Tumor cell adaptation to hypoxic stress is an important determinant of malignant progression. While much emphasis has been placed on the role of HIF-1 in this context, the role of additional mechanisms has not been adequately explored. Here we demonstrate that cells cultured under hypoxic/anoxic conditions and transformed cells in hypoxic areas of tumors activate a translational control program known as the integrated stress response (ISR), which adapts cells to endoplasmic reticulum (ER) stress. Inactivation of ISR signaling by mutations in the ER kinase PERK and the translation initiation factor eIF2a or by a dominant-negative PERK impairs cell survival under extreme hypoxia. Tumors derived from these mutant cell lines are smaller and exhibit higher levels of apoptosis in hypoxic areas compared to tumors with an intact ISR. Moreover, expression of the ISR targets ATF4 and CHOP was noted in hypoxic areas of human tumor biopsy samples. Collectively, these findings demonstrate that activation of the ISR is required for tumor cell adaptation to hypoxia, and suggest that this pathway is an attractive target for antitumor modalities.

Hypoxia is a dynamic feature of the tumor microenvironment that contributes to cancer progression. In order to adapt and overcome hypoxic stress, tumor cells activate survival pathways that attempt to couple metabolic processes to reduced energy availability due to oxygen deprivation. While the hypoxia-inducible factors HIF-1 and HIF-2 are critical to the cellular response to hypoxia, HIF-independent processes are known to contribute to this adaptation. Recent evidence demonstrates that hypoxia activates components of the Unfolded Protein Response (UPR), a coordinated program that regulates cellular adaptation to increased levels of unfolded proteins in the endoplasmic reticulum (ER). Here we review the evidence implicating the ER kinase PERK, its downstream target translation initiation factor eIF2alpha, and the subsequent translational upregulation of the transcription factor ATF4 in this response. Not only are cells with compromised PERK-eIF2alpha-ATF4 signaling more sensitive to hypoxic stress in vitro but they also form tumors that grow slower in vivo with smaller hypoxic areas, indicating that the PERK-eIF2alpha-ATF4 pathway confers a survival advantage for tumor cells under hypoxia. These results, together with evidence for an involvement of other UPR pathways and ER stress proteins in hypoxia tolerance and tumor maintenance, point to a central role for UPR activation in tumor progression and suggest that this response may offer an attractive target for new anti-tumor modalities.

Aerobic exercise training (AET) is an effective adjunct therapy to attenuate the adverse side-effects of adjuvant chemotherapy in women with early breast cancer. Whether AET interacts with the antitumor efficacy of chemotherapy has received scant attention. We carried out a pilot study to explore the effects of AET in combination with neoadjuvant doxorubicin–cyclophosphamide (AC+AET), relative to AC alone, on: (i) host physiology [exercise capacity (VO2 peak), brachial artery flow-mediated dilation (BA-FMD)], (ii) host-related circulating factors [circulating endothelial progenitor cells (CEP) cytokines and angiogenic factors (CAF)], and (iii) tumor phenotype [tumor blood flow (15O–water PET), tissue markers (hypoxia and proliferation), and gene expression] in 20 women with operable breast cancer. AET consisted of three supervised cycle ergometry sessions/week at 60% to 100% of VO2 peak, 30 to 45 min/session, for 12 weeks. There was significant time × group interactions for VO2 peak and BA-FMD, favoring the AC+AET group (P < 0.001 and P = 0.07, respectively). These changes were accompanied by significant time × group interactions in CEPs and select CAFs [placenta growth factor, interleukin (IL)-1β, and IL-2], also favoring the AC+AET group (P < 0.05). 15O–water positron emission tomography (PET) imaging revealed a 38%decrease in tumor blood flow in the AC+AET group. There were no differences in any tumor tissue markers (P > 0.05). Whole-genome microarray tumor analysis revealed significant differential modulation of 57 pathways (P < 0.01), including many that converge on NF-κB. Data from this exploratory study provide initial evidence that AET can modulate several host- and tumor-related pathways during standard chemotherapy. The biologic and clinical implications remain to be determined.