Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2020 May 20.
Published in final edited form as: Cancer Epidemiol Biomarkers Prev. 2011 Dec 5;21(2):337–346. doi: 10.1158/1055-9965.EPI-11-0786

Serum macrophage inhibitory cytokine-1 (MIC-1/GDF15): a potential screening tool for the prevention of colon cancer?

David A Brown 1,*, Kenneth W Hance 2,*, Connie J Rogers 2, Leah B Sansbury 3, Paul S Albert 4, Gwen Murphy 5, Adeyinka O Laiyemo 6, Zhuoqiao Wang 7, Amanda J Cross 5, Arthur Schatzkin 5,†, Mark Danta 8, Preeyaporn Srasuebkul 9, Janaki Amin 9, Matthew Law 9, Samuel N Breit 1,*, Elaine Lanza 10,*
PMCID: PMC7238292  NIHMSID: NIHMS341304  PMID: 22144502

Abstract

Background

Macrophage inhibitory cytokine-1 (MIC-1/GDF15) mediates NSAID protection from colonic polyps in mice and is linked to the development of colorectal carcinoma in humans. Therefore, changes in serum MIC-1/GDF15 levels could predict the presence of pre-malignant colonic polyposis and assist in population screening strategies.

Methods

Serum MIC-1/GDF15 levels were measured in subjects in the Polyp Prevention Trial, where NSAID use and colon cancer risk factors were defined. Subjects had an initial adenoma removed, a repeat colonoscopy removing previously unidentified polyps, and serum MIC-1/GDF15 estimation. Three years later recurrent adenomas were identified and serum MIC-1/GDF15 levels re-estimated. The relationship between serum MIC-1/GDF15 levels and adenoma presence or recurrence was examined.

Results

Serum MIC-1/GDF15 levels differed by adenoma status and were significantly related to colon cancer risk factors. Additionally, mean serum MIC-1/GDF15 levels rose with increasing numbers of adenomas present and high-risk adenoma recurrence. NSAID users had higher serum MIC-1/GDF15 concentrations, which were related to protection from adenoma recurrence. Further, adjusted serum MIC-1/GDF15 levels at final follow up were related to adenoma recurrence (highest quartile MIC-1/GDF15; OR 14.7 95%CI 3.0–73).

Conclusions

These data suggest that MIC-1/GDF15 mediates at least some of the protection afforded by NSAIDs against human colonic polyposis. Further, serum MIC-1/GDF15 levels vary with the development of adnenomatous colonic polyps.

Impact

Serum MIC-1/GDF15 determination may hold promise as the first serum screening test to assist the detection of pre-malignant adenomatous colonic polyposis.

Keywords: MIC-1, GDF15, colonic polyposis, colon cancer, screening and prevention

Introduction

The transforming growth factor-beta (TGF-β) superfamily member Macrophage inhibitory cytokine-1 (MIC-1/GDF15) is present in the serum of all normal individuals with a normal range of 150–1150 pg/ml (1). Elevated serum levels of MIC-1/GDF15 have been reported in patients with many cancers, including colorectal neoplasia (1–7). Serial analysis of gene expression indicated that MIC-1/GDF15 was one of nine secreted or cell surface expressed colonic adenomas / carcinoma protein transcripts highly upregulated, relative to normal colonic epithelium (8). Additionally, MIC-1/GDF15 protein is easily detectible in both colonic adenomas and carcinomas (1). Consistent with these findings, MIC-1/GDF15 serum levels progressively increase with development of colonic adenomas, high-grade dysplasia, localized and then advanced colonic carcinoma (1).

Expression of MIC-1/GDF15, at least in cell lines, is upregulated by p53 (9) and NSAIDs, the latter through the induction of the transcription factor early growth response protein-1 (10). NSAID induced expression of MIC-1/GDF15 has been reported in many cancer cell lines (11–14) and is associated with pro-apoptotic activity in vitro and in vivo (11, 12, 15). MIC-1/GDF15 gene KO mice, when crossed with adenomatous polyposis coli gene mice (APCMin/+), lose the protection from colonic polyposis development afforded by NSAID treatment (16). Additionally, over expression of human MIC-1/GDF15 in APCMin/+ mice suppresses azoxymethane induced colonic tumor formation (17, 18). These findings support a role for MIC-1/GDF15 in suppressing early colonic neoplasia and suggest that MIC-1/GDF15 may partly mediate NSAID chemoprevention of colonic neoplasia. Finally, in a very small exploratory pilot experiment, serum MIC-1/GDF15 levels decreased, and in one case halved, after removal of a colonic adenoma (unpublished data). Therefore, whilst MIC-1/GDF15 may inhibit the development of colonic adenomas, once present, atypical colonic epithelium also produces MIC-1/GDF15. These expression characteristics suggested that serum MIC-1/GDF15 might be a useful tool to predict colonic adenoma presence. However, adjustment might be needed for potential confounding factors such as MIC-1/GDF15 derived from colonic (adenomas) and/or non-colonic sources, as well as induction by NSAID use. We therefore sought to test this hypothesis in the best available cohort.

To date there has been no serum marker of pre-malignant colonic disease. Because of this, prospective cohorts examining this condition have not prioritized serum collection, particularly with respect to the timing of collection before polypectomy. Indeed, many do not collect serum. This severely limits the number of existing cohorts that have appropriate timed blood sampling to test our hypothesis that serum MIC-1/GDF15 levels can predict the presence of colonic adenomas. The best available cohort was the Polyp Prevention Trial (19–21). These prospectively collected data allowed for the examination of single and serial measurements of serum MIC-1/GDF15 concentrations in relation to colonic adenoma, NSAID use and known risk factors for colorectal cancer. Additionally, we undertook an assessment of serial serum MIC-1/GDF15 level determinations for the prediction of adenoma recurrence. Even this “best available” cohort had significant limitations, nonetheless we were able to show that single and serial serum MIC-1/GDF15 levels were associated with the presence of premalignant colonic adenomas. These data justify the significant expense of appropriately designed prospective trials to examine the role of serum MIC-1/GDF15 measurement in the management of pre-malignant colonic polyposis.

Materials and Methods

Study population.

Participants in this study were 35 years or older with at least one histologically confirmed adenoma removed during a qualifying colonoscopy and were randomized to the control arm of the PPT (19–23). Blood samples from the intervention arm were not available for analysis. Eligible participants had no history of colorectal cancer, surgical resection of adenomas, bowel resection, polyposis syndrome, or inflammatory bowel disease. Of a total of 2,079 participants, 1,042 were assigned to the control arm of the trial and 947 completed the study with 626 (66.1%) having serum available from T1 and T4 (1 and 4 years after baseline) for the analysis of MIC-1/GDF15. Three subjects were excluded after diagnosis of cancer during the study, leaving 623 subjects for analysis. Serum MIC-1/GDF15 level was determined in all patients. However, for determining the utility of serial MIC-1/GDF15 serum levels for adenoma detection, the time of blood sampling was inappropriate in a significant number of subjects (n=370, 59%). Inappropriate timing of blood sampling included sampling MIC-1/GDF15 prior to adenoma removal at T1, or after an adenoma had been removed at T4. Additionally, in some patients NSAID usage, which may affect serum MIC-1/GDF15 levels, changed during the course of the study. Accordingly, we identified two additional patient subsets that we called 1. ‘T1-adenoma free’ (n=528 (85%)); and 2. ‘Adenoma/NSAID appropriate’ (253 (41%)). The ‘T1-adenoma free’ subset was made up of patients that had their serum MIC-1/GDF15 level measured at T1 and had no adenoma at this screening exam, or MIC-1/GDF15 was measured after their adenoma was removed at T1. From this group of patients, the ‘Adenoma/NSAID appropriate’ subjects were defined as those who had no adenoma recurrence or had their serum MIC-1/GDF15 level measured prior to adenoma removal at T4 and did not change their NSAID usage status (use vs. no use), but may have changed their NSAID dosage from T1 to T4.

Case ascertainment.

Participants had full colonoscopies at baseline (T0), 1 year (T1), and 4 years after randomization (T4). The colonoscopy at year 1 detected and removed any lesions missed at the baseline colonoscopy. There were 240 pathologically confirmed recurrent adenomas diagnosed at year 4 from the control arm of the PPT. A subset of recurrent cases were examined with either a) multiple adenoma recurrence or b) high-risk adenoma recurrence. ‘Multiple recurrence’ was defined as those individuals with >1 adenoma identified during their follow-up endoscopic procedure (n=102). ‘High risk recurrence’ was defined by 1 of 4 possible criteria: 1) adenoma diameter ≥1 cm, 2) evidence of high-grade dysplasia, 3) adenoma with >25% villous elements, or 4) greater than 2 adenomas present at T4 (n=67).

Blood sampling and MIC-1/GDF15 serum estimation.

All participants provided fasting venous blood samples at years 1 and 4 from which serum was separated and stored at −70°C. The time of sampling was between 366 days prior to and 391 days (mean=6 days; standard deviation=136 days) after the T1 colonoscopy and between 600 days before and 1184 days (mean = 140 days; standard deviation= 306 days) after the T4 colonoscopy. Serum MIC-1/GDF15 levels were determined using an enzyme immunoassay (24, 25).

Assessment of NSAID use.

Regular NSAID use was defined as those participants who reported either aspirin or non-aspirin NSAID use at least once per month (n=202) at study entry. The total dose of NSAID was assessed by an experienced interviewer at study entry, T1 and T4. NSAIDs included aspirin and other non-aspirin NSAIDs such as ibuprofen, naproxen, and indomethacin. Cyclooxygenase-2 specific inhibitors, were unavailable at the time of the study.

Statistical Analysis.

Statistical analyses were performed using STATA 11 (StataCorp, College Station, Tx, USA). Data presented as proportions, such as the baseline characteristics of study participants, stratified by adenoma recurrence, were compared by the χ2 test. Serum MIC-1/GDF15 concentrations stratified by covariate data or adenoma recurrence were evaluated using the appropriate nonparametric statistical tests (Wilcoxon rank-sum or Kruskal-Wallis tests). Odds ratios (ORs) and 95% confidence intervals (CIs) for adenoma recurrence were estimated within quartiles of serum MIC-1/GDF15 concentrations. Comparison of MIC-1/GDF15 serum levels with NSAID dosage was performed using simple linear regression. Multivariate logistic regression models included covariates that changed the OR for MIC-1/GDF15 by >10%, if they were significant predictors of adenoma recurrence (p<0.05 using the likelihood ratio test), or they had previously been documented to be associated with serum MIC-1/GDF15 levels (2, 3, 26–28). All models included age and gender. All statistical analyses were two-sided and differences were considered significant at P<0.05.

Results

Population characteristics

The baseline patient characteristics that exhibited a relationship with adenoma recurrence at 4 years (T4) after baseline (Table 1) were male gender (P<0.01), a history of multiple adenoma (P<0.01), and elevation in the waist-to-hip ratio (P<0.01). The proportion of regular NSAID users with adenoma recurrence at year 4 (64/204 [32%]) was significantly lower than the proportion of non-NSAID users (177/421 [42%], P=0.01). Additionally, NSAID dosage significantly and negatively correlated with adenoma recurrence (P=0.04) (Table 1).

Table 1.

Characteristics of participants in Polyp Prevention Trial by adenoma recurrence.a

Total No Recurrence Recurrence
Baseline Characteristics N % N % N % P-Value
Age
 Quartile 1 (35–53) 150 24 100 16 50 8
 Quartile 2 (54–62) 159 26 93 15 66 11
 Quartile 3 (63–70) 163 26 104 17 59 9
 Quartile 4 (71–86) 151 24 86 14 65 10 P = 0.2620
Sex
 Male 382 61 209 34 173 28
 Female 241 38 174 28 67 11 P < 0.0001
Race
 Caucasian 572 92 354 57 218 35
 Other 51 8 29 5 22 4 P = 0.4820
Waist to Hip Ratio
 Tertile 1 (0.62–91) 204 33 146 23 58 9
 Tertile 2 (0.92–0.98) 205 33 114 18 91 15
 Tertile 3 (0.99–1.51) 204 33 115 18 89 14 P = 0.0014
Smoking History
 No 546 88 336 54 210 34
 Yes 77 12 210 34 30 5 P = 0.9331
Family History of CRC
 No 173 28 103 17 70 11
 Yes 450 72 280 45 170 27 P = 0.5382
History Multiple adenoma
 No 410 66 283 45 127 20
 Yes 213 34 100 16 113 18 P < 0.0001
Education Status
 <=High School 154 23 96 15 58 9
 >High School 469 75 287 46 182 29 P = 0.8002
Regular NSAID useb
 No 421 68 245 39 176 28
 Yes 202 32 138 22 64 10 P= 0.0144
NSAID dose (mg per day)b
 None 421 68 245 39 176 28
 0–143 70 11 47 8 23 4
 144–325 77 12 49 9 28 4
 326–4725 55 9 42 7 13 2 P= 0.0363
Alcohol Intake (grams per day)
 None 251 40 165 26 86 13
 Tertile 1 (0.3–3.99) 139 22 83 13 56 9
 Tertile 2 (2.00–12.99) 107 17 66 10 41 7
 Tertile 3 (13.00–139.00) 120 19 65 10 55 9 P = 0.0684
Open in a new tab
a

Any Adenoma recurrence at T4 vs. no adenoma recurrence at T4.

b

Defined as Regular NSAID use and dose at study entry.

MIC-1/GDF15 serum level predicts adenoma presence

At both T1 and T4, mean serum MIC-1/GDF15 levels differed significantly by polyp status with the lowest concentrations in polyp free subjects and the highest concentration in subjects with adenoma present at the time of the blood sampling (T1: 823 vs. 917 pg/ml, P=0.02 and T4: 928 vs. 1,020 pg/ml, P=0.04) (Table 2). At both T1 and T4, serum MIC-1/GDF15 concentrations also increased with age (P<0.01), waist-to-hip ratio (P<0.01), current smoking (P<0.01) and male sex (P<0.01) and history of multiple adenomas (P<0.01) (Table 2). Males had a significantly higher BMI (P<0.01), consumed more alcohol (P<0.01) and were more likely to have a smoking history (P<0.01). Serum MIC-1/GDF15 levels in patients who had had an adenoma removed were no different from patients who had had no adenoma detected at both T1 and T4 (T1: 823 vs. 885 pg/ml, P=0.15 and T4: 928 vs. 962 pg/ml, P=0.9) (Table 2). Patients with multiple adenomas had significantly higher serum MIC-1/GDF15 levels at T1 and T4 (P=0.02, P<0.01: respectively: Table-3). Additionally, serum MIC-1/GDF15 levels at T4 significantly increased with increasing numbers of adenomas present and high-risk adenoma recurrence (P<0.01; Table-3).

Table 2.

Geometric means of MIC-1/GDF15 levels at T1 and T4 by patient characteristics

Serum MIC-1/GDF15 levels T1 (pg/ml) Serum MIC-1/GDF15 levels T4 (pg/ml)
Patient characteristics N % Mean SEM P-Value N % Mean SEM P-Value
Total 623 100 848 16 623 100 949 19
Polyp status
 No polyp 417 67 823 29 383 61 928 44
 Polyp removed 111 18 885 49 152 24 962 52
 Polyp present 95 15 917 42 P = 0.0255 88 14 1,020 51 P = 0.0433
Age
 Quartile 1 (35–53) 150 24 575 17 150 24 608 20
 Quartile 2 (54–62) 159 26 771 24 159 26 857 28
 Quartile 3 (63–70) 163 26 995 31 163 26 1,165 41
 Quartile 4 (71–86) 151 24 1,160 38 P < 0.0001 151 24 1,317 45 P < 0.0001
Sex
 Male 382 61 906 23 382 61 1,011 27
 Female 241 37 763 21 P < 0.0001 241 37 763 27 P < 0.0001
Waist to Hip Ratio
10 2 10 2
 Tertile 1 (0.62–0.91) 204 33 740 22 204 33 740 22
 Tertile 2 (0.92–0.98) 205 33 877 29 205 33 877 29
 Tertile 3 (0.99–1.51) 204 33 935 30 P < 0.0001 204 33 935 30 P < 0.0001
Smoking Status
 Never or Never Regular 257 41 761 22 257 41 761 22
 Former 289 46 885 24 289 46 885 24
 Current 77 12 1,037 49 P < 0.0001 77 12 1,037 49 P < 0.0001
Regular NSAID usea
3 0 1 0
 No 386 62 821 19 359 58 885 24
 Yes 234 38 891 28 P = 0.0554 263 42 1,038 31 P = 0.0001
History of multiple adenoma
 No 339 54 779 24 339 54 873 42
 Yes 284 46 938 40 P < 0.0001 284 46 1,048 45 P < 0.0001
Open in a new tab
a

Regular NSAID use (<1 per month) vs. no regular NSAID use (<1 per month) reported at years 1 (T1) and 4 (T4), respectively

Table 3.

Geometric means of MIC-1/GDF15 levels at T1 and T4 by presence of a recurrent adenoma at T1 and T4

Serum MIC-1/GDF15 levels T1 (pg/ml) Serum MIC-1/GDF15 levels T4 (pg/ml)
N % Mean SEM P-Value N % Mean SEM P-Value
Adenoma recurrence
 No adenoma 417 67 823 15 383 61 928 44
 Adenoma recurrence 206 33 900 33 P = 0.0118 240 39 983 38 P = 0.0254
  Present at sampling 95 15 917 28 P = 0.0124 88 14 1,020 51 P = 0.0188
  Absent at sampling 111 18 885 49 P = 0.1482 152 24 962 52 P = 0.8524
Multiple adenoma recurrence
 No adenoma 417 67 823 15 383 61 928 44
 Multiple adenoma recurrence 76 12 939 48 P = 0.0208 102 16 1,078 54 P = 0.0006
  Present at blood sampling 29 5 954 82 P = 0.0474 37 6 1,145 73 P = 0.0024
  Absent at blood sampling 47 8 929 94 P = 0.1329 65 10 1,042 73 P = 0.0261
Number of recurrent adenoma (Adenoma present at blood sampling)
0 417 67 823 15 383 61 928 44
1 66 11 901 52 51 8 937 69
2 17 3 896 91 26 4 1,138 85
3 5 1 904 204 7 1 1,149 203
≥4 7 1 1,155 142 P = 0.0758 4 1 1,187 235 P = 0.0492
Number of recurrent adenoma (Adenoma removed prior to blood sampling)
0 417 67 823 15 383 61 928 44
1 64 10 854 49 87 14 905 73
2 24 4 967 164 27 4 912 101
3 12 2 815 101 22 4 1,075 135
≥4 11 2 982 42 P = 0.4516 16 3 1,249 153 P = 0.0428
High risk recurrence at T4
 No adenoma 383 61 928 44
 Advanced recurrence 67 11 1,105 60 P = 0.0022
Open in a new tab

MIC-1/GDF15 levels are increased in NSAID users

Serum MIC-1/GDF15 concentrations were higher among NSAID users at both T1 and T4 (Table 2). However, this just failed to reach significance at T1 (P=0.06), while being highly significant at T4 (P<0.01; Table 2). The significant number of patients that had blood sampling with an adenoma present could have attenuated the relationship of MIC-1/GDF15 levels to NSAID use. When regular NSAID users were further stratified according to the presence or absence of an adenoma at the time of blood sampling, NSAID users at T1 and T4 with no adenoma present had significantly higher levels of serum MIC-1/GDF15 compared with subjects without a polyp who were not taking NSAIDs (T1: 882 vs. 805pg/ml, P<0.01 and T4: 1,044 vs. 860 pg/ml, P<0.01). In these patients at T1 (n=525) and T4 (n=534) serum MIC-1/GDF15 level was associated with the dose of NSAIDs used (T1, P<0.05; T4, P=0.03; linear regression).

NSAIDs reduce adenoma recurrence risk when MIC-1/GDF15 levels are increased

NSAID use is known to provide protection from adenoma recurrence in this cohort (Table-1) (29). Additionally, as demonstrated above, MIC-1/GDF15 serum levels were higher among subjects on NSAIDs at T1 and T4 with no adenoma present (Table-2). Further, serum MIC-1/GDF15 levels were significantly related to the dose of NSAIDs taken (P<0.05; linear regression). These results suggested that high serum MIC-1/GDF15 level, which is associated with NSAID use, could also be associated with a reduced risk of adenoma development. In the ‘T1-adenoma free’ subgroup, serum MIC-1/GDF15 was significantly higher in patients taking NSAIDs (805 vs. 882 pg/ml; P<0.01). In patients with elevated serum MIC-1/GDF15 levels (≥1200 pg/ml (1)) at T1 (n=139), NSAID use was associated with protection from adenoma recurrence (P=0.03), whilst NSAID use with no elevation of MIC-1/GDF15 (<1200 pg/ml; n=481), did not protect from recurrent adenoma (P=0.84). This suggested that a high adenoma free, NSAID associated, MIC-1/GDF15 serum level could identified subjects who were relatively protected from adenoma formation. Further examination of this phenomena indicated that those patients having a serum MIC-1/GDF15 level less than 1200 pg/ml were taking, on average, half the dose of NSAIDs than those patients with a higher serum MIC-1/GDF15 level (p<0.01). However, in multivariate logistic regression analysis NSAIDs protected against polyp recurrence independently of age, NSAID dosage and MIC-1/GDF15 level ≥1200 pg/ml (p=0.026) indicating a protective role for NSAID use, independent of MIC-1/GDF15. Therefore, both elevated polyp free MIC-1/GDF15 serum level, NSAID use and possibly NSAID dose, each, independently, are associated with reduced risk of recurrent adenoma in this cohort.

Serum MIC-1/GDF15 levels predict adenoma recurrence

From the above results, change in NSAID use and dose, as well as the time of blood sampling relative to polypectomy might significantly affect analyses examining whether MIC-1/GDF15 serum levels could be used to identify risk of adenoma recurrence. We therefore examined the ‘Adenoma/NSAID appropriate’ subgroup of 253 subjects where MIC-1/GDF15 serum level determination was appropriate with respect to polypectomy and NSAID usage status was the same at T1 and T4 (Table-4). Univariate analysis indicated that the top quartile of T4 MIC-1/GDF15 serum levels predicted adenoma recurrence (OR=3.8; 95%CI 1.4–10.4: P<0.01). Adjustment for NSAID use and dosage failed to attenuate the association of serum MIC-1/GDF15 to predict adenoma recurrence (Table-4). Similarly, adjustment for factors that might be related to serum MIC-1/GDF15 levels (Table-2), independent of NSAIDs, also failed to reduce this association. Indeed, in both cases the relationship of MIC-1/GDF15 serum level with adenoma recurrence appeared to strengthen (Table-4). Further adjustment for these factors, as well as the potential protective nature of polyp free MIC-1/GDF15 at T1, indicated that the risk of adenoma recurrence was more than 14 times more likely if the serum MIC-1/GDF15 serum level was in the top quartile at T4 (OR=14.7 95%CI 3.0–73; P<0.01).

Table 4.

Risk of adenoma recurrence by quartiles of serum MIC-1/GDF15 levels at T4 adjusted for factors influencing MIC-1/GDF15 level and the protective effect of MIC-1/GDF15 in the ‘Adenoma/NSAID appropriate’ group.

Any Adenoma Recurrence (n=253)a
Regression Model OR* 95% CI P-Value
Univariate
Quartile 2 (612 – 831 pg/mL) 2.3 0.8 – 6.6 0.131
Quartile 3 (832 – 1158 pg/mL) 3.3 1.2 – 6.4 0.022
Quartile 4 (1159 – 6520 pg/mL) 3.8 1.4 – 10.4 0.009
Multivariate
Adjustment for NSAID use
Quartile 2 (612 – 831 pg/mL) 2.7 0.9 – 7.9 0.079
Quartile 3 (832 – 1158 pg/mL) 4.4 1.5 – 12.9 0.007
Quartile 4 (1159 – 6520 pg/mL) 5.2 1.8 – 15.1 0.002
NSAID use (Yes) 0.3 0.2 – 0.8 0.008
Change in NSAlD dose (100 mg) 0.9 0.8 – 1.0 0.023
Adjustment for non-NSAID factors associated with serum MIC-1/GDF15 level
Quartile 2 (612 – 831 pg/mL) 3.0 0.9 – 9.5 0.069
Quartile 3 (832 – 1158 pg/mL) 4.8 1.4 – 16.8 0.013
Quartile 4 (1159 – 6520 pg/mL) 5.9 1.6 – 21.8 0.008
Sex (M) 1.8 0.7 – 4.5 0.264
Waist-to-hip T1 (cm/cm) 1.3 0.0 – 105 0.877
Age (10 years) 0.7 0.4 – 1.1 0.111
Alcohol use T4 (10g/day) 0.9 0.7 – 1.1 0.712
History of multiple adenoma (yes) 2.1 1.1 – 4.1 0.040
Time T1 to T4 (1 year) 0.3 0.0 – 3.4 0.674
Adjustment for significant NSAID and non-NSAID factors
Quartile 2 (612 – 831 pg/mL) 3.7 1.1 – 12 0.035
Quartile 3 (832 – 1158 pg/mL) 5.8 1.6 – 21 0.008
Quartile 4 (1159 – 6520 pg/mL) 7.5 2.0 – 29 0.003
Sex (M) 2.1 1.0 – 4.3 0.045
Age (10 years) 0.7 0.5 – 1.1 0.116
History of multiple adenoma (yes) 1.9 0.9 – 3.7 0.078
NSAID use (Yes) 0.4 0.2 – 0.8 0.011
Change in NSAID dose (100 mg) 0.9 0.8 – 1.0 0.025
Additional adjustment for protective effect of MIC-1/GDF15 at T1
MIC-1/GDF15 T4
Quartile 2 (612 – 831 pg/mL) 4.1 1.2 – 14 0.025
Quartile 3 (832 – 1158 pg/mL) 7.7 2.0 – 30 0.003
Quartile 4 (1159 – 6520 pg/mL) 14.7 3.0 – 73 0.001
Sex (M) 2.1 1.0 – 4.4 0.038
Age (10 year) 0.8 0.5 – 1.2 0.231
History of multiple adenoma (yes) 2.0 1.0 – 3.9 0.063
NSAID use (Yes) 0.4 0.2 – 0.8 0.012
Change in NSAID dose (100 mg) 0.9 0.8 – 1.0 0.017
MIC-1/GDF15 T1 (1000 pg) 0.5 0.2 – 1.3 0.152
Open in a new tab
a

Any adenoma recurrence at T4 (n=48) vs. no recurrence at T4 (n=205)

Discussion

To our knowledge, this is the first study to report measurements of serum MIC-1/GDF15 in relation to NSAID use and adenoma presence / recurrence in prospectively followed, at risk patients. Consistent with data from experimental animals, we observed a clear association between elevated serum MIC-1/GDF15 concentrations, NSAID use and protection from adenoma recurrence. Further, and as previously reported (1) elevated serum MIC-1/GDF15 serum levels were associated with adenoma presence. Changes in serum MIC-1/GDF15 levels on serial measurements were also associated with adenoma recurrence.

The protective and predictive roles of MIC-1/GDF15 with respect to colonic adenomatosis might seem, at first glance, to be paradoxical. However, these findings are consistent with both our basic understanding of the role of MIC-1/GDF15 in polyposis from animal studies (16–18) and the change in serum MIC-1/GDF15 levels throughout the development of colon cancer in humans (1). MIC-1/GDF15 is produced by neoplastic colonic epithelium at a different stage of the disease process (30) and protects from colonic tumor formation in animal models (16–18) although the reasons underlying these changes are not clear. MIC-1/GDF15, like its relative TGF-β, seems to have a complex effect on tumour growth and development. In in vitro and in vivo experimental systems, MIC-1/GDF15 most frequently reduces tumour growth activity, but has also been reported to promote tumour growth and spread under some circumstances (reviewed by Breit et al. (30)) These factors are likely to contribute to the complex relationship between serum MIC-1/GDF15 serum levels and the presence, recurrence and/or protection from colonic polyposis

As far as we are aware MIC-1/GDF15 is the first serum marker having any relationship to the presence of colonic adenomas with potential clinical utility. Because there are no clinically useful serum markers of premalignant colonic disease, available cohorts studying colonic polyposis are limited. This cohort was studied because it is the only cohort to have prospectively evaluated at risk patients and collected serum that we were aware of. However, even the analysis of this cohort was significantly limited by the timing of blood sampling. Many subjects had their blood taken while a polyp was present at T1 or after it was removed at T4 leading to exclusion from the analysis of serial MIC-1/GDF15 serum levels. Whilst this issue was managed by exclusion of inappropriately timed samples, it resulted in a significant reduction in the number of subjects available to assess the utility of serum MIC-1/GDF15 measurement in the prediction of recurrent adenomas. This selection procedure may have also introduced bias from unappreciated sources. Another limiting factor was the large variation in the time of serum MIC-1/GDF15 measurement with respect to colonoscopy. This could not be adjusted for in our models examining serial MIC-1/GDF15 measurement, as those patients having recurrence were identifiable by blood sampling prior to polypectomy, while patients with no recurrence were sampled before and after their colonoscopy at T4. This variation in the timing of blood sampling, combined with the strong relationship between age and MIC-1/GDF15, probably contributed the relatively small differences in serum MIC-1/GDF15 serum levels between polyp free and adenoma relapse states between groups. However, because of the range of serum MIC-1/GDF15 levels, these differences may be larger in the individual undergoing serial sampling. Despite these major limitations, in the current study we were able to demonstrate a relationship of serum MIC-1/GDF15 serum levels with the presence and recurrence of a colonic adenoma. Finally, the PPT cohort used in the current study was 92% Caucasian; and thus, results from this study may not be generalizable to more ethnically diverse populations. However, the results as they stand suggest that an initial polyp free serum MIC-1/GDF15 level, defined by colonoscopy in this case, with repeated serum MIC-1/GDF15 estimation over time, might be a clinically useful screening strategy for the detection of recurrent or initial colonic polyps.

Additional findings suggest that MIC-1/GDF15 would preferentially detect premalignant colonic adenomas requiring intervention. MIC-1/GDF15 serum levels were significantly related to the number of adenomas present in the starting cohort of 623 patients (Table-3) and were further elevated in subjects with high-risk recurrences or multiple adenomas present. Therefore it is possible that raised serial MIC-1/GDF15 levels could indicate clinically relevant adenoma recurrences in preference to low-risk adenoma recurrence. Indeed, as the study progressed the relationship of MIC-1/GDF15 serum levels to adenoma presence appeared to strengthen. Perhaps this was because there were adenomas that were developing or missed at T1 colonoscopy and became apparent three years later. Tandem back-to-back colonoscopic studies indicating that up to 27% of adenomas can be missed (31). With this in mind, it seems likely that a significant number of polyps would have been missed at repeat colonoscopy at T1 and be more easily detected at T4.

In this cohort, Tangrea and colleagues (29) reported a 23% reduction in the risk of adenoma recurrence with regular NSAID use. In our examination of the cohort, subjects taking NSAIDs who did not have elevated serum MIC-1/GDF15 levels had the same risk of adenoma recurrence as patients not taking NSAIDs, suggesting that, as in animal models (16, 18), MIC-1/GDF15 might mediate part of the protection from adenoma afforded by NSAID use. The complex interactions between NSAID use, adenoma recurrence and serum MIC-1/GDF15 level make it difficult to interpret the adjustment for NSAIDs in multivariate logistic regression as they are interrelated and might lead to ‘over fitting’ of regression models. However, univariate regression indicated a significant relationship which, when adjusted for potentially confounding factors, only strengthened. This situation might have occurred because MIC-1/GDF15 serum levels are related to most risk factors for colonic polyposis and the development of cancer (Table-2). While potentially affecting multivariate regression analysis, it would seem that such relationships support, rather than detract from, the likelihood that serum MIC-1/GDF15 serum levels are related to NSAID use and adenoma formation. Supporting MIC-1/GDF15 as a mediator of NSAID protection from adenomas is the finding that serum MIC-1/GDF15 levels were correlated to NSAID dose at both T1 and T4. Additionally, those subjects with low MIC-1/GDF15 using NSAIDs were taking about half the dose of those subjects that had serum levels (≥1200 pg/ml). While data showing MIC-1/GDF15 protects from, and is produced by, colonic adenomas might seem paradoxical, they are consistent with animal data showing that MIC-1/GDF15 mediates the protective actions of NSAIDs against colonic polyposis (16, 18). Interestingly, NSAID induced cell cycle arrest in ovarian cancer cells is also dependent on MIC-1/GDF15 (14).

The apparent paradoxical actions of MIC-1/GDF15 are not unprecedented, as a close relative, TGF-β, is produced by normal and neoplastic colonic epithelium, and has similar anti-neoplastic as well as tumor promoting actions in the colon (32). Early studies of MIC-1/GDF15 suggested that it has anticancer activity and induced apoptosis of cancer cells in vitro. However, there is also evidence that MIC-1/GDF15 may participate in tumor progression. The anti-tumourigenenic effect of MIC-1/GDF15 is best demonstrated in transgenic or induced animal models of cancer outlined above. A limited number of tumor xenograft studies also show that MIC-1/GDF15 over expression in HCT-116 colon resulted in reduced tumor size when engrafted in nude mice (11, 33). A glioblastoma cell line, unresponsive to MIC-1/GDF15 in-vitro, completely failed to grow as a tumor xenograft in nude mice when transfected with MIC-1/GDF15 (34). This suggests MIC-1/GDF15 may have significant paracrine effects that modulate the tumor environment. One potential paracrine mechanism could be anti-angiogenic activity that has been documented both in vitro and in vivo (35).

A number of in vitro studies have been performed to gain an understanding of the molecular pathways and mechanisms utilised by MIC-1/GDF15. For example, many dietary compounds associated with neoplastic cell growth suppression (Kim JS et al., 2005 Lee SH et al., 2005) induce MIC-1/GDF15 expression (36–38). Many studies have also suggested that MIC-1/GDF15 induces tumor apoptosis (11, 39, 40). However, in one study MIC-1/GDF15 expression was associated with a more invasive gastric cancer cell line phenotype and could induce increased gastric cancer cell invasion in vitro. This appeared to be due to MIC-1/GDF15 increasing expression of the urokinase type plasminogen activator (uPA) and the uPA receptor (uPAR) (41). Thus while most studies highlight an anti-tumorigenic role for MIC-1/GDF15, some suggest support for tumor growth and/or dissemination.

In conclusion, our data demonstrate that serum MIC-1/GDF15 concentrations are associated with known modifiers of risk of colorectal cancer, including NSAID use, and suggest a biological role for MIC-1/GDF15 in suppressing early colonic neoplasia. These data suggest that inducing an ‘appropriate’ rise in serum MIC-1/GDF15 levels could optimize NSAID prevention of colonic neoplasia. Additionally, where polyps are present, serum MIC-1/GDF15 levels appear to be a biomarker of adenomatous polyp burden and are related to adenoma recurrence in this cohort. Despite the limitations of the cohort, these data are encouraging. They suggest that prospective clinical trials specifically designed to evaluate MIC-1/GDF15 are justified and required to determine the optimal strategy for the use of serum MIC-1/GDF15 level measurement for the prevention of colon cancer.

Financial support

This research was supported in part by grants from Intramural Research Program of the NIH, National Cancer Institute, Center for Cancer Research, The National Cancer Institute Cancer Prevention Fellowship Program, The National Health and Medical Research Council of Australia, a New South Wales Health Research and Development Infrastructure grant and St Vincent’s Clinic Foundation grant. David A Brown is funded by an NHMRC Career Development Fellowship. The funding sources had no direct or indirect involvement in the design and conduct of the study; nor the collection, management, analysis, and interpretation of the data, nor in the preparation, review, or approval of the manuscript.

Footnotes

§

Disclosure statement

David A. Brown, Kenneth W. Hance, Connie J. Rogers, Elaine Lanza and Samuel N. Breit are co-inventors on patents filed by St Vincent’s Hospital, and the NIH, which pertain to the use of a serum-based assay for MIC-1/GDF15 in colon cancer.

References

  • 1.Brown DA, Ward RL, Buckhaults P, Liu T, Romans KE, Hawkins NJ, et al. Mic-1 serum level and genotype: Associations with progress and prognosis of colorectal carcinoma. Clin Cancer Res 2003;9:2642–50. [PubMed] [Google Scholar]
  • 2.Brown DA, Lindmark F, Stattin P, Balter K, Adami HO, Zheng SL, et al. Macrophage inhibitory cytokine 1: A new prognostic marker in prostate cancer. Clin Cancer Res 2009;15:6658–64. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Brown DA, Stephan C, Ward RL, Law M, Hunter M, Bauskin AR, et al. Measurement of serum levels of macrophage inhibitory cytokine 1 combined with prostate-specific antigen improves prostate cancer diagnosis. Clin Cancer Res 2006;12:89–96. [DOI] [PubMed] [Google Scholar]
  • 4.Selander KS, Brown DA, Sequeiros GB, Hunter M, Desmond R, Parpala T, et al. Serum macrophage inhibitory cytokine-1 concentrations correlate with the presence of prostate cancer bone metastases. Cancer Epidemiol Biomarkers Prev 2007;16:532–7. [DOI] [PubMed] [Google Scholar]
  • 5.Koopmann J, Rosenzweig CN, Zhang Z, Canto MI, Brown DA, Hunter M, et al. Serum markers in patients with resectable pancreatic adenocarcinoma: Macrophage inhibitory cytokine 1 versus ca19–9. Clin Cancer Res 2006;12:442–6. [DOI] [PubMed] [Google Scholar]
  • 6.Koopmann J, Buckhaults P, Brown DA, Zahurak ML, Sato N, Fukushima N, et al. Serum macrophage inhibitory cytokine 1 as a marker of pancreatic and other periampullary cancers. Clin Cancer Res 2004;10:2386–92. [DOI] [PubMed] [Google Scholar]
  • 7.Welsh JB, Sapinoso LM, Kern SG, Brown DA, Liu T, Bauskin AR, et al. Large-scale delineation of secreted protein biomarkers overexpressed in cancer tissue and serum. Proc Natl Acad Sci U S A 2003;100:3410–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Buckhaults P, Rago C, St Croix B, Romans KE, Saha S, Zhang L, et al. Secreted and cell surface genes expressed in benign and malignant colorectal tumors. Cancer Res 2001;61:6996–7001. [PubMed] [Google Scholar]
  • 9.Osada M, Park HL, Park MJ, Liu JW, Wu G, Trink B, et al. A p53-type response element in the gdf15 promoter confers high specificity for p53 activation. Biochem Biophys Res Commun 2007;354:913–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Baek SJ, Kim JS, Moore SM, Lee SH, Martinez J, Eling TE. Cyclooxygenase inhibitors induce the expression of the tumor suppressor gene egr-1, which results in the up-regulation of nag-1, an antitumorigenic protein. Mol Pharmacol 2005;67:356–64. [DOI] [PubMed] [Google Scholar]
  • 11.Baek SJ, Kim KS, Nixon JB, Wilson LC, Eling TE. Cyclooxygenase inhibitors regulate the expression of a tgf-beta superfamily member that has proapoptotic and antitumorigenic activities. Mol Pharmacol 2001;59:901–8. [PubMed] [Google Scholar]
  • 12.Baek SJ, Wilson LC, Lee CH, Eling TE. Dual function of nonsteroidal anti-inflammatory drugs (nsaids): Inhibition of cyclooxygenase and induction of nsaid-activated gene. J Pharmacol Exp Ther 2002;301:1126–31. [DOI] [PubMed] [Google Scholar]
  • 13.Kim KS, Yoon JH, Kim JK, Baek SJ, Eling TE, Lee WJ, et al. Cyclooxygenase inhibitors induce apoptosis in oral cavity cancer cells by increased expression of nonsteroidal anti-inflammatory drug-activated gene. Biochem Biophys Res Commun 2004;325:1298–1303. [DOI] [PubMed] [Google Scholar]
  • 14.Kim JS, Baek SJ, Sali T, Eling TE. The conventional nonsteroidal anti-inflammatory drug sulindac sulfide arrests ovarian cancer cell growth via the expression of nag-1/mic-1/gdf-15. Mol Cancer Ther 2005;4:487–93. [DOI] [PubMed] [Google Scholar]
  • 15.Jang TJ, Kang HJ, Kim JR, Yang CH. Non-steroidal anti-inflammatory drug activated gene (nag-1) expression is closely related to death receptor-4 and −5 induction, which may explain sulindac sulfide induced gastric cancer cell apoptosis. Carcinogenesis 2004;25:1853–8. [DOI] [PubMed] [Google Scholar]
  • 16.Zimmers TA, Gutierrez JC, Koniaris LG. Loss of gdf-15 abolishes sulindac chemoprevention in the apcmin/+ mouse model of intestinal cancer. J Cancer Res Clin Oncol 2010;136:571–6. [DOI] [PubMed] [Google Scholar]
  • 17.Eling TE, Baek SJ, Shim M, Lee CH. Nsaid activated gene (nag-1), a modulator of tumorigenesis. J Biochem Mol Biol 2006;39:649–55. [DOI] [PubMed] [Google Scholar]
  • 18.Baek SJ, Okazaki R, Lee SH, Martinez J, Kim JS, Yamaguchi K, et al. Nonsteroidal anti-inflammatory drug-activated gene-1 over expression in transgenic mice suppresses intestinal neoplasia. Gastroenterology 2006;131:1553–60. [DOI] [PubMed] [Google Scholar]
  • 19.Schatzkin A, Lanza E, Freedman LS, Tangrea J, Cooper MR, Marshall JR, et al. The polyp prevention trial I: Rationale, design, recruitment, and baseline participant characteristics. Cancer Epidemiol Biomarkers Prev 1996;5:375–83. [PubMed] [Google Scholar]
  • 20.Lanza E, Schatzkin A, Ballard-Barbash R, Corle D, Clifford C, Paskett E, et al. The polyp prevention trial ii: Dietary intervention program and participant baseline dietary characteristics. Cancer Epidemiol Biomarkers Prev 1996;5:385–92. [PubMed] [Google Scholar]
  • 21.Schatzkin A, Lanza E, Corle D, Lance P, Iber F, Caan B, et al. Lack of effect of a low-fat, high-fiber diet on the recurrence of colorectal adenomas. Polyp prevention trial study group. N Engl J Med 2000;342:1149–55. [DOI] [PubMed] [Google Scholar]
  • 22.Lanza E, Hartman TJ, Albert PS, Shields R, Slattery M, Caan B, et al. High dry bean intake and reduced risk of advanced colorectal adenoma recurrence among participants in the polyp prevention trial. J Nutr 2006;136:1896–1903. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Lanza E, Schatzkin A, Daston C, Corle D, Freedman L, Ballard-Barbash R, et al. Implementation of a 4-y, high-fiber, high-fruit-and-vegetable, low-fat dietary intervention: Results of dietary changes in the polyp prevention trial. Am J Clin Nutr 2001;74:387–401. [DOI] [PubMed] [Google Scholar]
  • 24.Brown DA, Bauskin AR, Fairlie WD, Smith MD, Liu T, Xu N, et al. Antibody-based approach to high-volume genotyping for mic-1 polymorphism. Biotechniques 2002;33:118–20, 122, 124 passim. [DOI] [PubMed] [Google Scholar]
  • 25.Moore AG, Brown DA, Fairlie WD, Bauskin AR, Brown PK, Munier ML, et al. The transforming growth factor-ss superfamily cytokine macrophage inhibitory cytokine-1 is present in high concentrations in the serum of pregnant women. J Clin Endocrinol Metab 2000;85:4781–8. [DOI] [PubMed] [Google Scholar]
  • 26.Wiklund FE, Bennet AM, Magnusson PK, Eriksson UK, Lindmark F, Wu L, et al. Macrophage inhibitory cytokine-1 (mic-1/gdf15): A new marker of all-cause mortality. Aging Cell 2010;9:1057–64. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Wakchoure S, Swain TM, Hentunen TA, Bauskin AR, Brown DA, Breit SN, et al. Expression of macrophage inhibitory cytokine-1 in prostate cancer bone metastases induces osteoclast activation and weight loss. Prostate 2009;69:652–61. [DOI] [PubMed] [Google Scholar]
  • 28.Johnen H, Lin S, Kuffner T, Brown DA, Tsai VW, Bauskin AR, et al. Tumor-induced anorexia and weight loss are mediated by the tgf-beta superfamily cytokine mic-1. Nat Med 2007;13:1333–40. [DOI] [PubMed] [Google Scholar]
  • 29.Tangrea JA, Albert PS, Lanza E, Woodson K, Corle D, Hasson M, et al. Non-steroidal anti-inflammatory drug use is associated with reduction in recurrence of advanced and non-advanced colorectal adenomas (united states). Cancer Causes Control 2003;14:403–11. [DOI] [PubMed] [Google Scholar]
  • 30.Breit SN, Johnen H, Cook AD, Tsai VW, Mohammad MG, Kuffner T, et al. The tgf-beta superfamily cytokine, mic-1/gdf15: A pleotrophic cytokine with roles in inflammation, cancer and metabolism. Growth Factors 2011;29:187–95. [DOI] [PubMed] [Google Scholar]
  • 31.Hewett DG, Rex DK. Cap-fitted colonoscopy: A randomized, tandem colonoscopy study of adenoma miss rates. Gastrointest Endosc 2010;72:775–81. [DOI] [PubMed] [Google Scholar]
  • 32.Saltzman BS, Yamamoto JF, Decker R, Yokochi L, Theriault AG, Vogt TM, et al. Association of genetic variation in the transforming growth factor beta-1 gene with serum levels and risk of colorectal neoplasia. Cancer Res 2008;68:1236–44. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Li PX, Wong J, Ayed A, Ngo D, Brade AM, Arrowsmith C, et al. Placental transforming growth factor-beta is a downstream mediator of the growth arrest and apoptotic response of tumor cells to DNA damage and p53 overexpression. J Biol Chem 2000;275:20127–35. [DOI] [PubMed] [Google Scholar]
  • 34.Strelau J, Schmeer C, Peterziel H, Sackmann T, Herold-Mende C, Steiner H, et al. Expression and putative functions of gdf-15, a member of the tgf-beta superfamily, in human glioma and glioblastoma cell lines. Cancer Lett 2008;270:30–9. [DOI] [PubMed] [Google Scholar]
  • 35.Albertoni M, Shaw PH, Nozaki M, Godard S, Tenan M, Hamou MF, et al. Anoxia induces macrophage inhibitory cytokine-1 (mic-1) in glioblastoma cells independently of p53 and hif-1. Oncogene 2002;21:4212–9. [DOI] [PubMed] [Google Scholar]
  • 36.Baek SJ, Wilson LC, Eling TE. Resveratrol enhances the expression of non-steroidal anti-inflammatory drug-activated gene (nag-1) by increasing the expression of p53. Carcinogenesis 2002;23:425–34. [DOI] [PubMed] [Google Scholar]
  • 37.Lee SH, Kim JS, Yamaguchi K, Eling TE, Baek SJ. Indole-3-carbinol and 3,3’-diindolylmethane induce expression of nag-1 in a p53-independent manner. Biochem Biophys Res Commun 2005;328:63–9. [DOI] [PubMed] [Google Scholar]
  • 38.Lee SH, Krisanapun C, Baek SJ. Nsaid-activated gene-1 as a molecular target for capsaicin-induced apoptosis through a novel molecular mechanism involving gsk3beta, c/ebpbeta and atf3. Carcinogenesis 2010;31:719–28. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Liu T, Bauskin AR, Zaunders J, Brown DA, Pankhurst S, Russell PJ, et al. Macrophage inhibitory cytokine 1 reduces cell adhesion and induces apoptosis in prostate cancer cells. Cancer Res 2003;63:5034–40. [PubMed] [Google Scholar]
  • 40.Pang RP, Zhou JG, Zeng ZR, Li XY, Chen W, Chen MH, et al. Celecoxib induces apoptosis in cox-2 deficient human gastric cancer cells through akt/gsk3beta/nag-1 pathway. Cancer Lett 2007;251:268–77. [DOI] [PubMed] [Google Scholar]
  • 41.Lee DH, Yang Y, Lee SJ, Kim KY, Koo TH, Shin SM, et al. Macrophage inhibitory cytokine-1 induces the invasiveness of gastric cancer cells by up-regulating the urokinase-type plasminogen activator system. Cancer Res 2003;63:4648–55. [PubMed] [Google Scholar]

RESOURCES