, Q.H., Y.J. and L.X.; writing—review and editing, J.C. and J.F.; visualization, L.X. and J.F.; literature searching, Q.H. and Y.J.; supervision, L.X.; funding acquisition, L.L.; All authors have read and agreed to the published version of the manuscript.

Funding

This work was supported by the Natural Science Foundation of Sichuan Province (2025ZNSFSC1829).

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Declarations

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Competing interests

The authors declare no conflicts of interest.