Mechanisms and therapeutic implications of cell death induction by indole compounds.

Indole compounds, obtained from cruciferous vegetables, are well-known for their anti-cancer properties. In particular, indole-3-carbinol (I3C) and its dimeric product, 3,3´-diindolylmethane (DIM), have been widely investigated for their effectiveness against a number of human cancers in vitro as well as in vivo. These compounds are effective inducers of apoptosis and the accumulating evidence documenting their ability to modulate multiple cellular signaling pathways is a testimony to their pleiotropic behavior. Here we attempt to update current understanding on the various mechanisms that are responsible for the apoptosis-inducing effects by these compounds. The significance of apoptosis-induction as a desirable attribute of anti-cancer agents such as indole compounds cannot be overstated. However, an equally intriguing property of these compounds is their ability to sensitize cancer cells to standard chemotherapeutic agents. Such chemosensitizing effects of indole compounds can potentially have major clinical implications because these non-toxic compounds can reduce the toxicity and drug-resistance associated with available chemotherapies. Combinational therapy is increasingly being realized to be better than single agent therapy and, through this review article, we aim to provide a rationale behind combination of natural compounds such as indoles with conventional therapeutics.

Introduction

A number of natural products found in fruits and vegetables are known to possess anti-mutagenic and anti-carcinogenic properties [1,2]. Cruciferous vegetables are a rich source of many phyto-chemicals, including indole derivatives, dithiolthiones, and isothiocyanates. Indoles are natural compounds that are found in many plants but particularly associated with cruciferous vegetables such as broccoli, cauliflower, cabbage and brussels sprouts. All compounds that contain an indole ring system are indoles. Chemically, they are aromatic heterocyclic organic compounds that have a bicyclic structure, consisting of a six-membered ring fused to a five-membered nitrogen-containing pyrrole ring. A beneficial effect of high dietary intake of fruits and vegetables against carcinogenesis is known [3] and an inhibitory effect of indoles and cruciferous vegetables against tumorigenesis and risk of cancers has also been demonstrated [4,5]. Epidemiological data suggests that populations that consume higher amounts of cruciferous vegetables have lower incidence of cancer or improved biochemical parameters, such as decreased oxidative stress, compared to controls [6-8] and cruciferous vegetables protect more effectively against cancer than the total intake of fruits and other vegetables [9]. The National Research Council, Committee on Diet, Nutrition, and Cancer has recommended increased consumption of cruciferous vegetables as a measure to decrease the incidence of cancer.

Indole-3-carbinol (I3C) and its Dimer 3,3′-Diindolylmethane (DIM)

I3C is an indole found in some fruits and vegetables, including members of the cruciferous family and, particularly, in members of the genus Brassica. I3C is derived from the hydrolysis of glucobrassicin, a glucosinolate, which is predominant in Brassica vegetables including broccoli, brussels sprouts, cabbage, cauliflower, collard greens, kale, kohlrabi, mustard greens, radish, rutabaga and turnip. The stability of glucosinolates is strongly influenced by the presence of external factors, thus the amount of I3C formed from glucobrassicin in foods is variable and depends on the processing and preparation of those foods. I3C is synthesized from indole-3-glucosinolate by the action of enzyme myrosinase. The amount of I3C found in the diet can vary greatly, ranging from 20 and 120 mg daily, and is dependent on dietary intake of cruciferous vegetables and their changeable concentrations [10]. Its anti-carcinogenic effects in experimental animals [11-14] and humans [15,16] are well-documented and, therefore, I3C has received special attention as a possible chemopreventive agent [17].

I3C, in the acidic environment of the stomach, dimerizes to form a complex mixture of biologically active compounds, known collectively as acid condensation products [18]. Among them, the most prominent one is the dimer DIM which is readily detectable in the liver and feces of rodents that are fed I3C [19]. DIM accounts for about 10–20% of the breakdown products of I3C; therefore, the typical daily ingestion of I3C from the diet provides between 2 and 24 mg of DIM. I3C could not be detected in tissues of I3C-treated rodents, suggesting that DIM may mediate the physiologic effects of dietary I3C [20]. However, there is evidence to suggest that I3C, in addition to its acid condensation products, is absorbed from the gut and distributed systemically into a number of well-perfused tissues [21]. This raises the possibility for some in vivo pharmacological activity of the parent compound as well.

Induction of Cell Death by Indoles

Carcinogenesis involves perturbation of normal cellular processes with an imbalance favoring cell survival and inhibition/suppression of endogenous cell death [22]. Anti-cancer agents have been traditionally evaluated for their apoptosis-inducing action and this is true for indole compounds as well, where they have been demonstrated to inhibit the proliferation, growth and invasion of human cancer cells [2,23-25]. As a mechanism of apoptosis induction, I3C has been to shown to down-regulate anti-apoptotic gene products (Bcl-2, Bcl-XL, survivin, inhibitor-of-apoptosis protein; IAP, X chromosome-linked IAP; XIAP, Fas-associated death domain protein-like interleukin-1-beta-converting enzyme inhibitory protein; FLIP), up-regulate pro-apoptotic factors (such as Bax), release mitochondrial cytochrome C as well as activate caspase-9 and caspase-3 [26-37]. In human cancer cell models, indoles (I3C/DIM) have been shown to induce apoptosis in breast [27,28,30-34,38-42], squamous cell carcinoma [43], cholangiocarcinoma [44], colon [45-49], cervical [37,50], ovarian [51], pancreatic [52,53] and prostate [29,54-57] cancer cells.

A number of mechanisms for apoptosis-induction by indoles have been proposed such as down-regulation of NF-κB signaling [33,56,58-62], survivin [63,64] and uPA/uPAR [60,65,66]; regulation of Akt/FOXO3a/GSK-3beta/beta-catenin/AR signaling [67] and induction of p75(NTR)-dependent apoptosis via the p38 MAPK pathway [68]. In addition to I3C/DIM, other related compounds such as 1,1-bis(3′-indoly)-1-(p-substituted phenyl)methanes; p-bromo (DIM-C-pPhBr), p-fluoro (DIM-C-pPhF) and structurally related analogues have also been shown to inhibit proliferation and induce apoptosis in cancer cells [69,70].

Modulation of Pro-/Anti-Apoptotic Factors by Indoles

Our own investigations with apoptosis-induction by indoles, with focus on modulation of pro-Vs. anti-apoptotic factors have revealed that indoles can inhibit Bcl-2 and Bcl-XL protein expression in prostate and breast cancer cells [30,31]. The ratio of Bax to Bcl-2 was significantly increased after just 24 hours of treatment which corresponded with a jump in the number of apoptotic cells. These results suggest that up-regulation of Bax and down-regulation of Bcl-2 and Bcl-XL may represent molecular mechanism(s) by which indoles I3C and DIM induce apoptosis. It is believed that the ratio of Bax:Bcl-2, rather than Bcl-2 alone, is important for the survival of drug-induced apoptosis [71]. We also analyzed the intracellular movement and distribution of Bax by confocal microscopy and found Bax translocation to the mitochondria in breast cancer cells, which caused the mitochondrial depolarization and release of cytochrome c [30]. These alterations, in conjunction with alteration in Bid and Bad, contributed to the activation of caspase adapter Apaf-1 and generation of active caspases (caspase-9 and caspase-3) during I3C induced apoptosis. No apoptosis was seen in non-tumorigenic cells treated with I3C [30,31] suggesting that translocation of Bax to mitochondria activates the mitochondrial death pathway in I3C-induced apoptosis in breast cancer cells but not in non-tumorigenic breast epithelial cells. In human melanoma cells, I3C has been shown to down-regulate Bcl-2 and activate caspases (caspase-8 and caspase-3) [72]. These reports suggest that modulation of pro-and anti-apoptotic factors by indoles in such a way that results in shifting of balance towards pro-apoptotic factors is one way by which these compounds ensure efficient induction of cell death in cancer cells.

Inhibition of NF-κB Signaling by Indoles

NF-κB is a transcription factor important for the processes of cell growth, invasion and metastasis [73-78]. It exists in a latent state in the cytoplasm bound to specific inhibitory proteins, IκBs. Many pro-survival stimuli cause IKK-dependent phosphorylation and subsequent proteasome-mediated degradation of IκB proteins. Degradation of inhibitory IκB proteins results in the release of NF-κB and this activated NF-κB migrates into the nucleus to regulate the transcription of multiple target genes which influence the various stages of carcinogenesis and cancer progression [79,80]. In a study comparing the effect of I3C treatment on estrogen receptor-α-negative MDA-MB-468 breast cancer cells vs. immortalized non-tumorigenic HBL100 cells [41], phosphatidylinositol 3′-kinase (PI3-K) and protein kinase B (PKB)/Akt were identified as targets of I3C. I3C was found to inhibit phosphorylation and activation of PKB in MDA-MB-468 cells but not in the HBL100 cells. I3C decreased NF-κB-DNA binding, but no decrease was observed in IKK activity or the nuclear levels of NF-κB (p65) suggesting that I3C affected DNA binding of NF-κB protein family members, including p65 and p50, by a mechanism that did not involve inhibition of IKK activity. I3C was also shown to decrease phospho-Akt levels and induce apoptosis in the prostate cell line LNCaP [41]. Our own results established a direct cross-talk between Akt and NF-κB pathways in breast cancer cells [32]. We have also demonstrated a similar anti-cancer activity of indole DIM [33]. We showed that DIM is able to induce apoptosis in MCF10A derived malignant cell lines but not in non-tumorigenic parental MCF10A cells. DIM also specifically inhibited Akt kinase activity and abrogated the epidermal growth factor-induced activation of Akt. Further, we found that DIM inhibited IκBα phosphorylation, and blocked translocation of p65 subunit of NF-κB to the nucleus. Our in vitro as well as in vivo data showed, for the first time, that the inactivation of Akt and NF-κB activity plays a very crucial role in apoptosis induced by indole compounds in breast cancer cells.

A cancer-cell specific action of DIM has also been reported in prostate cells and DIM has been shown to induce apoptosis in PC-3 prostate cancer cells but not in non-tumorigenic CRL2221 human prostate epithelial cells through inhibition of PI3K kinase activity as well as Akt activation [81]. DIM treatment inhibits DNA binding activity of NF-κB leading to down-regulation of its downstream target genes such as VEGF, IL-8, uPA, and MMP-9, all of which are involved in angiogenesis, invasion, and metastasis [60]. In a study that directly compared the efficacy of I3C and DIM, it was reported that DIM is a better anti-proliferative agent than I3C in androgen-dependent LNCaP cells [82] as well as androgen-independent DU-145 cells [83] and down-regulates phosphorylated Akt and PI3-K, both of which are connected to NF-κB signaling [84]. In pancreatic cancer model, it has been shown that DIM potentiates the killing of pancreatic cancer cells by down-regulation of constitutive as well as drug-induced activation of NF-κB and its downstream genes [53]. Such action of DIM was found to be relevant in vivo as well, with significantly reduced tumor burden. Further, in an interesting report detailing the role of microRNAs (miRNAs) in DIM-mediated inhibition of pancreatic cancer cells, it has been shown that treatment with DIM leads to up-regulation of miR-146a expression resulting in down-regulation of EGFR and NF-κB which leads to inhibition of pancreatic cancer cell aggressiveness [85].

There are reports in literature which provide a hint that indoles modulate NF-κB signaling in several other cancers as well. One such activity of I3C has been reported in myeloid and leukemia cells where this indole suppressed constitutive as well as tumor necrosis factor (TNF)-induced induction of NF-κB [86]. I3C was found to down-regulate all the downstream signaling molecules suggesting a very potent inhibition of NF-κB signaling pathway by this indole. In cholangiocarcinoma cells [44], DIM has been shown to inhibit Akt phosphorylation and NF-κB, and, recently, DIM has been shown to be protective against tumor progression in skin through inhibition of NF-κB signaling pathway [87]. All these events suggest an effective inhibition of NF-κB pathway by indoles leading to the observed anti-tumor effects. Thus, a number of research reports have identified inhibition of NF-κB signaling as an important mechanism in the killing of cancer cells by indoles.

Down-Regulation of Survivin by Indoles

Survivin plays an important role in multiple cellular processes that are essential for tumor cell proliferation and viability [88]. It is expressed in most human cancers [89], is an inhibitor of caspase-9 [90], and is, therefore, a potent therapeutic target against cancers [91,92]. Since the first report [86] on down-regulation of survivin by indole I3C, a number of other reports, including some from our own laboratory, have provided mechanistic details of down-regulation of survivin by indole compounds which seems to be important for their ability to induce apoptosis. Our microarray gene profiling analysis identified survivin as a gene down-regulated by DIM-treatment and we found that down-regulation of survivin by small interfering RNA prior to DIM treatment, in breast cancer cells, resulted in increased cell growth inhibition and apoptosis, whereas over-expression of survivin by cDNA transfection abrogated DIM-induced cell growth inhibition and apoptosis [34].

In prostate cancer model, we observed that DIM enhanced taxotere-induced apoptotic death in both LNCaP and C4-2B prostate cancer cells [63]. These enhancing effects were related to decreased survivin expression as well as significantly reduced DNA-binding activity of NF-κB. A combination of DIM and taxotere significantly inhibited C4-2B bone tumor growth through the down-regulation of survivin and NF-κB activity. Similarly, in colon cancer cells there is evidence to indicate down-regulation of survivin by DIM [64]. Further, synthetic analogs of DIM (DIM-C-pPhBr and 2,2′-diMeDIM-C-pPhBr) have also been shown to induce apoptosis in various cancer cells through down-regulation of survivin at both mRNA and protein expression levels [93]. Thus, there is ample evidence to suggest that indole compounds such as DIM, and its analogs, effectively down-regulate survivin which serves as one important mechanism responsible for their apoptosis-inducing activity.

Inhibition of Invasion and Metastases by Indoles

Indoles, I3C and DIM, can inhibit the invasion of cancer cells [94-96] and development of new blood vessels (angiogenesis) [60,97]. There is evidence supporting a critical role of angiogenesis in tumor growth, metastasis [98,99] and a study by Chang and coworkers [100], to test the effect of DIM on angiogenesis and tumorigenesis in a rodent model, found that DIM produced a concentration-dependent decrease in proliferation, migration, invasion and capillary tube formation of cultured human umbilical vein endothelial cells (HUVECs). Another study described that I3C can significantly inhibit cell adhesion, spreading and invasion associated with an up-regulation of PTEN (a tumor suppressor gene) and E-cadherin (a regulator of cell-cell adhesion and indicator of epithelial phenotype) expression in T47D human breast cancer cells [95]. In another study by the same group, it was reported that I3C significantly causes a dose-dependent increase in E-cadherin, three major catenins (alpha, beta, and gamma-catenin) and BRCA1 expression, suggesting that I3C can activate the function of invasion suppressor molecules associated with the suppression of invasion and migration in breast cancer cells [96].

In a study investigating the role of angiogenic factors secreted by prostate cancer cells with a view to explore the molecular mechanism by which DIM inhibits angiogenesis and invasion, Kong et al. [60] reported that DIM could inhibit angiogenesis and invasion by reducing the bioavailability of vascular endothelial growth factor (VEGF) via repressing extracellular matrix-degrading proteases, such as matrix metalloproteinase (MMP)-9 and urokinase-type plasminogen activator (uPA). As a mechanism it was suggested that DIM treatment inhibited DNA binding activity of NF-κB and this contributed to the regulated bioavailability of VEGF by MMP-9 and uPA which, in turn, negatively influenced the processes of invasion and angiogenesis. Subsequently, it was reported [97] that DIM could inactivate both mammalian target of rapamycin (mTOR) and Akt activity in PDGF-D-over-expressing prostate cancer cells, PC3. PC3 cells stably transfected with PDGF-D cDNA exhibit increased growth and proliferation rates and enhanced cell invasion that is associated with the activation of mTOR and reduced Akt activity. Rapamycin represses mTOR activity resulting in the activation of Akt, which could attenuate the therapeutic effects of mTOR inhibitors. DIM is a better therapeutic agent in this setting because it can significantly inhibit both mTOR and Akt in PC3-PDGF-D cells, which can be correlated with decreased cell proliferation and invasion. CXCR4 in the tumor microenvironment may function to promote breast and prostate cancer proliferation, migration, and invasion, and our published data suggests that I3C could interrupt CXCR4/SDF-1α signaling pathway, resulting in tumor growth inhibition of breast cancer bone metastasis [101]. These results further extend the potential therapeutic application of I3C for metastatic cancer. Modulation of CXCR4 and CXCL2 levels has also been suggested as a possible mechanism by which DIM can lower the invasive and metastatic potential of different human cancer cells [102,103].

In an in vivo lung metastasis model [104], it has been shown that gavage with DIM can inhibit the lung metastasis of 4T1 mouse mammary carcinoma cells with concomitant reduction in the levels of MMP-2, MMP-9, tissue inhibitor of metalloproteinase (TIMP)-1, vascular cell adhesion molecule (VCAM)-1, interleukin (IL)-1beta, IL-6 and tumor necrosis factor (TNF) alpha. To further elucidate the mechanism of inhibition of invasion and metastasis in prostate [65] as well as breast [66] cancer cells, we investigated the role of urokinase-type plasminogen activator, uPA, and its receptor, uPAR in DIM-mediated inhibition of cancer cell growth and motility. Our studies revealed that DIM treatment leads to down-regulation of uPA as well as uPAR in highly aggressive cancer cells (prostate-PC3 and breast-MDA-MB-231) leading to inhibition of proliferation, growth as well as migration and invasion of these cells. Furthermore, while analyzing microarray data, we found down-regulation of Forkhead Box M1 (FoxM1) in DIM-treated breast cancer cells [34]. To confirm the alternations of FoxM1 expression after DIM treatment in MDA-MB-231 breast cancer cells, we conducted real-time reverse transcription-PCR analysis for the FoxM1 gene [34]. The altered mRNA expression of FoxM1 was observed as early as 24 hours after DIM treatment and was significantly more evident after 48 hours treatment [34]. The results of RT-PCR analysis for FoxM1 suggest that DIM could regulate the transcription of genes involved in angiogenesis, tumor cell invasion and metastasis. Thus, indole compounds hold a lot of promise as anti-cancer agents because of their ability to inhibit the processes of invasion, metastasis and angiogenesis in multiple cancer models.

Cancer Therapy: The Problem of Drug-Resistance

While a number of therapeutic options are available for cure of various cancers, a major clinical problem is the development of drug-resistance. Resistance to anticancer drugs can broadly be classified into two categories: intrinsic and acquired resistance [105]. Intrinsic resistance tends to make anticancer therapy ineffective from the very first dose because of the inherent ability of tumor cells to demonstrate resistance against the therapy. However, it is frequently observed that cancers which seem to respond initially to conventional therapeutic drugs eventually become refractory to the same drug. This kind of drug-resistance which develops on sustained exposure to drugs is termed acquired resistance. For the purpose of this review article, we will only focus on acquired drug-resistance. Not much is known regarding the mechanism(s) that lead to development of acquired drug-resistance and although several mechanisms have been proposed for this phenomenon [106,107], the problem remains one of the most daunting task in the management of cancer patients in the clinics. When cancer cells initially show sensitivity to anti-cancer therapy and acquired resistance develops during the treatment, this leads to much aggressive tumor which is also characterized by tumor recurrence and metastasis. As such, increasing the drug sensitivity is a major goal of the current anti-cancer research. Although use of combinational anti-cancer therapy has been advocated, this often results in increased toxicity. It is now increasingly being believed that natural compounds, such as indoles, which induce apoptosis in human cancer cells without causing unwanted toxicity in normal cells, could be useful in combination with conventional chemotherapeutic agents for the treatment of human malignancies with diminished toxicity and higher efficacy [23]. In the next section, we will summarize how the apoptosis-inducing activity of indole compounds has been reported to increase sensitivity to conventional chemotherapeutic drugs in various cancers, both in vitro and in vivo.

Chemosensitization by Indole Compounds

Chemosensitization is the process by which compounds, such as the indoles I3C/DIM, modulate cellular signaling pathways leading to apoptosis and thus overcoming the chemo- as well as immuno-resistance of established chemotherapeutic drugs [108] (Figure 1). I3C has been reported to sensitize multidrug resistant tumors to chemotherapeutic drugs without any associated toxicity [109]. FoxM1 is an oncogenic transcription factor in aggressive human breast cancers [34,110] and we have recently showed that targeting FoxM1 by DIM enhances sensitivity of breast cancer cells to chemotherapeutic agents such as taxotere [111]. This is in continuation of our previous studies where we observed an ability of DIM to sensitize breast cancer cells to taxotere [112]. We found that a combination treatment with DIM and taxotere resulted in a significantly greater inhibition of cell growth compared with either agent alone, and induced enhanced apoptosis compared with single agent treatments. These results were further supported by in vivo studies, which showed that DIM sensitized the breast tumors to taxotere, resulting in greater antitumor activity. Our recent investigations also revealed that DIM could sensitize breast cancer cells to Herceptin (unpublished data). Inhibition of NF-κB was found to be crucial to this chemosensitizing activity of DIM. Such inhibitory effect of DIM on NF-κB activity has since been described for other cancers as well, such as, pancreas [53,113] and squamous cell carcinoma [43], leading to sensitization to drugs. This is in line with the notion that Akt-NF-κB nexus plays a role in resistance of cancer cells to chemotherapy [114]. Additionally, in prostate cancer cells [63], we have demonstrated such chemosensitization activity of DIM against hormone-refractory prostate cancer (HRPC), in context of anticancer activity of taxotere. Thus, our results in breast as well as prostate cancer models suggest a potent chemosensitization potential of indole DIM towards the anticancer activity of taxotere.

Figure 1.

Mechanisms of anticancer and chemosensitizing effects of Indole compounds. Indole compounds, such as I3C and its dimmer DIM, induce apoptosis through inhibition of several pro-survival pathways. Emerging evidence also documents the ability of indoles to reverse the process of EMT via regulation of key miRNAs. An efficient induction of apoptosis and reversal of EMT not only ensures increased sensitivity to conventional drugs (chemosensitization) but also results in significantly reduced invasion and metastasis.

In addition to chemosensitization to taxotere-induced cell death, DIM has been shown to sensitize cancer cells to other drugs as well. For example, it has been reported that a combination of DIM and paclitaxel results in significantly increased apoptosis, compared to either agent alone [115]. The combination of DIM and paclitaxel also resulted in down-regulation of anti-apoptotic Bcl-2. In pancreatic cancer model, there is in vitro and in vivo evidence in support of DIM-mediated chemosensitization [53,113]. In these studies, similar to our studies involving chemosensitization to taxotere, down-regulation of NF-κB signaling was identified as a key mechanism responsible for the chemosensitization activity of DIM when combined with either erlotinib [113] or cisplatin, gemcitabine and oxaliplatin [53]

Indole Compounds in Combinational Therapy

I3C has been shown to foster the activity of tamoxifen in DMBA-initiated mammary tumors in mice [116]. Although the individual activity of I3C was observed to be much less compared to that of tamoxifen, but in combination, it enhanced the effectiveness of tamoxifen. Earlier, a combination of I3C and tamoxifen was reported to inhibit the growth of MCF-7, the estrogen receptor-positive breast cancer cells, more effectively than either agent alone [36]. The combination was found to cause an effective cell cycle arrest leading to the observed effects. It was reported that I3C and tamoxifen work through distinct signal pathways and, therefore, may, represent a potent and effective combinational therapy. The indole DIM can synergistically inhibit growth of Her2-expressing breast cancer cells [115] through cell-cycle arrest and induction of cell death, in combination with paclitaxel, by modulating Her2-mediated cellular signaling that involves ERK1/2 which demonstrates that DIM may potentially be a beneficial addition to a traditional (taxane-based) chemotherapy regimen. In pancreatic cancer cells MiaPaca2 and SU86.86, I3C has been shown to lower the LD50 of gemcitabine, as measured by decreased growth [117]. In MiaPaca2 cells, I3C reactivated the tumor suppressor gene p16INK4a through the demethylation of its promoter region suggesting that a combination of I3C and gemcitabine can be a powerful strategy for treating pancreatic cancer. As discussed above, our own studies have shown a cytotoxic action of DIM in synergy with chemotherapeutic agent taxotere in breast as well as prostate cancer models [63,111,112]. We have also tested the effect of DIM plus taxotere on the expression of transcription repressors associated with Epithelial-Mesenchymal Transition (EMT), as well as mesenchymal and epithelial markers in MDA-MB-231 and MDA-MB-468 breast cancer cells. Our results showed that expression of vimentin was significantly inhibited by DIM in combination with taxotere, while the expression of E-cadherin was increased in MDA-MB-468 breast cancer cells (unpublished data). Recently, we evaluated the effects of DIM in combination with Herceptin using Herceptin-sensitive and Herceptin-resistant breast cancer cells. Our mechanistic investigations suggest that a great number of breast cancer cells could be killed by DIM in combination with Herceptin (unpublished data). We also found that DIM plus Herceptin could reverse EMT phenotype by modulating miR-21 expression (unpublished data). We believe that combination of DIM and Herceptin is more potent than individual compounds, which could maximize the effect of Herceptin-based therapies. Interestingly, other researchers have demonstrated such action of I3C where this indole enhanced doxorubicin as well as cisplatin-induced cytotoxicity [86]. It, thus, appears that, in addition to chemosensitization, indole compounds also enhance the cell growth inhibiting and apoptosis-inducing cytotoxic potential of widely used chemotherapeutic drugs. Since most of the cellular signaling action of indole compounds is independent of cell type or the cancer, this property of indole compounds might be of particular interest to clinicians. Through further detailed mechanistic studies, it might be possible to work out optimum doses of indole compounds that might be clinically relevant in enhancing the efficacy of chemotherapeutic drugs. It might even be possible to reduce the administered doses of chemotherapeutic drugs, and the associated toxicity, by combining common drugs with indole compounds in the chemotherapeutic regime.

Conclusions and Perspective

With all the advancements in cancer research, a number of therapeutic drugs have been approved for treatment of specific cancers. A majority of these compounds exert their biological activity through induction of apoptosis. Since tumors are characterized by disturbed cellular signaling which supports pro-survival pathways, the apoptosis-inducing activity of drugs is very crucial to their efficacy. In addition to all the compounds that have been investigated/approved for cancer treatment, there is a parallel world of natural compounds which is based on knowledge from traditional and cultural medicines. Natural compounds have attracted a lot of research attention, primarily due to their pleiotropic effects whereby they can effectively target multiple signaling pathways. This is demonstrated by studies with indole compounds, as discussed above, because these compounds clearly possess an ability to modulate multiple cellular signaling pathways such as Akt, NF-κB, FoxM1, uPA-uPAR, survivin, Bcl-2, GSK-3beta/beta-catenin etc. Such modulation of multiple signaling pathways is in stark contrast to action of conventional chemotherapeutic drugs/compounds which generally target only a single cellular target/pathway. While efficient inhibition of a single target/pathway usually results in efficient slow down of cancer progression initially, cancer cells are notoriously known to switch their dependence for survival on alternate pathways. As such, indole compounds, with their ability to modulate multiple targets, particularly the several cross-talking pathways, cross across as promising agents against progression of various cancers (Figure 1).

Of particular interest to clinicians is the ability of indole compounds to chemosensitize cancer cells to the standard chemotherapeutic regimes. For instance, the indole DIM has been demonstrated to chemosensitize human cancer cells to different chemotherapeutic drugs such as taxotere, paclitaxel, oxaliplatin, gemcitabine, erlotinib etc. The reason for increased interest in such chemosensitization activity stems from the realization that, in the presence of a chemosensitizing agent such as an indole compound, the standard chemotherapeutic drug can be used at a significantly reduced dosage which reduces its associated toxicity. In addition to increasing the efficacy of chemotherapeutic drug, indole compounds have been shown to increase the sensitivity of cancer cells to radiation therapy as well [93].

Although many studies, as discussed here, underline the chemopreventive and therapeutic properties of indole compounds against progression of human cancers, there are some reports that have actually shown opposite effects of I3C [118]. Such studies have documented different effects of I3C, ranging from no protection against progression of chemically induced carcinogenesis [119,120] to actual promotion of tumorigenesis [121-124]. These early reports cautioned the indiscriminate use of I3C as an anticancer agent, however, more detailed studies in the last decade have provided evidence in support of a potent anticancer action of this compound in vitro as well as in vivo. A recent study [125] suggested liver tumor-promoting effects of I3C through production of reactive oxygen species (ROS). Since there is evidence in literature documenting ROS-producing prooxidant effect of natural chemopreventive agents through mobilization of chromatin-associated transition metal copper, resulting in cell death and anticancer action [126-128], it would be interesting to further characterize the prooxidant activity of indole compounds that might be responsible for their anticancer potential.

With all the promising results emerging from studies on indole compounds, there are a few roadblocks in the development of these compounds into clinically relevant drugs. The most important among these is the issue of bioavailability. Some of the in vitro effects of these compounds are difficult to replicate in vivo because many in vitro studies are carried out with such high concentrations of compounds that are physiologically impossible to achieve. Even in this context, the chemosensitizing activity of indole compounds is still relevant because most of the studies demonstrating such action of these compounds have actually reported suboptimal, physiologically attainable doses which by themselves are just not enough to induce significant biological effect but are still able to modulate cellular signaling targets/pathways so as to significantly enhance the efficacy of targeted drugs. Nano-chemoprevention is one way which might be relevant to the issue of bioavailability of these natural compounds [129]. Another approach to ensure increased clinical relevance of indole compounds is by way of synthesizing novel synthetic analogs [69,70,93,130].

Recently, there have been reports on the ability of indole compounds, especially DIM, to modulate novel microRNAs (miRNAs) [85,131] as well as the process of EMT [131]. Since miRNAs and EMT have themselves been implicated in the progression to drug-resistant phenotypes [132-134], their modulation by indole compounds defines one more mechanism through which these natural compounds might be relevant for chemosensitization against acquired drug-resistance (Figure 1). Clearly, the results from numerous in vitro studies have not yet been able to translate into clinics for the management of cancer patients but the preliminary results are encouraging and with the emergence of more mechanistic studies detailing the anticancer efficacy of indole compounds, the future looks brighter than ever before.