Copyright ©The Author(s) 2021.
World J Clin Oncol. Jul 24, 2021; 12(7): 522-543
Published online Jul 24, 2021. doi: 10.5306/wjco.v12.i7.522
Table 1 Mode of action of the chemotherapeutic agents and cellular and molecular mechanism of action of the combination treatment in preclinical and clinical studies
Chemotherapeutic agent
Mode of action
Patients or animal model or cell lines
Cellular and molecular mechanism of action of the combination treatment
CyclophosphamideAlkylates guanine base and causes the formation of DNA crosslinks leading to cell deathSKBR-3 and MDA-231 breast cancer cellsIncreases the percentage of cells in G1 and sub- G1 phases. Downregulates the phosphorylation of Akt and the expression of cyclin D1 and upregulates PTENEmadi et al[25], Khan et al[27]
TemozolomideMethylates DNA at specific sites on guanine and adenine bases causing cell demiseU87MG human glioblastoma multiforme cellsIncreases the mitochondrial membrane potential disruption, cytochrome c release, ROS generation, DNA fragmentation and Bax/Bcl-2 ratio. Activates p53, caspases 9 and 3 and reduces NO and GSH levels. Reduces the expression and secretion of MMP-2 and MMP-9. Downregulates beclin-1 and ATG-7Stupp et al[29], Khazaei et al[32], Pazhouhi et al[33], Pazhouhi et al[35]
CisplatinInteracts with purine bases and forms DNA crosslinks resulting in cell deathID8-NGL mouse ovarian cancer cells. OVCAR3 and NCI/ADR-RES human ovarian cancer cells. BL/6 mice injected with ID8-NGL cellsIncreases the level of Bax, pH2AX (ser139), cleaved caspase 3 and PARP. Decreases the level of PCNA and Ki67Siddik et al[36], Wilson et al[39]
Eca-109 human esophageal cancer cells. BALB/c nude mice inoculated with Eca-109 cellsDecreases the expression of p-STAT3, p-JAK2, Bcl-2, survivin and cyclin D1. Increases the expression of Bax and activates caspases 3, 7 and 9. Induces chromatin condensation and nuclear fragmentationHu et al[40]
NCI-H460 non-small lung cancer cells. SCID mice injected with NCI-H460 cancer cellsReduces the ratio of phosphor-Ser529 NFkB/NFkBJafri et al[42]
UMSCC-14C head and neck squamous cancer cells and normal oral epithelial cellsIncreases p53 and caspase 9 expression. Decreases Bcl-2 expressionAlaufi et al[43]
SGC-7901 human gastric cancer cells. BALB/c mice implanted with gastric cancer cellsIncreases the level of Bax, AIF, cytochrome c, cleaved caspases 9 and 3. Decreases the level of cyclin D1, Bcl-2, procaspases 9 and 3. Inhibits PI3K/Akt signaling pathway and downregulates P-gp by upregulating PTENMa et al[44]
5-FluorouracilA pyrimidine analogue inhibiting the activity of thymidylate synthase enzyme causing the disruption of DNA synthesis and cell deathBGC-823, SGC-7901, MGC-803 and HGC-27 human gastric cancer cells. BALB/c athymic nude mice inoculated with gastric cancer cellsIncreases the release of mitochondrial cytochrome c and the level of Bax, caspases 3 and 9. Decreases the level of Bcl-2 and induces nuclear fragmentation and chromatin condensationWilson et al[45], Lei et al[48]
Azoxymethane-induced colorectal tumors in Wistar ratsIncreases the expression of DKK-1, CDNK-1A, TGF-β1, TGF-βRII, Smad4 and GPx. Decreases the expression of Wnt, β-catenin, NFκB, COX-2, iNOS, VEGF and TBRASKensara et al[49]
HCT116, HT29 and SW620 human colon cancer cellsSW837 rectal cancer cells. Normal human intestinal epithelial cells. CAM tumors derived from HCT116 cellsDownregulates Wnt/β-catenin and PI3K/Akt pathwaysNdreshkjana et al[50]
FADU nasopharyngeal cancer cellsDecreases the level of GSHWilliams et al[51]
MG63 human osteosarcoma cellsSarman et al[52]
GemcitabineA deoxycytidine analog preventing chain elongation during DNA synthesis causing cell deathPANC-1 and MIA PaCa-2 human pancreatic cancer cellsDownregulates PKM2 and decreases the expression of procaspase 3 and PARPMoysan et al[53], Pandita et al[56]
PANC-1, BxPC-3, and AsPC-1 human pancreatic cancer cell lines. BALB/c nude mice injected with PANC-1 cellsDownregulates Notch1, NICD, Bcl-2, Bcl-xL and XIAP. Inactivates Akt/mTOR/S6 signaling pathway and decreases the phosphorylation and nuclear translocation of p65. Upregulates PTEN, caspases 3 and 9 and Bax and increases cytochrome c releaseMu et al[57]
MCF-7 and T47D human breast cancer cellsIncreases pre-G1 cell populationBashmail et al[58]
PaclitaxelInhibits microtubules disassembly and induces mitotic arrest4T1 mouse breast cancer cells. Ehrlich tumor cells. Balb/c mice injected with Ehrlich tumor ascites cellsIncreases the level of full length and cleaved caspases 3, 7 and 12 and PARP. Reduces phosphorylated p65 and Akt1. Modulates genes involved in apoptosis, cytokine -cytokine receptor interaction, Fas signaling, p53 signaling and JAK/STAT signalingOjima et al[59], Şakalar et al[63]
MCF-7 and T47D human breast cancer cellsIncreases pre-G1 cell population. Increases the level of cleaved caspase 3 and PARP and the expression of beclin-1 and LC3-IIBashmail et al[64]
MCF-7 human breast cancer cellsSoni et al[65]
DocetaxelInhibits microtubules disassembly and induces mitotic arrestDU-145 human prostate cancer cellsBlocks PI3K/Akt signaling pathway and induces DNA fragmentationOjima et al[59], Dirican et al[69]
DU-145 and C4-2B human prostate cancer cellsInhibits PI3K/Akt signaling pathway. Increases the expression of Bax, Bid, caspase 3 and PARP and decreases the expression of Bcl-xLSingh et al[70]
MCF-7 and MDA-MB-231 human breast cancer cellsInduces DNA damage, cells shrinkage, nuclear fragments, apoptotic bodies and cytoplasmic vacuolationAlkhatib et al[71]
MCF-7 and MDA-MB-231 human breast cancer cellsZafar et al[72]
MCF-7 and MDA-MB-231 human breast cancer cells. Balb/c mice healthy or injected with Ehrlich ascites carcinoma cellsInduces nuclear fragmentation and restores the levels of oxidative stress parameters MDA, SOD and GSH. Prevents the alteration of blood cell count and serum biochemical parameters AST, ALT, creatinine and BUNZafar et al[73]
MCF-7 breast cancer cellsOdeh et al[74]
CabazitaxelInhibits microtubules disassembly and induces mitotic arrestMCF-7 and MDA-MB-231 human breast cancer cellsInduces DNA fragmentation and increases the sub-G1 populationOjima et al[59], Kommineni et al[78]
Doxorubicin Intercalates DNA, inhibits topoisomerase II, forms free radicals when reduced leading to cell cycle arrest and cell deathHuman HTLV-1 positive (HuT-102) and HTLV-1 negative (Jurkat) CD4+ malignant T-cell lines. NOD/SCID mice inoculated with HuT-102 tumor cellsIncreases the sub-G1 population and induces ROS production. Disrupts the mitochondrial membrane potential. Downregulates the expression of NFkΒ and Ki67 and increases the phosphorylation of p53Meredith et al[79], Fatfat et al[83]
HL-60 acute myeloid leukemia cells. Dox resistant HT-29 colon carcinoma cells. MCF-7/TOPO multi-drug resistant breast cancer cellsInduces caspases 3 and 8 activity and ROS generation. Disrupts the mitochondrial membrane potentialEffenberger-Neidnicht et al[84]
BALB/c OlaHsd-foxn1 nude mice injected with MDA-MB-231 breast cancer cellsInduces p38 MAPK phosphorylation and inhibit the expression of XIAP, survivin, Bcl-xL and Bcl-2Woo et al[85]
SMMC-7721 and HepG2 hepatocarcinoma cells and human normal liver cells HL-7702Increases caspase 3 and PARP cleavageJehan et al[86]
MDA-MB-231 human breast cancer cells. MCF-10A and 3T3 non-neoplastic cellsInduces cell shrinkage, membrane blebbing and apoptotic bodies and disrupts the cell membrane. Increases the Sub-G0 populationIbiyeye et al[87]
MCF-7 human breast adenocarcinoma and HEPG2 human hepatocellular carcinoma. Albino mice implanted with Heps murine liver cancer cellsDecreases NFkB level and increases that of caspase 3. Increases the level of renal antioxidant enzymes SOD and catalase. Modulates the level of renal oxidative stress biomarkers GSH and MDA. Decreases the level of nephrotoxicity biomarkers BUN and serum creatinineZidan et al[88]
Albino transplanted with Ehrlich carcinoma cellsUpregulates p53 and reduces the level of Bcl-2. Decreases the level of cardiac MDA. Decreases the serum level of cardiac markers lactate and creatineEl-Ashmawy et al[89]
TopotecanInhibits DNA topoisomerase I and causes the formation of irreversible DNA double stranded breaks resulting in cell death. Inhibits hypoxia-inducible factor 1αU937 acute myelogenous leukemia cellsIncreases the sub-G1 population. Increases the expression level of Bax/Bcl-2, p53 and p21 and the cleavage of caspases 3 and 9Robati et al[90], Khalife et al[95]
HT-29 human colon cancer cellsIncreases the sub-G1 population. Has no effect on p53, Bax and Bcl-2 expressionKhalife et al[96]
BortezomibInhibits the proteasomeU266, H929, KMS, RPMI-8226, RPMI-8226-Dox-6 (doxorubicin-resistant clone), RPMI-8226-LR-5 (a melphalan-resistant clone) human multiple myeloma cells. Balb/c mice implanted with U266 cellsIncreases the sub-G1 population and the cleavage of caspase 3 and PARP. Reduces the phosphorylation of NFkB (p65) and the expression of Ki67, VEGF, Bcl-2 and the serum levels of IL-6 and TNF-αSiveen et al[99]
ImatinibInhibits tyrosine kinaseHCT116 human colorectal cancer cellsDecreases the expression of ABCB1, ABCG2 and hOCT1. Increases the uptake/efflux ratio of imatinibThabet et al[103]
TamoxifenCompetes with estrogen and estradiol for the binding to their receptors and modulates their signaling pathwayMCF-7 and MDA-MB-231 human breast cancer cellsDay et al[104], Ganji-Harsini et al[106]
MCF-7, MDA-MB-231, MDA-MB-468, T47D, NIH/3T3 and HaCaT human breast cancer cells. Athymic BALB/c mice injected with MDA-MB-231 cellsDecreases the expression of XIAP and the level of p-Akt, p-Bad, p-MAPK and p-GSK-3β and downregulates the expression of Bcl-xL, Bcl-2 and Ki67. Increases the cleavage of caspase 9 and PARP and induces the expression of Bax, AIF, cytochrome c and p27. Increases the percentage of cells in sub-G1 phase and the fragmentation of DNARajput et al[107]
Breast cancer patientsIncreases the tumor tissue catalase, SOD and caspase 3. Decreases the tumor tissue Bcl-2, TGF-β1, MDA, TNF-α and IL-6Kabel et al[108]
Zoledronic acidInhibits osteoclast-mediated bone resorptionPC-3 and DU- 145 human prostate cancer cellsIncreases DNA fragmentation and activates caspases 3 and 7Polascik et al[109], Dirican et al[112]
Arsenic trioxideHuman HTLV-I positive (HuT-102 and C91) and HTLV-I negative (CEM and Jurkat) malignant T-cell lines. NOD SCID mice inoculated with HuT-102 cellsIncreases the percentage of cells in Pre-G1 phase, the disruption of the mitochondrial membrane potential and the cleavage of PARP and caspase 3. Upregulates p53, Bax and downregulates XIAP and Bcl- 2Houssein et al[117]
Table 2 Cellular and molecular mechanism of action of the combination treatment in preclinical studies
Therapeutic agent
Animal model or cell line
Cellular and molecular mechanism of action of the combination treatment
RadiationMCF-7 and T47D human breast cancer cellsIncreases the percentage of cells in sub-G1 phaseVelho-Pereira et al[121]
MCF-7 and MDA-MB-231 human breast cancer cellsRestores the expression levels of TGF-β and its downstream molecules NFkB, Smad2, Snail and Twist, adhesion molecules E-cadherin and cytokeratin 19, mesenchymal markers integrin αV, MMP-9, and MMP-2Rajput et al[122]
B16-F10 melanoma cellsInhibits the phosphorylation of JAK2 and STAT3. Increases the expression of caspase 3 and Bax. Reduce the expression of Bcl-2 and survivin and the level of VEGF-A, MCP-1, TGF-β1, RANTES and IL-1β. Induces DNA damageHatiboglu et al[123]
microRNA-34aBT-549 metastatic breast cancer cellsTargets and downregulates TWIST1 and ZEB1Imani et al[126]
Akt-siRNAAkt-overexpressing MCF-7 and T47D. Tamoxifen resistant MCF-7 and T47D breast cancer cells. BALB/c mice injected with MCF-7/TAM cellsReduces Akt expression and MDM-2 activation. Activates p53, increases the level of Bax and Bim and decreases the level of Bcl-2 and Ki67Rajput et al[127]
Vitamin D3Azoxymethane-induced colorectal tumors in Wistar ratsReduces the level of Wnt, β-catenin, NFkB, COX-2, iNOS, VEGF and HSP-90 and increases that of DKK-1, CDNK-1A, TGF-β1, TGF-β/RII and Smad4Mohamed et al[131]
MelatoninEMT6/P mouse breast cancer cells. Balb/C mice transplanted with EMT6/P cellsReduces the expression of VEGF and the serum level of AST and ALT. Increases the serum level of IFN-α and decreases that of IL-4Odeh et al[134]
ArtemisininCCRF-CEM and multidrug-resistant CEM/ADR5000 human leukemia cells. Healthy human foreskin fibroblastsFröhlich et al[136]
Artesunic acidHCT116, HT29, Caco-2, DLD-1 colon cancer cells. HCEC nonmalignant colon epithelial cellsInduces ROS generation, DNA damage, PARP and caspase 9 cleavage. Increases the level of ɣ-H2AXFröhlich et al[137]
DiosgeninA431 and Hep2 human squamous cell carcinoma. Swiss albino mice injected with sarcoma 180 cellsInduces DNA fragmentation and cytoskeletal changes. Decreases the expression of CD31 and Ki67Das et al[138]
EmodinMCF-7, MDA-MB-231, MDA-MB-468 and T47D human breast cancer cells. CAM inoculated with MCF-7 cellsIncreases the percentage of cells in sub-G1 phase. Increases ROS generation, cytochrome c release, expression levels of p53, Bax and cleaved caspase 3. Reduces Bcl-2, pFAK and integrinβ1 expression level. Induces nuclear fragmentation, shrinkage, apoptotic body formation, chromatin condensation and membrane blebbingBhattacharjee et al[140]
Ferulic acidMDA-MB-231 human breast cancer cellsAl-Mutairi et al[143]
GenisteinCALC-62 and ACC448 human thyroid cells derived from anaplastic carcinoma CGTH-W1, ACC360 derived from follicular carcinomaReduces the expression level of human telomerase reverse transcriptase, VEGF-A and NFkB. Increases the expression level of PTEN and p21 and activates caspase 3Ozturk et al[145]
Indirubin-3-monoximeA549 human lung cancer cells. HFL-1 human fetal lung fibroblast. CD1-nude mice injected with A549 cellsIncreases the percentage of cells in Sub-G0 phase. Reduces Bcl-2/Bax ratio, TNF-α release and p-Akt (s473), p-mTOR, NFkB/p65, caspase3 and p53 expression levelDera et al[147]
PiperineEMT6/P mouse mammary cancer cells. Balb/C female mice injected with EMT6/P cancer cellsReduces VEGF expression. Increases IFN-γ and IL-2 level and caspase 3 activityTalib et al[149]
HepG2 human hepatocellular cancer cellsIncrease ROS generation and decreases GSH and NADPH levelDas et al[151]
ResveratrolHepG2 human hepatocellular cancer cellsIncreases caspase 3 activity. Decreases GSH and MDA levelIsmail et al[153]
EMT6/p mouse epithelial breast cancer cells. MCF-7 and T47D human epithelial breast cancer cells kidney epithelial cells. Balb/C mice injected with EMT6/p cancer cellsInduces DNA fragmentation and increases IFN-γ and IL-4 level. Reduces VEGF expressionAlobaedi et al[154]
SeleniumMG-63 human osteosarcoma cell lineIncreases cellular damage, and decreases the level of alkaline phosphatase and GSHBarron et al[156]