Cytogenetic effects of tobacco smoke exposure among involuntary smokers

Tobacco smoke is highly genotoxic and produces chromosomal damage in several experimental systems. Active smokers have been shown to have an increased prevalence of somatic chromosome damage in their peripheral blood lymphocytes: this is seen in most cases as an increased sister-chromatid exchange (SCE) frequency and often also as increased structural chromosome aberrations (CAs). Among passive smokers, in association with exposure to environmental tobacco smoke, no such induction of chromosomal damage has been documented. In the present paper we report negative results on induction of chromosomal damage in 2 separate groups of intensive involuntary exposure to tobacco smoke, non-smoking restaurant personnel and newborn children of smoking mothers. While significant exposure in these groups is clearly seen in biochemical intake markers, e.g. cotinine and thiocyanate values in plasma, the conventional cytogenetic parameters, structural chromosome aberrations and sister-chromatid exchanges, are unable to detect the low exposures of involuntary smokers.     

Chromosome aberrations in workers at a tannery in Iraq

Blood samples were collected from 17 healthy chromium-exposed workers at a tanning plant near Baghdad city and 13 controls matched for age, period of service and social background. For each individual more than 100 lymphocyte metaphases were examined. The results showed no significant differences in the per cell frequencies of chromatid and isochromatid gaps, single chromatid breaks, various chromosome-type aberrations and all aberrations combined. However, smoking workers exhibited statistically higher frequency of chromosome-type aberrations than non-smoking workers and smoking controls.     

Cytogenetic damage in workers exposed to ethylene oxide

Sister-chromatid exchanges (SECs) and chromosomal aberrations (CAs) were detected in the peripheral lymphocytes of 41 sanitary workers exposed to ethylene oxide (EO) in the sterilizing units of 8 hospitals in the Venice Region. The first group (19 workers) was exposed to 10.7 +/- 4.9 ppm EO, expressed as the time-weighted average concentration for an 8-h working day (TWA/8 h conc.), and the second group (22 workers) to 0.35 +/- 0.12 ppm. Each exposed worker was paired with a control of similar age and smoking habits. A highly significant (P less than 0.001) increase in the mean frequency of SCEs was found in the higher exposure group, 14 (74%) exposed subjects having significantly increased levels of SCEs compared to their matched controls. In the lower exposure group, the increase in mean frequency of SCEs was lower, though still significant (P less than 0.05): 7 (33%) exposed subjects had higher and 1 (5%) had a lower SCE level than the matched controls. From the first group, 10 subjects, 7 of whom had increased SCE levels, were reanalysed 12-18 months after their exposure had been lowered or interrupted: in only 2 of them the SCE level was significantly decreased. A statistically significant correlation between SCE frequency and level of EO exposure (TWA/8 h conc.), as well as a multiple correlation between SCE level and EO exposure, smoking and age were found. However, no interaction could be detected between EO exposure and smoking in the induction of SCEs. In controls, SCE frequency was correlated with smoking and age. In the higher exposure group, the number of both chromatid- and chromosome-type aberrations, independent of gaps, was significantly increased, whereas in the lower exposure group only the frequency of chromosome-type aberrations, excluding gaps, was statistically higher than in controls. The level of CAs remained to a great extent unchanged in the 10 subjects re-examined at a later stage after lowering or halting exposure. Taking the group as a whole, the frequency of cells with total CAs was found to be weakly (P = 0.05) correlated with EO exposure, and was not correlated with smoking, age or SCE frequency.     

The influence of mother's active smoking during pregnancy on body mass index of newborns

Many investigations have noted bad influence of smoking during pregnancy. In the present article, the influence of mothers smoking during pregnancy on the body mass index (BMI), birth weight and birth length are examined. This retrospective research included 219 children: Group I: 109 children from rural area of east Slavonia (born in General Hospital-Vinkovci) and group II: 110 children from industrial area (born in Zagreb). The questioned subjects were divided into two groups depending on mothers smoking during pregnancy: newborns of mothers who didn't smoke during pregnancy (subgroup A) and newborns of mother who did smoke 10 or more cigarettes per day during pregnancy (subgroup B). Anthropometric parameters (BMI, birth length and birth weight) in newborns of non-smoking mothers were statistically higher (p < 0.05) than in newborns of smoking mothers. Moderate correlation between birth length and birth weight in newborns of non-smoking and smoking mothers from rural area and from non-smoking mothers in urban area was statistically significant, but correlation in the group in newborns of smoking mothers from Zagreb was not statistically significant. Results of this research show that smoking during pregnancy significantly influences the birth weight and birth length. Further investigation is needed, to investigate the lack of correlation between the birth length and birth weight in newborns of smoking mothers from industrial city.     

Maternal and cord blood ghrelin in the pregnancies of smoking mothers: possible markers of nutrient availability for the fetus

AIMS: To investigate the role of ghrelin in maternal and fetal metabolism, we determined its value in maternal smoking, a specific cause of reduced placenta function and fetal growth. METHODS: In 85 normal term pregnancies, 42 in smoking and 43 in non-smoking mothers, we measured ghrelin in the maternal blood at the onset of labor and in the cord blood of their 85 singletons immediately after birth. We determined the relationships between ghrelin and placental GH (PGH), pituitary GH (pitGH), and IGF-I. RESULTS: The newborns of smoking mothers weighed 0.24 kg less (p < 0.05) than those of non-smoking mothers. Cord blood ghrelin was 71% higher and PGH and cord blood IGF-I were 34% and 32% lower, respectively, in the pregnancies of smoking compared with non-smoking mothers (p < 0.05). Cord blood ghrelin was unrelated to pitGH and cord blood IGF-I. Maternal ghrelin was unchanged in smoking mothers, increased with maternal fasting duration (r = 0.26, p < 0.05), showed no correlation with PGH and negative correlation with cord blood IGF-I (r = -0.42, p < 0.01). CONCLUSION: The decrease in placental function and fetal growth in smoking mothers is associated with an increase in cord blood ghrelin, and no change in maternal ghrelin. Maternal ghrelin concentration increases with fasting, and is negatively correlated with cord blood IGF-I: it may signal a reduction in the level of nutrients available for placental transfer. No correlation supports a role for ghrelin in PGH or pitGH secretion.     

Weight growth in infants born to mothers who smoked during pregnancy.

OBJECTIVE--To determine whether maternal smoking during pregnancy causes impairment in growth after birth. DESIGN--Longitudinal study. SETTING--Six medical university centres of six towns of north, central, and south Italy. SUBJECTS--12,987 babies (10,238 born from non-smoking mothers, 2276 from mothers smoking one to nine cigarettes a day, and 473 from mothers smoking > or = 10 cigarettes a day) entered the study. MAIN OUTCOME MEASURES--Difference in weight gain between children born to smoking mothers and those born to non-smoking mothers. Weight was measured at birth and at 3 and 6 months of age. Maternal smoking habit was derived from interview on third or fourth day after delivery. RESULTS--Compared with children born to mothers who did not smoke during pregnancy, the birth weights of children born to mothers who smoked up to nine cigarettes a day were 88 g (girls) and 107 g (boys) lower; in children born to mothers who smoked > or = 10 cigarettes a day weights were 168 g and 247 g lower. At six months of age for the first group the mean weight for girls was 9 g (95% confidence interval -47 g to 65 g) higher and for boys 64 g (-118 g to -10 g) lower than that of children born to mothers who did not smoke. The corresponding figures for the second group were 28 g (-141 g to 85 g) lower for girls and 24 g (-136 g to 88 g) lower for boys. CONCLUSIONS--The deficits of weight at birth in children born to mothers who smoked during pregnancy are overcome by 6 months of age. These deficits are probably not permanent when smoking habit during pregnancy is not associated with other unfavourable variables (such as lower socioeconomic class).     

Sporadic chromosome aberrations in healthy individuals studied between 1986-2001

In the second half of 2002, IARC for Central and Eastern European countries targeted studies on the relationship between chromosomal aberrations (CAs) and cancer risk. For these purposes we preliminarily investigated, under identical methodological circumstances, the base-line level of CAs in peripheral blood lymphocytes of 1414 healthy Hungarian persons between 1986 and 2001. The age and sex as biological, and smoking habit and residency (Budapest, industrial- and agricultural settlements) as environmental confounding factors were evaluated. Previously, people were not exposed to any known potential mutagens. The overall frequencies of aberrant cells (1.60+/-0.05%) were not influenced by sex, age and residency, but the smoking habits (1.84+/-0.09%) had significant impact on the elevation of aberrant cells. Aneuploidy, exchange-type dicentric chromosomes and the total of aberrations increased significantly with the age of the donors. The individual frequency of aberrant cells ranged between 0-12%. No aberrant cells were detected in 35% of individuals, and 1 aberrant cell was found in 23% of the total population, while 42% of the examined persons were characterized with aberrant cell rates between 2-12%. The initial value of 0.85% of aberrant cells doubled by the end of the examined 16-year period, following 2-4-fold fluctuations. None of the investigated biological or environmental factors was responsible for the elevation of the CAs. The causes of the elevation of CA-level can be explained more precisely when these data will be compared to cancer registry database of these persons.     

Chromosomal instability in the lymphocytes of breast cancer patients

Genomic instability in the tumor tissue has been correlated with tumor progression. In the present study, chromosomal aberrations (CAs) in peripheral blood lymphocytes (PBLs) of breast tumor patients were studied to assess whether chromosomal instability (CIN) in PBLs correlates with aggressiveness of breast tumor (i.e., disease stage) and has any prognostic utility. Cultured blood lymphocyte metaphases were scored for aberrations in 31 breast cancer patients and 20 healthy age and sex-matched controls. A variety of CAs, including aneuploidy, polyploidy, terminal deletions, acentric fragments, double minutes, chromatid separations, ring chromosome, marker chromosome, chromatid gaps, and breaks were seen in PBLs of the patients. The CAs in patients were higher than in controls. A comparison of the frequency of metaphases with aberrations by grouping the patients according to the stage of advancement of disease did not reveal any consistent pattern of variation in lymphocytic CIN. Neither was any specific chromosomal abnormality found to be associated with the stage of cancer. This might be indicative of the fact that cancer patients have constitutional CIN, which predisposes them to the disease, and this inherent difference in the level of genomic instability might play a role in disease progression and response to treatment.     

Cytogenetic monitoring of chemical workers in production of the drug 1-propoxy-2-acetamino-4-nitrobenzol with reference to their smoking habits

The induction of chromosome aberrations (CAs) and sister-chromatid exchanges (SCEs) was examined in cultured lymphocytes from 23 individuals employed in the production of the drug 1-propoxy-2-acetamino-4-nitrobenzol. Lymphocytes of workers were cultured before and 13 weeks after starting professional activity. The latter showed a significant increase in both CAs and SCEs. Smokers (11 individuals) and non-smokers (12 individuals) were indistinguishable with respect to the frequencies of CAs or SCEs before starting professional activity, 13 weeks later smokers exhibited significantly more SCEs than non-smokers. This strongly suggests a comutagenic interaction of cigarette smoke and exposure to chemicals during drug production. On the basis of the technology applied the compound inducing CAs and SCEs in lymphocytes of smoking workers seems to be 2-acetamino-4-nitrophenol.     

Cytogenetic studies of workers from the rubber industry.

Lymphocytes from 21 vulcanizers from a tire factory were analyzed for the presence of chromosome aberrations (CAs), sister-chromatid exchanges (SCEs) and for proliferation indices (PIs). An increase in the frequencies of CAs and SCEs and a decrease in PIs were observed. Cytogenetic parameters were correlated with age, smoking habits, and duration of occupational exposure. From the present study it can be concluded that cigarette smoking enhances the genotoxic effects of mixtures of chemicals to which workers in the rubber industry are exposed.     

Analysis of chromosomal aberrations,sister chromatid exchanges and micronuclei among power linesmen with long-term exposure to 50-Hz electromagnetic fields

Chromosomal aberrations, sister chromatid exchanges (SCEs), replication indices and micronuclei in peripheral blood lymphocytes were analysed among 27 nonsmoking power linesmen with considerable long-term exposure to 50-Hz electromagnetic (EM) fields, and among 27 nonsmoking telephone lines-men serving as a reference group, pairwise matched with the exposed workers for age and geographical region. Blood samples from the two groups were collected, cultured and analysed in parallel. No differences between the groups were observed on analysis of SCEs, replication indices or micronuclei. However, the mean rate of lymphocytes with chromatid-type breaks was higher among the power linesmen (0.96% gaps excluded, 1.41% gaps included) than among the reference group (0.44% and 0.70%, respectively). The excess of aberrant cells was concentrated among those power linesmen who had smoked earlier in their life. Although the interpretation is somewhat complicatedy the confounding effect of previous smoking, these results suggest that exposure to 50-Hz EM fields is associated with a slight increase in chromatid breaks.     

Etiology of individual differences in birth weight of twins as a function of maternal smoking during pregnancy.

Birth weight is in large extent influenced by gestational age. In addition genetic and environmental factors determine intrauterine growth and birth weight. The contributions of these factors may be influenced by maternal smoking during pregnancy. We examined birth weight and maternal smoking in a sample of 2930 twin pairs from the Netherlands Twin Register using structural equation modelling. Gestational age accounted for 27-44% of the variance in birth weight. A lower variability of birth weight and a lower association of birth weight with gestational age was found in twins whose mothers smoked during pregnancy. The variance not associated with gestational age was independent of maternal smoking during pregnancy. A systematic smaller part of the variability in birth weight was associated with variability in gestational age in second born twins compared to first born twins. The heritability of interindividual differences in birth weight was modest (10% for twins with non-smoking mothers and 11% for twins with smoking mothers). Common environmental influences other than gestational age accounted for a slightly larger part of the variance not associated with gestational age (17-20%).     

Chromosomal aberrations in peripheral lymphocytes of train engine drivers.

Studies of Swedish railway employees have indicated that railroad engine drivers have an increased cancer morbidity and incidence of chronic lymphatic leukemia. The drivers are exposed to relatively high magnetic fields (MF), ranging from a few to over a hundred microT. Although the possible genotoxic potential of MF is unclear, some earlier studies have indicated that occupational exposure to MF may increase chromosome aberrations in blood lymphocytes. Since an increased level of chromosomal aberrations has been suggested to predict elevated cancer risk, we performed a cytogenetic analysis on cultured (48 h) peripheral lymphocytes of Swedish train engine drivers. A pilot study of 18 engine drivers indicated a significant difference in the frequency of cells with chromosomal aberrations (gaps included or excluded) in comparison with seven concurrent referents (train dispatchers) and a control group of 16 office workers. The engine drivers had about four times higher frequency of cells with chromosome-type aberrations (excluding gaps) than the office workers (P < 0.01) and the dispatchers (P < 0.05). Seventy-eight percent of the engine drivers showed at least one cell per 100 with chromosome-type aberrations compared with 29% among the dispatchers and 31% among the office workers. In a follow-up study, another 30 engine drivers showed an increase (P < 0.05) in the frequency of cells with chromosome-type aberrations (gaps excluded) as compared with 30 referent policemen. Sixty percent of the engine drivers had one or more cells (per 100 cells) with chromosome-type aberrations compared with 30% among the policemen. In conclusion, the results of the two studies support the hypothesis that exposure to MF at mean intensities of 2-15 microT can induce chromosomal damage.     

Maternal cigarette smoking increases F2-isoprostanes and reduces prostacyclin and nitric oxide in umbilical vessels.

The objective of this study was to evaluate the influence of smoking on F2-isoprostanes, prostacylin and nitric oxide in human umbilical vessels. Umbilical cords from 13 babies of smoking mothers and from 28 babies of non-smoking mothers were examined for levels of F2-isoprostanes, prostacyclin, L-arginine, and L-citrulline. Forty-one umbilical arteries and eleven umbilical veins were analyzed. Statistical analysis of data was done using modified t-test. Cigarette smoking increased F2-isoprostane levels and reduced the generation of prostacyclin, L-arginine and L-citrulline comparably in umbilical arteries and veins. Notably, in umbilical cords of babies of non-smoking mothers the F2-isoprostane level was significantly higher in arteries. Cigarette smoking correlates with a direct vasoconstrictive effect. We suggest that smoking might enhance the vasoconstrictory capacity in umbilical arteries by increased F2-isoprostanes and by a simultaneous decrease in the production of the vasodilatory compounds, prostacyclin, and nitric oxide.     

Maternal Smoking and Metabolic Health Biomarkers in Newborns

Background

Maternal smoking has been associated with elevated risk of type 2 diabetes among the offspring in adulthood. The mechanisms underlying this fetal “programming” effect remain unclear. The present study sought to explore whether maternal smoking affects metabolic health biomarkers in fetuses/newborns.

Methods

In a prospective singleton pregnancy cohort (n = 248), we compared metabolic health biomarkers in the newborns of smoking and non-smoking mothers. Outcomes included cord plasma insulin, proinsulin, insulin-like growth factor I (IGF-I), IGF-II, leptin and adiponectin concentrations, glucose-to-insulin ratio (an indicator of insulin sensitivity) and proinsulin-to-insulin ratio (an indicator of β-cell function).

Results

Independent of maternal (glucose tolerance, age, ethnicity, parity, education, body mass index, alcohol use) and infant (sex, gestational age, birth weight z score, mode of delivery, cord blood glucose concentration) characteristics, the newborns of smoking mothers had lower IGF-I concentrations (mean: 6.7 vs. 8.4 nmol/L, adjusted p = 0.006), and marginally higher proinsulin-to-insulin ratios (0.94 vs. 0.72, adjusted p = 0.06) than the newborns of non-smoking mothers. Cord plasma insulin, proinsulin, IGF-II, leptin and adiponectin concentrations and glucose-to-insulin ratios were similar in the newborns of smoking and non-smoking mothers.

Conclusions

Maternal smoking was associated with decreased fetal IGF-I levels, and borderline lower fetal β-cell function. Larger cohort studies are required to confirm the latter finding. The preliminary findings prompt the hypothesis that these early life metabolic changes may be involved in the impact of maternal smoking on future risk of metabolic syndrome related disorders in the offspring.     

Genotoxicity of food preservative sodium sorbate in human lymphocytes in vitro

The genotoxic effects of antimicrobial food additive sodium sorbate (SS) was assessed by using chromosome aberrations (CAs), sister-chromatid exchanges (SCEs), and micronucleus (MN) in cultured human lymphocytes and comet assay in isolated human lymphocytes. Lymphocytes were treated with four concentrations (100, 200, 400 and 800 μg/ml) of SS as well as a negative (sterile distilled water) and a positive control (Mitomycin-C: MMC for cultured lymphocytes and H₂O₂ for isolated lymphocytes). The result of this study indicated that SS increased the frequency of CAs at both 24 and 48 h period compared to control. When gaps were included, this increase was significant at 200, 400 and 800 μg/ml concentrations at 24 h and, at all concentrations at 48 h treatment time. When gaps were excluded, this increase was significant at only 800 μg/ml concentration at both 24 and 48 h treatments. In addition, SS increased SCEs/cell and MN frequency at 400 and 800 μg/ml concentrations at both 24 and 48 h compared to negative control. Furthermore, this additive caused DNA damage at all concentrations in isolated human lymphocytes after 1 h in vitro exposure. The present results show that SS is genotoxic to the human peripheral blood lymphocytes in vitro at the highest concentrations.     

Effect of recombinant interferon-alpha on streptonigrin-induced chromosome aberrations and sister-chromatid exchanges in hamster cells

The effect of recombinant interferon-alpha-2a (rIFN-alpha-2a) on the induction of chromosomal aberrations (CAs) and sister-chromatid exchanges (SCEs) by the radiomimetic antibiotic streptonigrin (SN, 250 ng/ml, 20 min, 37 degrees C) in Chinese hamster ovary (CHO) cells was investigated. Recombinant IFN-alpha-2a (4500-45,000 IU/ml) was added to the cell cultures 30 min before SN and left in the culture medium until the end of SN treatment or until cell harvesting. A statistically significant increase in the frequency of CAs and SCEs was observed following treatment with SN (P < 0.05), whereas treatments with rIFN-alpha-2a alone did not produce any significant increase of CAs and SCEs over control values. Low rIFN-alpha-2a doses produced a reduction in the frequency of CAs and an increase in the yield of SCEs induced by SN, while high doses of the cytokine caused an increase in the yield of CAs and a reduction in the frequency of SCEs induced by the antibiotic. In addition, rIFN-alpha-2a caused a marked inhibition (around 50%) on the yield of SN-induced chromatid-type aberrations in the G(2) phase of the cell cycle. It is suggested that the inhibitory effect of rIFN-alpha-2a on the SN-induced chromosome damage is due to the stimulation of DNA synthesis and repair by the cytokine. On the other hand, our results give further support to our previous hypothesis that the induction of CAs and SCEs by SN is based on different mechanisms.     

Genetic polymorphisms of DNA repair and xenobiotic-metabolizing enzymes: effects on levels of sister chromatid exchanges and chromosomal aberrations

Elevated levels of chromosomal aberrations (CAs) in peripheral blood lymphocytes, widely used as a cytogenetic biomarker of genotoxic effects, have been linked to cancer predisposition. However, tobacco smoking, occupational carcinogen exposure, or time since CA analysis do not appear to explain the cancer predictivity of CAs. Alternatively, the observed CA-cancer association could reflect unidentified exposures or individual susceptibility. We assessed the effects of genetic polymorphisms of DNA repair proteins and xenobiotic-metabolizing enzymes (XMEs) on the levels of CAs and sister chromatid exchanges (SCEs) in peripheral lymphocytes of 145 (CAs) and 60 (SCEs) healthy Caucasians. Genotypes of DNA repair genes X-ray repair cross-complementation group 1 (XRCC1 codons 194, 280, 399) and 3 (XRCC3 codon 241 [corrected]), and XME genes glutathione-S-transferase (GST) M1 and T1 and N-acetyl transferase 2 (NAT2) were determined using polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP)-based methods. After Poisson regression adjustment for age, sex, smoking, country, and genotypes, a higher frequency of chromosome-type breaks was observed for NAT2 slow acetylators (in nonsmokers) and GSTT1 null subjects (in smokers). Individuals carrying variant alleles for XRCC1 codons 280 and 194 showed a decreased level of chromosome-type breaks. The effect of GSTM1 null and XRCC1 codon 399 genotypes on the frequency of CAs was modified by smoking. In linear regression models adjusting for age, sex, smoking, and genotypes, none of the polymorphisms significantly affected SCE frequency, although GSTT1 null subjects had a slightly elevated SCE level. Our results are in line with earlier findings on the influence of NAT2, GSTT1, and GSTM1 polymorphisms on the level of lymphocyte chromosome damage and suggest that also XRCC1 polymorphism affects CA frequencies, thus apparently influencing DNA repair phenotype. It remains to be examined whether these or other genetic polymorphisms could explain the observed cancer risk predictivity of high CA frequency.     

Genotoxicity of cigarette smoking in maternal and newborn lymphocytes

Tobacco smoke contains a large number of substances known to induce DNA damage and to be hazardous to human health. Several reviews and meta-analyses have reported an association between maternal or paternal smoking habits and genetic-related diseases, such as cancer, in children. The aim of the present study was to evaluate the level of DNA damage in lymphocytes of active- and passive-smoking mothers and in their newborns, using the comet assay. A total of 40 active smokers, 40 passive smokers, and 40 non-smokers, and their respective newborns, were evaluated. The active smokers presented a statistically significant increase of DNA damage when compared to the non-smokers and passive-smokers. No significant difference was observed between passive and non-smoking women. Similar results were detected in newborns. Those born to active-smoking mothers presented higher levels of DNA damage than those from passive- and non-smoking mothers. Additionally, no significant difference was detected between newborns from non-smoking and passive-smoking mothers. Also, no statistically significant difference in DNA damage was observed between mothers and their respective newborns, and a positive correlation in the level of DNA damage was detected between them. Logistic regression analyses showed positive associations between DNA damage, spontaneous abortion and smoking status. In conclusion, our data indicate that tobacco exposure during pregnancy has genotoxic effects for both mother and child, and it can be considered an important risk factor for childhood cancer or other genetic-related diseases.     

Chromosomal aberrations under basal conditions and after treatment with X-ray in human lymphocytes as related to the GSTM1 genotype

The frequency of chromosomal aberrations (CAs) was evaluated in blood lymphocytes from 18 healthy subjects. Basal CA frequencies were not significantly different in GSTM1 positive and GSTM1 null subjects (P>0.05), whereas they were considerably higher in smokers than in non-smokers. After 1 Gy dose of X-ray challenge of blood samples, CA frequencies were significantly higher in GSTM1 null subjects, compared to GSTM1 positive subjects (P<0.005), and in smokers, compared to non-smokers. These effects are ascribed to the influence of GSTM1 genotype and of smoking status on DNA repair capacities. As the induction of CAs are associated with carcinogenesis, the challenge assay is able to detect enhanced susceptibility for CA caused by genetic predisposition of DNA repair deficiency.