1. Physical activity change: what biomarkers
tell us about cancer mechanisms and effects
Prof. Dr. Cornelia Ulrich
Director
National Center for Tumor Diseases (NCT)
German Cancer Research Center (DKFZ)
and
Fred Hutchinson Cancer Research Center,
Seattle
World Cancer Research Fund
Obesity, Physical Activity &
Cancer
April 2013, London

2. The next 25 minutes
• Evidence base for mechanisms linking
physical activity to cancer
• Mechanisms – results and questions
 Inflammation
 Immunity
 Oxidative stress and DNA repair
 Sex hormones, metabolic hormones,
adipokines…
• Mechanisms in cancer patients
• Summary

3. Evidence base for mechanisms linking
physical activity to cancer risk (1)
• Animal studies
 Direct mechanistic effects in tissue and key biospecimens
 Limited generalizability compared to:
• Human physical activity
• Human biomarkers (e.g., inflammatory processes, PNAS 2013)
• Dose-response achievable in humans
• Observational epidemiological studies measuring
biomarkers concurrently with physical activity levels
 Detect long-term associations
 E.g., training status and DNA repair capacity
 Limitation: confounding factors, such as supplement use,
body weight, etc…

4. Evidence base for mechanisms linking
physical activity to cancer risk (2)
• Human intervention studies
 Experimental design (randomized controlled trial)
allows direct measurement of effects and inference of
causality
 Biomarkers can be “intermediate endpoints” in cancer
research
CRP  increases colorectal cancer risk (Toriola, Int J Ca 2013)
 is associated with cancer survival (Pierce,J Clin Onc 2009)
 Limited to:
• Shorter time periods (generally up to 1 year)
• Certain biospecimens
 Dependent on:
• Adherence

5. Physical Activity Caloric Restriction
Cancer Risk
DNA Repair
Capacity
Vitamin D
Immunity
Obesity
Inflammation
Sex hormones
Insulin/Glucose
Adipokines
Gut
microbiome?

6. Physical activity is highly correlated
with vitamin D levels (NHANES)
25 (OH)
Vit D
Frequency of outdoor activity (times in past month)
Scragg & Camargo, Am J Epi 2008
Non-Hispanic White Mexican American Non-Hispanic Black

7. Exercise Trial – Physical
Activity for Total Health Study
• Randomized controlled trial examining in overweight,
sedentary, postmenopausal women (n=173 PATH Study)
 the effects of a one-year
exercise intervention (5d/wk 45min)
 compared to a one-year
stretching program
 on cancer biomarkers
(0, 3,12 months)
• Very good adherence and minimal
drop out
• Significant improvement in VO2 max
McTiernan, Ulrich (IMEX) and colleagues

8. 0
1
2
3
4
CRP
(mg/L)
Ctrl-BL
Ctrl-12m
Ex-BL
Ex-12m
Waist circ. <88cm Waist circ. >88cm
12m exercise reduces C-reactive protein
among obese women
P. Campbell, Medicine Sports Science Exerc 2009
n.s.
CtrlCtrl ExerExer
p<0.001

9. Alberta Physical Activity and
Breast Cancer Prevention Trial –
similar effects on CRP
• RCT, parallel design, larger sample size
(n=160/160), biomarkers at 6 & 12 months
 Also excellent adherence and minimal dropout
• Differences over 12 months:
 Exercisers versus controls
Reduced CRP (TER = 0.87, 0.79-0.96, P = 0.005)
• But no changes in IL-6 or TNF-alpha.
 Decreasing CRP with increasing exercise
 Effect mediated by fat loss
 No intervention effect if adjusted for dietary
fiber  confounding?
Friedenreich et al, Cancer Prev Res 2012

10. Energy balance – is it about
exercise or about
weight loss?
 Better chubby and fit
or thin at every price?

11. PI: Anne McTiernan, Seattle TREC
(Ulrich Project Leader)
• Randomized, controlled, 12 month,
4-arm clinical trial of diet and/or exercise
• 439 postmenopausal overweight-to-
obese women
• Average Age: 58 years
• Average BMI: 30.8 kg/m2 Body fat: 48%
AIMS:
Assess effects of a moderate-intensity
exercise program, weight reduction diet,
or both exercise + diet in postmenopausal
women on body weight and composition,
and cancer biomarkers

12. CRP concentrations % change as a result of
12-month diet or exercise intervention
* p<0.0001
*
Imaya, Ulrich, McTiernan et al. Cancer Res 2012
*
-46.9%
P= <.001
- 37.7%
P= <.001
-46.9%
P= <.001
-11.4%
P= .09
1.1%

13. Changes in CRP by weight loss
*
-51.2%
P< .001†
-52.0%
P< .001†
-27.8%
P= .001†
0.9% 0.9% 0.9%
-3.7%
-13.0%
-7.3%
Diet Diet + Exercise Exercise
Imaya, Ulrich, McTiernan et al. Cancer Res 2012

14. Percent leukocytes % change as a result of
12-month diet or exercise intervention
*
-2.0%
-9.2%
P< .001
-7.1%
P< .001
-2.5%
p=.78
Imaya, Ulrich, McTiernan et al. Cancer Res 2012

15. 0
0.1
0.2
0.3
0.4
0.5
0.6
Incidence of
colds
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
12-month study period
Exercise
Control
P=0.02
Chubak et al Am J Med 2006

16. No effects of exercise intervention on broad
spectrum of biomarkers of immune function
• No effects on
 Lymphocyte proliferation
from cryopreserved cells
 Natural killer cell
cytotoxicity
 Cell counts and
phenotypes
 Immunoglobulins
• Despite excellent
retention, adherence and
intervention efficacy
• Value of snapshot
immune markers?
Campbell P et al, J Appl Physiol 2008

17. Oxidative stress and DNA repair
-- why do we expect effects?
Exercise or general metabolism induces
oxidative DNA damage
• Training of the DNA repair system through
exercise?
• Reduced levels of oxidative damage?
Supporting preliminary data from animal
experiments, cross-sectional studies
(frequently athletes) and small
interventions

18. -15
-10
-5
0
5
%Change
Overall By % gain in V02max
Physical Activity for Total Health Study:
Exercise reduces urinary
F2-isoprostane levels among those with greatest
training efficacy (n=173)
Campbell P et al. Med Sci Sports Exerc 2010
Ctrl
Ex
n.s.
P-trend=0.005
Ctrl
***
<5
5-15 >15
No effects on DNA repair capacity overall, as measured by Comet Assay
Other assays needed?
(Habermann, Ulrich et al, in prep.)

19. NEW: Diet & Exercise interventions decrease serum
leptin levels among postmenopausal women (n=439)
0
5
10
15
20
25
30
Diet+Exercise Diet Exercise Control
Leptinµg/mL
Baseline
12 months
Abbenhardt J Int Med 2013
P<0.0001 P<0.0001 P<0.005

20. NEW: Diet, but not exercise interventions
increase serum adiponectin levels among
postmenopausal women(n=439)
Abbenhardt C et al. J Int Med 2013
10
10.5
11
11.5
12
12.5
13
13.5
14
14.5
15
Diet+Exercise Diet Exercise Control
Adiponectinµg/mL
Baseline
12 months
P=0.001 P=0.001
N.S.

21. Alberta Physical Activity and
Breast Cancer Prevention Trial
(Friedenreich et al)
• Across the study period comparing
exercise group to controls (treatment
effect ratio:
statistically significant reduction in
leptin (TER=0.82, 0.78-0.87)
increase in the adiponectin/leptin ratio
(TER=1.21, 1.13-1.28)
Friedenreich et al. Endocr.-related Ca 2011

22. Half-time summary
• Intervention trials of exercise have shown
significant and reproducible effects on
biomarkers of cancer risk
 Inflammation, adipokines, sex hormones,
insulin/IGF, oxidative stress
• Unclear effects on immunity, DNA repair &
Vit D
• Effects strongest in diet and exercise group
• Fat-loss important mediator for many, but
not all mechanisms

23. Inflammation -
What’s fat got to do with it?

24. Targeting tissue – effects of
energy balance on adipose
tissue biology
• Adipose tissue is active in metabolism and synthesis
of IL-6, TNFalpha, sex steroid metabolism…
 Goal: To learn about molecular mechanisms in target tissue
• N=49 women randomized to exercise and or weight-
loss intervention
• Subcutaneous adipose tissue sampling at baseline
and 6 months

25. Adipose tissue biopsies and
biomarkers
Collagenase
digestion Adipocytes
Stromavascular cells (SVC)
for flow cytometry (Kratz)
Snap-frozen
whole tissue for
RNA extraction
and gene
expression
Biopsy:
subcutaneous abdominal fat
local anaesthetic (incision, 14-gauge needle)
yield ~ 500 mg
Campbell, Ulrich et al. Cancer Prev Res 2013
Analysis:
• candidate genes
• candidate pathways
• unsupervised clustering
• By intervention
• By weight-loss

26. Weight loss affects adipose
tissue gene expression
• Analysis by weight loss:
% change P trend
adj. P
value
Sex Steroid-Related:
HSD17B1 -0.35 0.0002 0.01
ESR1 0.24 0.0037 0.08
STS -0.26 0.0198 0.20
HSD17B10 -0.05 0.045 0.37
Inflammation-Related:
CRP 0.23 0.0081 0.13
ICAM4 -0.09 0.0110 0.13
SAA1 -0.38 0.0110 0.13
VCAM1 0.34 0.044 0.37
Other Genes of Interest:
LEP -0.44 0.0000 0.00
IGFBP3 0.37 0.0032 0.08
Campbell, Ulrich et al. Cancer Prev Res 2013

27. –omics results
• Unsupervised clustering of >37,000 transcripts
by weight loss
• Reveals 78 transcripts with statistically
significant adjusted p-values
 Multiple hits in histone clusters
 Leptin is #33  suggests strong effects of
weight loss on other pathways in adipose
tissue
• However: unsupervised approach results also
misses significant hits in candidate pathways
(=false negatives)
• Combination of hypothesis-driven and
empirical approach is complementary!!
Campbell, Ulrich et al. Cancer Prev Res 2013

28. 6m 12m 24m 36m
Treatment
information
• Blood draws
• Urine
• Feces
• Questionnaires on
symptoms, QoL &
current health habits,
Food frequency (FFQs)
• Accelerometer
3m
• Questionnaires
on symptoms,
QoL & current
health habits
Surgery
• Pre-surgery blood
• Urine
• Feces
• Tumor & normal tissue
• Visceral & subcutaneous
adipose tissue
• Fascia
• Questionnaires
Outcomes
•Surgical outcomes
•Treatment toxicity
• Recurrence
• Survival
• Symptoms, QoL
Baseline
Diagnosis
ColoCare – Study Design
Multicenter colorectal cancer patient cohort

30. Exercise in the adjuvant therapy of
cancer patients
There is substantial potential for exercise in aiding in the recovery of
cancer patients
 unknowns regarding type, timing, intensity and duration of intervention
Clinical trial: n=170 hematopoietic stem-cell transplantation patients
 exercise prior to and during the transplant process
 cancer-related fatigue, distress and  physical functioning/fitness
PFS (months)
Wiskemann, Blood 2011
Greatest benefit
on physical fitness
in the initially
unfit!

31. Biomarkers in cancer patients undergoing
energy balance interventions
• Little research during time periods during and
right after therapy
 Impact of therapy?
 Impact on therapy success?
 E.g., Biomarkers of inflammation related to
fatigue  differential effects of energy balance
on inflammation than in healthy individuals?
Multiple exercise trials underway in
Heidelberg
Breast, HSCT, lung, soon pancreas
With Karen Steindorf and Joachim Wiskemann

32. Summary and outlook
• There are many possible mechanisms by which
exercise/energy balance can affect cancer
 These are likely to act in combination
• Exercise/diet trials among overweight/obese show:
 ↓ Inflammation in plasma and tissue
• Substantial effect, but weight loss required
 ↓ Oxidative stress
 Effects on estrogens, adipokines, adipose gene expression
 Immunity? DNA repair?
• Studies in cancer patients are needed to understand
mechanisms and substantiate recommendations for
patients
 Different setting for biomarkers, e.g., biomarkers of
inflammation under therapy
• Interdisciplinary studies are needed that address multiple
dimensions of energy balance
 Physical activity, biomarkers, adipose tissue, etc…

33. FHCRC:
Anne McTiernan
Kristin Campbell
Mario Kratz
Karen Foster-Schubert
Clare Abbenhardt
Marc Horton
Kristin Campbell
Peter Campbell
Brandon Pierce
Alanna Boynton
Liz Poole
Jessica Chubak
Laura Hooper
Julie Meyers
NCT/DKFZ:
Karen Steindorf
Joachim Wiskemann
Dirk Jäger
Martina Schmidt
Ursula Bollow
Dominik van den Bergh
+ many others…
Support : NIH Grants (TREC)
Manfred Lautenschläger Stiftung
Stiftung Leben mit Krebs
Milon
Colleagues and staff from the
Heidelberg ISZB
NIH TREC Initiative
HEAL Study