Cancer Therapy: Phenothiazines in an Unexpected Role

Oxidative Dehydroxycyclization of Catechols with o-Mercaptoanilines to Access 1-Hydroxyphenothiazines

The protocol of aerobic oxidative dehydroxycyclization installed in the synthesis of rarely studied 1-hydroxyphenothiazines from catechols and o-mercaptoanilines is presented. Utilizing a natural renewable low-toxicity gallic acid as an organocatalyst, this established transformation proceeded smoothly in an aqueous ethanol solution under mild conditions with good functional group compatibility and up to a 94% isolated yield. This protocol is also characterized by its operational simple workup involving only recrystallization, revealing its sustainability and synthetic practicability.

Antitumor Activity of PEGylated and TEGylated Phenothiazine Derivatives: Structure–Activity Relationship

The paper aims to investigate the antitumor activity of a series of phenothiazine derivatives in order to establish a structure–antitumor activity relationship. To this end, PEGylated and TEGylated phenothiazine have been functionalized with formyl units and further with sulfonamide units via dynamic imine bonds. Their antitumor activity was monitored in vitro against seven human tumors cell lines and a mouse one compared to a human normal cell line by MTS assay. In order to find the potential influence of different building blocks on antitumor activity, the antioxidant activity, the ability to inhibit farnesyltransferase and the capacity to bind amino acids relevant for tumor cell growth were investigated as well. It was established that different building blocks conferred different functionalities, inducing specific antitumor activity against the tumor cells.

Treatment of cancer with antipsychotic medications: Pushing the boundaries of schizophrenia and cancer

Over a century ago, the phenothiazine dye, methylene blue, was discovered to have both antipsychotic and anti-cancer effects. In the 20th-century, the first phenothiazine antipsychotic, chlorpromazine, was found to inhibit cancer. During the years of elucidating the pharmacology of the phenothiazines, reserpine, an antipsychotic with a long historical background, was likewise discovered to have anti-cancer properties. Research on the effects of antipsychotics on cancer continued slowly until the 21st century when efforts to repurpose antipsychotics for cancer treatment accelerated. This review examines the history of these developments, and identifies which antipsychotics might treat cancer, and which cancers might be treated by antipsychotics. The review also describes the molecular mechanisms through which antipsychotics may inhibit cancer. Although the overlap of molecular pathways between schizophrenia and cancer have been known or suspected for many years, no comprehensive review of the subject has appeared in the psychiatric literature to assess the significance of these similarities. This review fills that gap and discusses what, if any, significance the similarities have regarding the etiology of schizophrenia.

Novel chlorpromazine derivatives as anti-endometrial carcinoma agents with reduced extrapyramidal side effects

As the traditional conservative remedy for endometrial carcinoma (EC), progesterone has great limitations due to its poor performance, and a new strategy is urgently needed. Our previous work revealed that the antipsychotic drug chlorpromazine (CPZ) has stronger antitumor activity on EC than progesterone does, which may provide a promising conservative alternative for EC patients. Unfortunately, the severe extrapyramidal symptoms (EPSs) at concentrations (>5 mg/kg) that are required for anticarcinoma activity limited its repurposing. Therefore, a series of novel CPZ derivatives were designed and synthesized to avoid EPS and retain its antitumor activity. Among them, 11·2HCl and 18 displayed greater inhibitory activity by modulating SOS1. Notably, even at a dose of 100 mg/kg, 11·2HCl/18 had little effect on the extrapyramidal system. In conclusion, 11·2HCl and 18 greatly repressed the malignant features of endometrial carcinoma and decreased extrapyramidal side effects compared with the original drug CPZ.

Escitalopram oxalate inhibits proliferation and migration and induces apoptosis in non-small cell lung cancer cells

Population-based cohort studies have revealed that neuroleptic medications are associated with a reduced cancer risk. Recent studies have demonstrated that selective serotonin reuptake inhibitors (SSRIs) have an antiproliferative or cytotoxic effect on certain cancer types. Known as a superior SSRI, escitalopram oxalate exhibits favorable tolerability with generally mild and temporary adverse events. The present study aimed to examine the effects of escitalopram oxalate on non-small cell lung cancer (NSCLC) cells. The experimental results revealed that escitalopram oxalate significantly inhibited the proliferation and invasion of A549, and H460 cells compared with BEAS-2B cells. Additionally, escitalopram oxalate significantly increased the sub-G₁ population and caspase-3 activity of A549, and H460 cells. Furthermore, escitalopram oxalate significantly induced mitochondria-dependent apoptotic signaling cascades in A549 and H460 cells, which included increases in the protein expression levels of apoptosis regulator Bax, truncated BH3-interacting domain death agonist, cytochrome c, apoptotic protease-activating factor 1, and cleaved caspase-9. These findings suggest that escitalopram oxalate could serve a therapeutic agent for the treatment of NSCLC due to its antiproliferative and apoptotic effects.

Escitalopram oxalate induces apoptosis in U-87MG cells and autophagy in GBM8401 cells

Glioblastoma multiforme (GBM) is recognized as a most aggressive brain cancer with the worst prognosis and survival time. Owing to the anatomic location of gliomas, surgically removing the tumour is very difficult and avoiding damage to vital brain regions during radiotherapy is impossible. Therefore, therapeutic strategies for malignant glioma must urgently be improved. Recent studies have demonstrated that selective serotonin reuptake inhibitors (SSRIs) have cytotoxic effect on certain cancers. Considering as a more superior SSRI, escitalopram oxalate exhibits favourable tolerability and causes generally mild and temporary adverse events. However, limited information is revealed about the influence of escitalopram oxalate on GBM. Therefore, an attempt was made herein to explore the effects of escitalopram oxalate on GBM. The experimental results revealed that escitalopram oxalate significantly inhibits the proliferation and invasive ability of U‐87MG cells and significantly reduced the expressions of cell cycle inhibitors such as Skp2, P57, P21 and P27. Notably, escitalopram oxalate also induced significant apoptotic cascades in U‐87MG cells and autophagy in GBM8401 cells. An animal study indicated that escitalopram oxalate inhibits the proliferation of xenografted glioblastoma in BALB/c nude mice. These findings implied that escitalopram oxalate may have potential in treatment of glioblastomas.

Inequalities in lung cancer care of elderly patients with schizophrenia: an observational cohort study

OBJECTIVE

Cancer mortality is higher in individuals with schizophrenia, a finding that may be due, in part, to inequalities in care. We evaluated gaps in lung cancer diagnosis, treatment, and survival among elderly individuals with schizophrenia.

METHODS

The Surveillance, Epidemiology, and End Results database linked to Medicare records was used to identify patients 66 years or older with primary non-small cell lung cancer. Lung cancer stage, diagnostic evaluation, and rates of stage-appropriate treatment were compared among patients with and without schizophrenia using unadjusted and multiple regression analyses. Survival was compared among groups using Kaplan-Meier methods.

RESULTS

Of the 96,702 patients with non-small cell lung cancer in the Surveillance, Epidemiology, and End Results database, 1303 (1.3%) had schizophrenia. In comparison with the general population, patients with schizophrenia were less likely to present with late-stage disease after controlling for age, sex, marital status, race/ethnicity, income, histology, and comorbidities (odds ratio = 0.82, 95% confidence interval = 0.73-0.93) and were less likely to undergo appropriate evaluation (p < .050 for all comparisons). Adjusting for similar factors, patients with schizophrenia were also less likely to receive stage-appropriate treatment (odds ratio = 0.50, 95% confidence interval = 0.43-0.58). Survival was decreased among patients with schizophrenia (mean survival = 22.3 versus 26.3 months, p = .002); however, no differences were observed after controlling for treatment received (p = .40).

CONCLUSIONS

Elderly patients with schizophrenia present with earlier stages of lung cancer but are less likely to undergo diagnostic evaluation or to receive stage-appropriate treatment, resulting in poorer outcomes. Efforts to increase treatment rates for elderly patients with schizophrenia may lead to improved survival in this group.

Familial and sporadic schizophrenia: a comparison of somatic diseases and abuse in patients and their relatives

OBJECTIVE

Comparing schizophrenia patients on the basis of familial and non-familial forms of the illness provides a promising approach to the identification of genes involved in schizophrenia. The aim of this study was to search for somatic factors that discriminate between patients with and without a family history of schizophrenia and between their relatives.

METHODS

Ninety-five schizophrenia patients were structurally interviewed about mental and physical health and alcohol and substance use in themselves and their families. Besides this, complementary information was obtained from the patients' case records. Patients with (41%) and without (59%) a family history were then compared.

RESULTS

The main differences were found in the patients' relatives. Fewer patients with a family history, compared with patients without a family history, had relatives with cancer (p = 0.002). Conversely, there was a tendency towards that more patients with a family history, compared with patients without a family history, had relatives with cardiac infarction (p = 0.05).

CONCLUSION

The genetic risk associated with schizophrenia seems to cosegregate into a factor(s) that protects against cancer and possibly also increases the risk for cardiac infarction.

Cancer risk among users of neuroleptic medication: a population-based cohort study

It has been suggested that neuroleptic medication may decrease cancer risk. We compared cancer risks in a population-based cohort study of 25 264 users (⩾2 prescriptions) of neuroleptic medications in the county of North Jutland, Denmark, during 1989–2002, with that of county residents who did not receive such prescriptions. Statistical analyses were based on age-standardisation and Poisson regression analysis, adjusting for age, calendar period, COPD, liver cirrhosis or alcoholism, use of NSAID, and, for breast cancer, additionally for use of hormone therapy, age at first birth, and number of children. Use of neuroleptic medications was associated with a decreased risk for rectal cancer in both women and men (adjusted IRRs of 0.61 (95% confidence interval, 0.41–0.91) and 0.82 (0.56–1.19), respectively) and for colon cancer in female users (0.78; 0.62–0.98). Some risk reduction was seen for prostate cancer (0.87; 0.69–1.08), but breast cancer risk was close to unity (0.93; 0.74–1.17). Overall, treatment with neuroleptic medications was not related to a reduced risk of cancer, but for cancers of the rectum, colon and prostate there were suggestive decreases in risk.

Risk for cancer in a cohort of patients hospitalized for schizophrenia in Denmark, 1969-1993

We investigated the cancer risk of patients hospitalized for schizophrenia in a nationwide cohort study. All 22766 adults admitted for schizophrenia, ICD-8 295, in Denmark between 1969 and 1993 were followed up for cancer through 1995. The incidence of site-specific cancers was compared with national incidence rates, adjusted for sex, age and calendar time. The risk for cancer was increased for both men and women during the first year of follow-up. When the first year of follow-up was excluded, the risk for all tobacco-associated cancers and for prostate and rectal cancers was reduced for male patients with schizophrenia. The standardized incidence ratio (SIR) of lung cancer was marginally reduced (SIR, 0.86; 95% CI: 0.65, 1.02) for male patients with schizophrenia; this was due, however, to a reduction in risk for older patients. An increased risk for breast cancer found for female patients with schizophrenia (SIR, 1.20; 95% CI: 1.05, 1.38) should be interpreted with caution, given the high proportion of nulliparous women with schizophrenia in Denmark. The data might support reduced risks for prostate and rectal cancer among male patients with schizophrenia, whereas a changing smoking pattern might explain the reduced risk for tobacco-related cancers.

Chlorpromazine-induced increase in dipalmitoylphosphatidylserine surface area in monolayers at room temperature

The Langmuir technique revealed that the surface area of acidic glycerophospholipids (dipalmitoylphosphatidylserine, -glycerol, and dipalmitoylphosphatidic acid) in monolayers increased dramatically when micromolar concentrations of the antipsychotic drug chlorpromazine (CPZ) were present in the subphase. Monolayers of neutral glycerophospholipids (dipalmitoylphosphatidylcholine and -ethanolamine) did not show such a large effect with CPZ. Compared to CPZ, millimolar concentrations of the monovalent cations Li+, K+, Na+, Rb+, and Cs+ did not appear to influence the dipalmitoylphosphatidylserine monolayer, suggesting that the effect of CPZ, a monovalent cationic amphophile, was due to an interaction with the acyl chains of the lipids. In addition, the effect of CPZ was reduced by 150 mM Na+, suggesting that the sodium cations might screen the negatively charged headgroups from an electrostatic interaction with the positively charged drug molecule. Two CPZ analogs, chlorpromazine sulfoxide and CPZ with 2 carbons in the side chain, were also studied. These observations suggest that part of the biological effects of CPZ, being antipsychotic and/or side effects, may be due to CPZ's action on the acidic glycerophospholipids in nerve cell membranes.

Enhancement of tumor growth by drugs with some common molecular actions

A group of structurally related drugs representing diverse therapeutic classes share, among a number of pharmacological properties, enhancement of tumor growth in several rodent models of malignancy. One common action, the inhibition of histamine binding to and catalytic activity of cytochrome P450 monooxygenases, is highly correlated with potency to enhance tumor growth. Among members of this drug ensemble, the antiestrogen tamoxifen has been shown in controlled clinical studies to increase the incidence of uterine and gastrointestinal cancer and to accelerate the course of gastric cancer, and the tamoxifen analogue clomiphene has been linked to neuroblastoma and the tricyclic group of antidepressants to ovarian cancer. The determination of drug affinities for protein modulators of cell growth, proliferation, and transformation suggests a strategy for identifying at least some classes of chemicals that impart oncologic risks to humans.

Successful cancer therapy with promethazine: the rationale

Evidence supporting the claim that specific phenothiazines, notably chlorpromazine and promethazine, may be used as sole agents for the treatment of cancer in man, has been reviewed. Selective destruction of cancerous tissue can be achieved by modulating energy metabolism in malignant cells. In the light of available information, the drug of choice is promethazine, the effects of which on the central nervous system are relatively weak. The maintenance of continuous pharmacological pressure against malignant growths forms an essential feature of the therapy. Protection against blood dyscrasias may be secured through the provision of adequate amounts of trace elements necessary for the function of enzyme systems which detoxicate active oxygen species. Tumour-cell death may be facilitated by nutritional supplements of specific polyunsaturated fatty acids. Interference from adventitious medications and drug resistance are discussed; appropriate therapy is outlined.

The occurrence of cancer in first admitted schizophrenic patients

The incidence of cancer was studied in a cohort of all first admitted 9156 patients in Denmark with a diagnosis of schizophrenia in the period 1970-1987. The overall incidence of cancer was reduced particularly in the males. Adjustment for the smoking habits of psychiatric patients enhanced this risk reduction. Fewer than expected had been diagnosed with cancer prior to the first schizophrenia admission. This tendency was limited to the female patients. The reduced cancer incidence was particularly marked for genital cancers, in particular testicular cancer, and skin cancers including malignant melanoma. Breast cancer risk was not increased, thus not substantiating concerns that neuroleptics would increase breast cancer risk through the elevation of serum prolactin levels. Some available evidence in the literature supports the hypothesis of an antineoplastic effect of neuroleptics as an explanation for the low occurrence of cancer in schizophrenic patients. Further large sample studies including an extension of the follow-up of this cohort are needed to establish the reduced risk of cancer in schizophrenic patients as well as exploring the causes for this reduction.

Cytotoxic and genetic effects of X-irradiation of human cells in the presence of chlorpromazine

Human epidermoid carcinoma cells (Hep-2) were X-irradiated in the presence of 5-10 micrograms/ml of chlorpromazine (CPZ). Survival of the cells decreased with increasing CPZ concentration. Lymphocytes from three normal volunteers exposed to X-irradiation in the presence of CPZ showed an increased frequency of dicentric and ring formation.

Mortality and causes of death in first admitted schizophrenic patients

Although many studies have shown an increased mortality in schizophrenic patients, the literature provides little information about mortality from specific causes in relation to age, gender, and duration of illness. This study examined mortality and causes of death in a total national sample of 9156 first admitted schizophrenic patients. Suicide accounted for 50% of deaths in men and 35% of deaths in women. Suicide risk was particularly increased during the first year of follow-up. Death from natural causes, with the exception of cancer and cerebrovascular diseases, was increased. Suicide risk during the first year of follow-up increased by 56%, with a 50% reduction on psychiatric in-patient facilities. The study confirms that mortality in schizophrenia is still markedly elevated, and the finding of an increasing suicide risk may be an indicator of some adverse effects of deinstitutionalisation.

Neuroleptic medication and reduced risk of prostate cancer in schizophrenic patients

A decreased incidence of cancer of the prostate has been demonstrated in a cohort of 6168 chronic schizophrenic patients followed up from 1957 to 1984. A case-control study was performed based on this cohort to determine the possible influence of neuroleptic treatment and other factors on the risk of developing prostate cancer. Thirty-eight male schizophrenic patients who had developed prostate cancer during the observation period were compared with 76 age- and sex-matched controls from the same cohort. The only significant association was that of a reduced risk of prostate cancer among those who had been treated with a cumulative dose of high-dose phenothiazines (primarily chlorpromazine) of 15 g or more. These patients had been treated with an average daily dose of 145 mg chlorpromazine for an average of 12.5 years. No other significant risk factors were identified.

Chlorpromazine-induced damage on nucleic acids: a combined cytogenetic and biochemical study

Chlorpromazine is now emerging as an adjuvant chemotherapeutic agent for the treatment of neoplasia. This was further supported in the present study by the following lines of evidence: it was shown that chlorpromazine causes damage in a series of native nucleic acids, though at somewhat high concentrations. Furthermore, chlorpromazine and caffeine were shown to act synergistically to potentiate the cytogenetic effect of adriamycin on human lymphocytes in vitro and on Ehrlich ascites tumour (EAT) cells in vivo. It is suggested that chlorpromazine alone or in combination with caffeine may exert its cytotoxic effect on normal and neoplastic cells not only indirectly, i.e. by facilitating the intracellular retention of adriamycin, but also directly by intercalating into nucleic acids.

Coca-Cola, cancers, and coronaries: personality and stress as mediating factors

A theory is presented relating the consumption of stimulant and depressant drugs to cancer and coronary heart disease, with stress/personality acting as an intermediary. The predictions from the theory that large-scale consumption of Coca-Cola would prevent cancer and promote coronary heart disease was tested and found to be supported by the results of a long-scale prospective study. Results replicate those from an earlier study using coffee as a stimulant drug.