Vol. 6, 687-692, September 1997 Cancer Epidemiology, Blomarkers & Prevention 687

Correlates of Mutagen Sensitivity in Patients with UpperAerodigestive Tract Cancer’

Margaret R. Spitz,2 R. Sue McPherson, Hong Jiang,

T. C. Hsu, Zoltan Trizna, J. Jack Lee,

Scott M. Lippman, Fadbo R. Khuri, Lyn Steffen-Batey,Robert M. Chamberlain, Stimson P. Schantz, and

Waun K. Hong

Departments of Epidemiology [M. R. S., H. J., R. M. Cl, Cell Biology

[T. C. HI, Clinical Cancer Prevention [S. M. L.], Biomathematics [J. J. LI, and

Head and Neck and Thoracic Medical Oncology [F. R. K., W. K. H., Z. Tb,

The University of Texas M. D. Anderson Cancer Center, Houston, Texas

77030; School of Public Health [R. S. M., L. S-B.l, Houston, Texas, 77030;

and Memorial Sloan Kettering Cancer Center, New York, New York, 10021[S.P.S.l

Abstract

Although tobacco and alcohol use are the major

determinants of upper aerodigestive tract carcinogenesis,

not all smokers develop cancer. This phenomenon is due

to individual variations in genetic susceptibility tocarcinogens. One explanation may be differences inmutagen sensitivity (as measured by the in vitro

bleomycin-induced mutagen sensitivity assay) in patientswith squamous cell carcinoma of the upper aerodigestivetract. Antioxidant supplementation has also been shownto decrease DNA damage and thus may also inhibitcarcinogenesis. In this study, we examined whether

smoking, alcohol intake, and dietary antioxidant intakewere correlated with mutagen sensitivity. The 612

patients evaluated are part of an ongoing multicenterPhase III trial of 13th retinoic acid for the prevention ofsecond primary tumors. We found that patients withpharyngeal cancers were more likely than patients with

oral cavity or larynx cancers to be mutagen sensitive.There were no significant differences in the distribution

of mutagen sensitivity by sex or alcohol use. Neversmokers were significantly more likely (61.1%) to bemutagen sensitive than current smokers (35.6%). Dietary

consumption of the micronutrients a-carotene, �3-carotene, lutein, lycopene, and vitamin C was not

correlated with mutagen sensitivity. Therefore, we suggestthat mutagen sensitivity is an independent marker of

cancer risk not affected by other known risk factors.

Received 9/4/96; revised 6/4/97; accepted 6/1 1/97.The costs of publication of this article were defrayed in part by the payment of

page charges. This article must therefore be hereby marked advertisement in

accordance with 18 U.S.C. Section 1734 solely to indicate this fact.t This work was supported by National Cancer Institute Grant P01 CA 52051.

2 To whom requests for reprints should be addressed, at Box 189, Department of

Epidemiology, The University of Texas M. D. Anderson Cancer Center, 1515

Holcombe Boulevard, Houston, Texas 77030. Phone: (713) 792-3020; Fax:

(713) 792-0807.

Introduction

The etiobogicab role of tobacco and alcohol exposure in upper

aerodigestive tract cancers is unquestioned. However, only afraction of exposed individuals will develop neoplastic lesions.

Genetically determined modulation of environmental exposuresis an attractive possible mechanism for the variation in host

susceptibility (1). Therefore, the concept of genetic suscepti-

bility to carcinogenic exposures must be factored into therisk-assessment process.

Hsu et a!. (2) have developed an in vitro mutagen sensi-tivity assay based on the quantification of bleomycin-inducedchromatid breaks in short-term cultured lymphocytes to meas-

ure human susceptibility to environmental carcinogens. In twoprevious retrospective case-control studies, we demonstratedthat bbeomycin-induced mutagen sensitivity (either as a contin-uous or dichotomous variable) was an independent risk factor

for head and neck cancers, after adjustment for tobacco andalcohol use, with adjusted odds ratios of 4.3 and 2.5 (3, 4). Our

data also showed that mutagen sensitivity was a significantpredictor of multiple primary cancer risk subsequent to an

initial head and neck cancer (5, 6).Considerable epidemiological evidence suggests that caro-

tenoids are associated with a decreased risk of epithelial can-cers. Because antioxidant supplementation has been shown to

decrease endogenous oxidative DNA damage in the lympho-

cytes of smokers and nonsmokers (7), it is important to assessthe correlation (if any) between the dietary intake of thesemicronutrients and the bevel of induced mutagen sensitivity.

This report presents baseline data on smoking status, bleo-mycin-induced mutagen sensitivity, and micronutrient intakefrom patients with upper aerodigestive tract cancers enrolled in

an ongoing multicenter Phase III placebo-controlled trial of13-cis retinoic acid for the prevention of second primary tu-

mors. The purpose of this analysis was to evaluate the associ-ation of baseline mutagen sensitivity values with smoking sta-

tus, clinical variables, and self-reported dietary micronutrient

and alcohol intake.

Materials and Methods

Each eligible patient for the chemoprevention trial was re-

quired to have had a confirmed diagnosis of squamous cellcarcinoma of the upper aerodigestive tract (oral cavity, phar-ynx, or larynx) and presented with stage I or II disease (as

defined by the American Joint Committee Staging criteria),diagnosed and treated within the previous 3 years. The

patients were identified from M. D. Anderson Cancer Cen-ter, the Radiation Therapy Oncology Group, and the Clinical

Community Oncology Program. These data are derived frombaseline examinations for entry into the trial that took placefrom November 1991 to July 1995.

Questionnaires that were administered at entry to the trialby a research nurse were the primary method of collectingrisk-factor data. These questionnaires comprehensively deter-

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688 Mutagen Sensitivity in tJpper Aerodigestive Tract Cancer

Table I Percentage distribution (in row percentage) of select demographic characteristics of patients by baseline smoki ng status

.Variable

Never smoker

(n = 73)Long-term quitter

(n = 292)

Recent quitter

(n 113)Current smoker

(n 134)

Overall (‘I = 612) 1 1.9 47.7 18.5 21.9

Age (years)

5�4() (It = 27) 22.2 40.8 22.2 14.8

41-50 (it 87) 13.8 31.0 25.3 29.9

SI-b)) (n = 156) 10.3 39.7 19.2 30.8

6l-7t) (it = 239 7.5 53.6 20.1 18.8

71 + (it 103) 20.4 62.1 6.8 10.7

Sex

Male (‘1 = 492) 10.0 49.8 17.9 22.3

Female (it = 20) 20.0 39.2 20.8 20.0

Ethnicity

White (0 555) I 1.7 48.3 18.7 21.3

Hispanic (it = 31) 19.4 41.9 16.1 22.6

African-American (it = 16) 5.6 33.3 22.2 38.9

Other (a - 8) 12.5 62.5 0.0 25.0

Education (years)

1-12 (it = 323) 10.2 43.7 19.8 26.3

13-16 (n = 198) 13.1 50.5 15.2 21.2

17+ (it 85) 16.5 56.4 20.0 7.1

Unknown (it = 6) 0.0 50.0 33.3 16.7

mined tobacco and alcohol consumption at baseline, as well as

before diagnosis. A self-administered food frequency question-naire (unquantified as to portion size) was used to determine

total nutrient intake during the month before the registration ofeach patient. This time frame for baseline dietary data collec-

tion is appropriate for estimating usual intake in a clinical trial.Patients have subsequent dietary assessments at years 3, 5, and7 to capture ongoing measures of usual intake while they arebeing followed in the trial. The methods used for the develop-

ment of the food frequency questionnaire are well documented(8-10). The foods included on the food list were selected from24-h recall data collected during an assessment of dietary intakein South Texas populations and from patients eligible for the

study who were selected from the Radiation Therapy Oncology

Group clinics. Other important sources of retinol and carote-noids in the American diet were identified from the published

literature, and appropriate additions were made to the final foodlist, which had 126 foods ( 1 1-13) and consisted of almost all(93%) of the food items on the Health Habits and HistoryQuestionnaire (8). The changes in the questionnaire includedthe addition of Hispanic foods, separation of fruits and vege-tables to allow the analysis of individual carotenoids, and theaddition of nutritional supplements. Validity and reliabilitystudies in several populations have documented the utility ofthe Health Habits and History Questionnaire for use in Amer-ican populations (9, 10). The patients were also asked to reporttheir use of vitamin, mineral, and fiber supplements.

Ten ml of blood were drawn into heparinized tubes forcytogenetic analyses and express mailed or hand delivered to

our laboratory at the M. D. Anderson Cancer Center. Themethodology for the bleomycin assay was described in detailpreviously (14). Briefly, 1 ml of whole blood was cultured in 9

ml of RPM! 1640 blood medium (Gibco, Grand Island, NY)with 20% FBS and 12.5 mI/liter of phytohemagglutinin (Murex

Diagnostic). After 67 h of cultivation, bleomycin (final con-centration of 30 �g/ml; Blenoxane; Nippon Kayaku Co., Ltd.)was added to the culture. Four h later, 0.04 �g/ml colcemid was

added to induce mitotic arrest. At 72 h, the cells were harvestedby conventional cell harvesting procedures. The cells were

treated with hypotonic KCI solution for I 2 mm, fixed, washed

with freshly prepared Carnoy’s mixture (methanol:acetic acid,

3: 1 v/v) and air dried on coded wet slides. The slides were thenstained with Giemsa solution. For each sample, the chromo-

some breaks in 50 metaphases were counted, and the resultswere averaged to determine the number of breaks/cell. A mm-

imum of 50 well-spread metaphases per sample was read undera X 100 dry objective to determine the frequency of spontane-ous aberrations. Gaps or attenuated regions were disregarded(2). We have demonstrated previously that scoring a minimumof 50 metaphases yields an acceptable reliability (15).

Descriptive statistics, including percentages, mean, and

SD were reported whenever appropriate. Patients were classi-fled into quintiles to study the age effect. f statistics werecomputed to assess the correlation between the categoricalvariables. Logistic regression analysis was applied for adjusting

the effect of multiple covariates on mutagen sensitivity. All Psreported were based on two-sided tests. The trial is still ongoingand blinded as to treatment arm.

Results

Baseline epidemiological data at entry into the tria] have nowbeen evaluated on 612 patients. Of these, 134 (21.9%) werecurrent smokers, 1 13 (18.5%) had quit within the previous year(recent quitters), 292 (47.7%) had quit more than 1 year pre-viously (long-term quitters), and 73 (1 1.9%) reported that they

had never smoked (never smokers; Table 1). The oldest stratum

of patients was significantly more likely to be bong-term quit-ters (62. 1%) than was the youngest stratum, of whom only

40.8% were long-term quitters (P < 0.001). The highest pro-

portions of never smokers were in the youngest (22.2%) andoldest (20.4%) age strata.

Although there were no sex differences in the proportions

of current smokers, only 10% of the male patients were neversmokers, compared with 20% of the female patients (Table 1).African-American patients were more likely to be currentsmokers (38.9%) than were subjects of other ethnic groups,although these differences were not statistically significant dueto the small numbers in some strata. The self-reported smokingstatus at baseline was validated by measuring serum cotinine

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Cancer Epidemiology, Biomarkers & Prevention 689

Table 2 No. (percentag e) of mutagen-sensitive and -insensitive subje cts by select variables

.Variable it Mean

Breaks/cellP

<1.0 �l.0

Overall 490 0.93 285 (58.2) 205 (41.8)Cancer site

Larynx 296 0.93 169 (57.1) 127 (42.9) 0.69

Oral cavity 156 0.91 95 (60.9) 61 (39.1)

Pharynx 38 1.01 21 (55.3) 17 (44.7)

Age (years)

�40 23 1.01 10 (43.5) 13 (56.5) 0.40

41-50 63 0.88 38 (60.3) 25 (39.7)51-60 122 0.91 76(62.3) 46 (37.7)61-70 199 0.97 110(55.3) 89(44.7)

71+ 83 0.89 51 (61.4) 32 (38.6)

Sex

Male 397 0.93 230(57.9) 167(42.1) 0.83

Female 93 0.94 55 (59.1) 38 (40.9)

Cigarette smoking

Neversmoked 54 1.02 21 (38.9) 33(61.1) 0.02

Long-term quitter 239 0.95 143 (59.8) 96 (40.2)

Recent quitter 93 0.88 54 (58.1) 39 (41.9)

Current smoker 104 0.88 67 (64.4) 37 (35.6)

Alcohol

Infrequent/none 95 0.97 51 (53.7) 44 (46.3) 0.39

Quit 158 0.92 89 (56.3) 69 (43.7)

Current 237 0.92 145 (61.2) 92 (38.8)

Stage

I 330 0.90 202 (61.2) 128 (38.8) 0.05II 160 0.99 83 (51.9) 77 (48.1)

Prior treatment

Surgery 120 0.80 86 (71.7) 34 (28.3) 0.00

Radiotherapy 313 0.97 170 (54.3) 143 (45.7)

Both 57 1.01 29(50.9) 28 (49.1)

levels (data not shown). Over 95% of the self-reported never

and current smokers were validated. Ninety percent of long-

term quitters were also biochemically confirmed to be non-smokers. However, only 30% of those who reported quittingwithin the past 3 months were biochemically confirmed to be

quitters. Forty-three (7%) of the patients reported using chew-ing tobacco and 12 (2%) using snuff, and 1 12 (18%) smokedpipes (data not shown).

Break/cell data were available at the time of this report on

a subset of these 612 patients (n = 490) in this ongoingchemoprevention trial. The overall percentage of sensitive in-dividuals (those having �l.0 break/cell) was 41.8% (Table 2).Patients with pharyngeab cancers and patients younger than 40years of age were more likely than patients with other subsites

of cancer and older patients, respectively, to be mutagen sen-

sitive (Table 2). The lowest breaks/cell were noted for patientswith oral cavity cancers. There were no significant differencesin the distribution of mutagen sensitivity by gender or age

categories. Alcohol use did not appear to be associated withsensitivity.

However, there were significant differences in mutagen

sensitivity by smoking status. It is interesting that 61% of neversmokers were mutagen sensitive compared with only 35.6% ofcurrent smokers, and 40.2 and 41.9% for long-term and short-term quitters, respectively (P = 0.02).

There was a tendency (P = 0.05) for patients with stage IIdisease to exhibit higher mean breaks/cell (0.99) compared with0.90 for stage I patients. There were also significant differencesin the distribution of mutagen sensitivity by prior treatment

modality (Table 2) Patients who were surgically treated were

significantly more likely to exhibit lower breaks/cell (mean

0.80) compared with means of 0.97 and 1 .01 in the patients whowere treated by radiotherapy or with combined modalities,

respectively (P = 0.001). Much of this effect was due tosite-specific differences in prior treatment modality, because

over 85% of laryngeal patients were treated only with radio-therapy, whereas 62% of oral cavity patients were treated

surgically. Patients with pharynx and oral cavity cancer whowere treated surgically had significantly lower mean breaks/cell

(0.67 and 0.79, respectively) than comparable patients treatedonly with radiotherapy (mean breaks/cell I .09 and I . I I , respec-tively). Because of the potential confounding influence of priortreatment on the cytogenetic analysis, we also categorized pa-

tients by duration since treatment, dichotomizing at 6 months.There were no significant differences in the break/cell score for

patients assessed more than 6 months after completion of ra-diotherapy (mean of 0.99) compared with those who had beentreated more recently (0.92). There was also no correlationbetween break/cell score and months since radiotherapy. In alogistic regression model, with multiple covariates, smokingstatus (never versus ever smokers) remained the most signifi-

cant predictor of the mutagen sensitivity phenotype (OR = 3.2;P = 0.01) after adjusting by stage (P = 0.03), prior treatment(surgery versus other treatments; P = 0.07), and smoking X

prior treatment interaction (P = 0.89).Current smokers had a significantly lower mean intake of

a-carotene (633 �.tg) than did never-smokers (1017 �tg) andlong-term quitters (819 pjg). Current smokers also reported

bower mean intakes of j3-carotene, lutein, and vitamin C than

did never-smokers and long-term quitters, although these dif-ferences were not statistically significant. This trend was notapparent for bycopene intake. There was a statistically signifi-

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690 Mutagen Sensitivity in Upper Aerodigestive Tract Cancer

The overall mean dietary intake of vitamin C among our3 The abbreviation used is: NHANES, National Health and Nutrition Examination

Survey.

Table 3 Me an (SD) of micronutrients by mutagen sensitivity

Micronutrients (;.cg) <1.0 Breaklcell �l.0 Break/cell P

a-carotene

f3-carotene

Lutein

Lycopene

Vitamin C

776 (727)

4337 (2992)

2434 ( I 853)

4560 (4207)

169 (106)

848 (877)

4539 (3893)

2480 (2039)

4276 (5050)

165 (104)

0.33

0.53

0.80

0.51

0.68

cant inverse association between years smoked and bycopene

intake (P = 0.04; data not shown). The prevalence of current

alcohol use at baseline was 48%. Men, on average, drank twice

as much alcohol as women (21 versus 1 1 g/day; tabular data not

shown). The prevalence of vitamin use at baseline was 53.9%.

Patients who reported taking vitamin supplements tended tohave higher mean dietary intakes of vitamin C than nonusers

did, (188 versus 159 p�g. P 0.04), respectively. These dif-

ferences probably reflect a greater health awareness in the

former group. There was a similar, but not statistically signif-

icant, pattern for lutein intake. Our eligibility requirementsprecluded participants from taking more than 25,000 lU. of

vitamin A or 30 mgs or more /3 carotene, so that supplement

intake was generally in the form of multiple vitamins.

There were no significant associations between baseline

mean intake of any of the micronutrients and breaks/cell values

(Table 3). In fact, individuals who were mutagen sensitive

reported higher mean intakes of a-carotene, /3-carotene, and

lutein than did nonsensitive patients.

Discussion

Like lung cancers, upper aerodigestive tract cancers can be

considered paradigms of tobacco-induced diseases. Although

approximately 90% of patients with upper aerodigestive tractcancers have ever smoked, a substantial proportion do quit

either at diagnosis or during therapy. Only 22% of our patients(who were diagnosed within the previous three years) were still

smoking, and 19% claimed to have recently quit but exhibited

high rates of recidivism based on cotinine assessments. Wehave shown previously that the fear of recurrent disease, the

effects of treatment, and physician advice were the most corn-mon incentives for successful smoking cessation in recently

treated patients (16). Contrary to commonly held perceptions,

Gritz et a!. ( 17) suggested that head and neck cancer patients

are willing to modify health-endangering behavior and at di-

agnosis are conducive to behavioral change.

There are epidemiologicab data to support the hypothesis

that the dietary intake of certain micronutrients has an inde-

pendent protective effect on the development of head and neck

cancer ( 1 8 -2 1 ). A nested case-control study by Zheng et a!.

(22) reported an inverse association between serum carotenoids

(especially f3-carotene) and a-tocopherob and cancer risk. A

consistent protective effect was noted for each of the individual

carotenoids, including a-carotene, cryptoxanthin, lutein, and

lycopene. In a study of 87 1 cases in four different areas of the

United States, fruit consumption had a dose-dependent protec-

tive effect on oral and pharyngeal cancer (23). A nested case-

control study evaluating the nutritional correlates of second

primary cancers reported nonsignificant, but similar, trends

(24).

patients appears to be higher than that reported in NHANES388-91 (170 versus 100-b 10 mg/day; Ref. 25). The mean intake

of vitamin A was also higher (1847 versus 1006-1193 RE/dayamong the NHANES population). However, current cigarette

smokers tended to have the lowest intake. There are no popu-lation-based data on the dietary intake of the individual caro-tenoids to compare these data. The fat calories consumed by our

population were equal to those reported in NHANES 88-91 for

adults of this age range.In vitro chromosornab analyses have been used fairly corn-

rnonby to study individual sensitivity to genotoxicity and cancerrisk and are gaining wider approval for formal hypothesis

testing by classic epidemiobogical methods. In a recently pub-bished long-term cohort study of 3182 workers occupationally

exposed to mutagenic agents and evaluated for chromosomababerrations at entry into the study, Hagmar et a!. (26) reporteda statistically significant increase in cancer risk (relative risk =

2. 1) in the highest stratum of baseline aberrations. Studies suchas this confirm the value of using chromosomal aberrations in

peripheral lymphocytes as a marker of cancer risk. Recently, weparticipated in a mubticenter meta-analysis of three case-control

studies of head and neck cancers that confirmed the robe of

bleomycin-induced mutagen sensitivity as a predictor of thesecancers and demonstrated that there were no differences across

institutions in the distribution of mutagen sensitivity and thatage and tobacco and alcohol use did not influence the mutagensensitivity values (27).

This chemoprevention trial included only early-stage pa-tients and patients who had been treated previously with sur-gery and/or radiotherapy. Our published retrospective analysisof a different series of 298 patients with previously untreatedupper aerodigestive-tract cancers of all stages at the M. D.

Anderson Cancer Center (6) documented a mean break/cellvalue of 0.98, identical to the mean value in the present series

of patients, all of whom had been treated previously. Thisfinding suggests that prior radiotherapy does not influence the

mutagen-sensitivity values. Thus, it would appear that this newseries of early-stage patients is fairly representative of all pa-

tients with upper aerodigestive-tract cancer.There were no differences in the mean breaks/cell for

laryngeal patients across any treatment arm; therefore, the sig-

nificantly lower-sensitivity values for patients treated surgicallyare intriguing. Oral cavity patients tended to have lower muta-

gen sensitivity scores and were most likely to be treated sur-gically. Furthermore, patients with oral cavity (n 96) and

pharyngeal cancers (n = 7) who were treated with surgery

alone had bower mutagen-sensitivity values (0.79 and 0.67,respectively) compared with the group of patients treated eitherwith radiotherapy alone or with combined modalities (1.1 1 for

60 oral cavity cancer patients and 1 .09 for 3 1 pharyngeab cancerpatients). This observation that the patients deemed most likelyto be curatively treated (by surgery) had the lowest mutagen

sensitivity scores needs to be confirmed in larger series ofpatients and by correlating mutagen sensitivity with diseaseoutcome.

Our observation that cancer patients who were nonsmok-ers had a higher prevalence of mutagen sensitivity than currentor former smokers suggests that nonsmokers constitute a par-ticubarly susceptible subgroup of head and neck cancer patients.

This intriguing finding was also noted in our previous head and

neck study (6), as well as in the case series reported by Schantz

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Cancer Epidemiology, Biomarkers & Prevention 691

4 Unpublished data.

et a!. (28). Free radical oxygen is generated from a variety of

both endogenous and exogenous sources besides tobacco, andindividuals with the mutagen-sensitive phenotype may be less

able to repair this free-radical oxygen damage. Our previousstudies have shown that mutagen sensitivity was a risk factor

independent of smoking status (3, 4). Furthermore, in our lungcancer studies, we have noted higher risks associated withmutagen sensitivity for former smokers compared with current

smokers and lighter versus heavier smokers (29). At bow- orno-exposure levels, a susceptible genotype or phenotype may

be more etiobogicably relevant than in heavily exposed patientsin whom exposure could overwhelm even a nonsusceptiblegenotype.

It is also important to consider the effect of antioxidants onchemicals that cause genetic damage by generating oxygenradicals. The cytotoxicity of bleomycin is due to its forming acomplex with ferrous iron and molecular oxygen. The complexintercalates into DNA, principally between GT and GC dinucle-

otides, and releases oxygen radicals. 8-Hydroxy guanosine res-idues also form. DNA is degraded by the bleomycin-ferrous

complex when a reducing agent (e.g., vitamin C) is added.

Trizna et a!. (30, 31) reported two in vitro studies demonstrat-ing that vitamins E and C protected against bleomycin-inducedbreakage in a dose-dependent manner. Pohl and Reidy (32)

showed a significant reduction in the number of bleomycin-induced chromosomal breaks in eight volunteers given supple-

mentary vitamin C (100 mg for 2 weeks and 1 g for another 2weeks). More recently, Kucuk et a!. (33) studied serial muta-

gen-sensitivity scores monthly in 25 healthy nonsmokers for 12months and noted significant correlations between certainplasma nutrient levels and the mutagen-sensitivity values.

However, our data, which are based on much larger num-

bers of patients, show no correlation between dietary intake of

any nutrient and mutagen-sensitivity scores. In a case-controlstudy of 167 head and neck cancer patients and 177 age- and

sex-matched controls, Schantz4 also observed no association

between mutagen sensitivity and dietary intake of vitamins Cand E, cryptoxanthin, or lycopene in either cases or controls. Itmust be remembered that these micronutrient data are derivedfrom dietary intake, not from plasma measures, and that dietaryintake of these antioxidants is not directly correlated with serummeasures. Plasma concentrations of carotenes reflect short- tomedium-term intake, and interindividual variation in the plasma

response to intake is substantial (34). A recent report from theUnited States Department of Agriculture-National Cancer In-

stitute database (12, 13) on the relationship between dietary

carotenoid and plasma concentrations of carotenoids indicateda significant correlation for a, f3, and total carotene (0.49; P <

0.05) (35). Vitamin C intake and plasma levels of ascorbate

typically have an S-shaped association curve. Higher intakes ofvitamin C are not well correlated with plasma levels because

excess vitamin C is excreted in the urine. Thus, these estimatesof dietary intake may better reflect true intake of vitamin C thanplasma ascorbate bevels do. Recently, Cboos et a!. showed noeffect on mutagen-sensitivity levels by the administration ofN-acetylcysteine in 19 treated patients compared with 14 un-

treated subjects (36).The underlying mechanism for mutagen sensitivity asso-

ciated with cancer proneness may reflect in part an altered

repair process. Pandita and Hittelman (37) suggested that themutagen-sensitivity phenotype may also involve an inherent

ch.romatin alteration that increases the efficiency of translating

DNA damage into chromosome damage after mutagen expo-sure. Wei et a!. (38) examined DNA repair capacity using a host

cell reactivation assay in parallel with the mutagen-sensitivityassay in 16 established lymphoblastoid cell lines, including 3head and neck cancer cell lines. Using UV radiation and nitro-

quinobine-4-oxide as the test mutagens for both assays, theyreported that reduced cellular DNA repair capacity was signif-

icantly correlated with increased frequency of mutagen-inducedchromatid breaks. This finding suggests that repair fidelity may

be impaired in hypersensitive persons.It is unlikely that head and neck cancer is caused by the

interaction of a single gene and the environment; one gene maynot have a strong effect but in conjunction with other genes mayshift the risk profile in an unfavorable direction. Therefore,

multiple susceptibility factors must be assessed to determine thetrue dimensions of gene environmental interactions. Thisknowledge is essential for the design of future epidemiological

and intervention studies. In the near future, integrated multi-disciplinary programs will seek to evaluate chemopreventive

strategies in cohorts of phenotypically normal individuals

deemed to be genetically susceptible to cancer development.

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1997;6:687-692. Cancer Epidemiol Biomarkers Prev   M R Spitz, R S McPherson, H Jiang, et al.   aerodigestive tract cancer.Correlates of mutagen sensitivity in patients with upper

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