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Relationship: 1978


A descriptive phrase which clearly defines the two KEs being considered and the sequential relationship between them (i.e., which is upstream, and which is downstream). More help

Increase, Mutations leads to Increase, Cell Proliferation

Upstream event
The causing Key Event (KE) in a Key Event Relationship (KER). More help
Downstream event
The responding Key Event (KE) in a Key Event Relationship (KER). More help

Key Event Relationship Overview

The utility of AOPs for regulatory application is defined, to a large extent, by the confidence and precision with which they facilitate extrapolation of data measured at low levels of biological organisation to predicted outcomes at higher levels of organisation and the extent to which they can link biological effect measurements to their specific causes.Within the AOP framework, the predictive relationships that facilitate extrapolation are represented by the KERs. Consequently, the overall WoE for an AOP is a reflection in part, of the level of confidence in the underlying series of KERs it encompasses. Therefore, describing the KERs in an AOP involves assembling and organising the types of information and evidence that defines the scientific basis for inferring the probable change in, or state of, a downstream KE from the known or measured state of an upstream KE. More help

AOPs Referencing Relationship

AOP Name Adjacency Weight of Evidence Quantitative Understanding Point of Contact Author Status OECD Status
Deposition of energy leading to lung cancer adjacent High Low Brendan Ferreri-Hanberry (send email) Open for citation & comment WPHA/WNT Endorsed
Deposition of energy leading to occurrence of cataracts adjacent Moderate Low Arthur Author (send email) Open for citation & comment

Taxonomic Applicability

Latin or common names of a species or broader taxonomic grouping (e.g., class, order, family) that help to define the biological applicability domain of the KER.In general, this will be dictated by the more restrictive of the two KEs being linked together by the KER.  More help
Term Scientific Term Evidence Link
human Homo sapiens High NCBI
rat Rattus norvegicus High NCBI
mouse Mus musculus High NCBI

Sex Applicability

An indication of the the relevant sex for this KER. More help
Sex Evidence
Unspecific High

Life Stage Applicability

An indication of the the relevant life stage(s) for this KER.  More help
Term Evidence
All life stages High

Key Event Relationship Description

Provides a concise overview of the information given below as well as addressing details that aren’t inherent in the description of the KEs themselves. More help

Mutations are defined as changes in the DNA sequence, which could occur in the form of deletions, insertions, missense mutations, nonsense mutations or frameshift mutations (Bertram, 2001; Danesi et al., 2003; Lodish, 2000). Elevated mutation frequencies may impact cellular activities by activating or inhibiting essential processes that control the natural course of cell proliferation (Bertram, 2001; Vogelstein and Kinzler, 2004; Lodish, 2000). Increased rates of cellular proliferation may arise due to mutations that activate proto-oncogenes, which results in sustained signaling for cell growth (Bertram, 2001; Vogelstein and Kinzler, 2004; Larsen and Minna, 2011; Lodish, 2000) and due to mutations that inactivate tumour suppressor genes (TSGs), resulting in the removal of cell cycle inhibition and/or decreased cell death signaling (Bertram, 2001; Vogelstein and Kinzler, 2004; Lodish, 2000). Mutations altering gene expression or protein activity can enable cells to escape growth inhibition by increasing resistance to apoptosis, or other inhibitory signals, or by escape of cell cycle checkpoints. Alternatively, mutations can stimulate growth by activating proliferative pathways such as EGFR.

Evidence Collection Strategy

Include a description of the approach for identification and assembly of the evidence base for the KER. For evidence identification, include, for example, a description of the sources and dates of information consulted including expert knowledge, databases searched and associated search terms/strings.  Include also a description of study screening criteria and methodology, study quality assessment considerations, the data extraction strategy and links to any repositories/databases of relevant references.Tabular summaries and links to relevant supporting documentation are encouraged, wherever possible. More help

Evidence Supporting this KER

Addresses the scientific evidence supporting KERs in an AOP setting the stage for overall assessment of the AOP. More help
Biological Plausibility
Addresses the biological rationale for a connection between KEupstream and KEdownstream.  This field can also incorporate additional mechanistic details that help inform the relationship between KEs, this is useful when it is not practical/pragmatic to represent these details as separate KEs due to the difficulty or relative infrequency with which it is likely to be measured.   More help

There is a strong biological plausibility for a relationship between increasing mutation frequencies and increasing cellular proliferation.  This relationship is especially evident when examining the molecular biology of carcinogenesis. It is well-known that exposure of cells to a DNA-damaging agent, such as ionizing radiation, may result in damage to the DNA that manifests as genomic instability, including mutations. If enough mutations accumulate in critical genes, cells may begin to proliferate uncontrollably. This, alongside other events, may eventually result in tumourigenesis and cancer (reviewed in Bertram, 2001; Vogelstein and Kinzler, 2004; Panov, 2005; Lodish, 2000). In fact, one of the hallmarks of cancer is sustained proliferative signalling, and one of the enabling characteristics of this increased proliferation is genomic instability/mutations (Hanahan and Weinberg, 2011).

To prevent the propagation of erroneous DNA, there are specific cell cycle checkpoints that must be passed before DNA replication and mitosis can proceed. One of the most important checkpoints for committing to cell proliferation occurs during late G1 (Bertram, 2001; Lodish, 2000). This checkpoint is managed by retinoblastoma protein (RB), transcription factor E2F, and transcription factor p53. In a resting cell, RB is tightly bound to E2F; when growth factor signals are present, proteins are activated that phosphorylate RB, resulting in a conformation change and the release of E2F. This transcription factor then initiates transcription of genes required for DNA synthesis and thus cell proliferation. If there is damage to the DNA, p53 is upregulated and binds to unphosphorylated RB, thereby preventing the dissociation of RB and E2F (Bertram, 2001). This gives the cell enough time to repair the damaged DNA prior to DNA replication, and thus minimizes the propagation of the DNA errors. Existing mutations in the checkpoint genes, however, may compromise this process. For example, if mutations in p53 render it non-functional, damaged DNA will not be stopped at the checkpoint and will continue to be synthesized, despite the damage. Although the majority of DNA damage is addressed through the activation of repair mechanisms, if the cells fail to prevent DNA synthesis prior to repairing DNA damage (eg. ATM mutant cells), erroneous repair accumulates which could lead to the activation of cell proliferation or cell death (Levine and Holland, 2018). Accumulation of mutations in this manner may affect genes that impact cell proliferation rates (Bertram, 2001; Lodish, 2000). There are three categories of genes that, if mutated, may allow for uncontrolled cell proliferation: proto-oncogenes, TSGs, and caretaker/stability genes. 

Proto-oncogenes are defined as genes that, when activated, promote cellular proliferation (Bertram, 2001; Lodish, 2000); they have been likened to the gas pedal of the car (Vogelstein and Kinzler, 2004). These genes are particularly dangerous if they are rendered abnormally active by gain-of-function (GOF) mutations; this may result in cellular proliferation being aberrantly activated (Bertram, 2001; Vogelstein and Kinzler,, 2004; Larsen and Minna 2011; Lodish, 2000).  Two common examples of mutated proto-oncogenes that contribute to increased cell proliferation rates are EGFR and KRAS. The EGFR gene encodes the epidermal growth factor receptor (EGFR), a trans-membrane protein with tyrosine kinase activity. Binding of growth factors to EGFRs results in receptor dimerization, autophosphorylation, and propagation of pro-proliferative signals to the nucleus (Danesi et al., 2003; Santos et al., 2010; Larsen and Minna, 2011; NIH, 2018 EGFR). KRAS is responsible for making the KRAS protein, which is a G-protein with GTPase activity that is used in the RAS/MAPK signalling pathway. When a signal that promotes cellular growth is detected, KRAS binds to GTP and activates downstream signalling molecules, thus facilitating signal propagation to the nucleus (Adjei, 2001; Panov, 2005; Jancik et al., 2010; NIH, 2018 KRAS). Mutations that render these receptors constitutively active would thus result in increased rates of cellular proliferation (Sanders and Albitar, 2010).

TSGs, which are analogous to the brakes in a car (Vogelstein and Kinzler, 2004; Lodish, 2000), are genes that negatively regulate cellular growth by preventing proliferation and in some cases, promoting apoptosis (Bertram, 2001; Vogelstein and Kinzler, 2004; Panov, 2005; Sanders and Albitar, 2010; Lodish, 2000). Many of the cell cycle checkpoint proteins and proteins controlling cell death are TSGs (Bertram, 2001; Lodish, 2000). Loss-of function (LOF) mutations that result in the inactivation of these TSGs may thus promote cellular proliferation (Bertram, 2001; Vogelstein and Kinzler, 2004; Lodish, 2000). A common example of a mutated TSG is TP53, which encodes the p53 protein. As mentioned above, p53 is a cell checkpoint protein that delays replication when damaged DNA is present; if damage is severe enough, p53 may also activate an apoptotic pathway (Bertram, 2001; Danesi et al., 2003; Panov, 2005; Larsen and Minna, 2011; Lodish, 2000, NIH 2018c). Inactivating mutations in p53 thus allow for unhindered progression through the cell cycle, resulting in higher cell proliferation rates (Danesi et al., 2003; Fernandez-Antoran et al., 2019).

Finally, caretaker/stability genes encode for proteins involved in the detection, repair and prevention of DNA damage (Vogelstein and Kinzler 2004; Hanahan and Weinberg 2011).  Genes involved in mismatch repair (MMR), nucleotide excision repair (NER) and base-excision repair (BER) pathways are examples of caretaker/stability genes (Vogelstein and Kinzler, 2004). Mutations in these genes may compromise aspects of DNA repair—the detection of damage, the initiation of repair, the repair process itself, or the removal of mutagens that could possibly damage DNA—thus allowing for more mutations to accumulate in the genome than usual (Hanahan and Weinberg, 2011). Although all genes may suffer from increased mutation rates when caretaker/stability genes are improperly functioning, mutations in TSGs and proto-oncogenes are the main contributors to increased cellular proliferation (Vogelstein and Kinzler, 2004). Caretaker/stability genes are similar to TSGs in that disruption of both alleles must occur for the gene function to be compromised (Vogelstein and Kinzler, 2004; Hanahan and Weinberg, 2011).

Uncertainties and Inconsistencies
Addresses inconsistencies or uncertainties in the relationship including the identification of experimental details that may explain apparent deviations from the expected patterns of concordance. More help

Uncertainties in this KER are as follows:

  1. The location of the mutation will be critical in determining the downstream effects. This can also be modulated by an individual’s susceptibility (Loewe and Hill 2010).
  2. Although activating mutations in oncogenes such as RAS and MYC may induce abnormally high rates of cellular proliferation, extremely high levels of these proteins may actually lead to the opposite—cells may enter into a state of senescence and cease proliferation (Hanahan and Weinberg 2011).\
  3. Cellular proliferation may be impacted by circadian cycles, such that disruptions to this natural circadian rhythm may also affect the cell cycle (Shostak 2017).

Known modulating factors

This table captures specific information on the MF, its properties, how it affects the KER and respective references.1.) What is the modulating factor? Name the factor for which solid evidence exists that it influences this KER. Examples: age, sex, genotype, diet 2.) Details of this modulating factor. Specify which features of this MF are relevant for this KER. Examples: a specific age range or a specific biological age (defined by...); a specific gene mutation or variant, a specific nutrient (deficit or surplus); a sex-specific homone; a certain threshold value (e.g. serum levels of a chemical above...) 3.) Description of how this modulating factor affects this KER. Describe the provable modification of the KER (also quantitatively, if known). Examples: increase or decrease of the magnitude of effect (by a factor of...); change of the time-course of the effect (onset delay by...); alteration of the probability of the effect; increase or decrease of the sensitivity of the downstream effect (by a factor of...) 4.) Provision of supporting scientific evidence for an effect of this MF on this KER. Give a list of references.  More help
Response-response Relationship
Provides sources of data that define the response-response relationships between the KEs.  More help

Data establishing a response-response relationship between mutation frequency and cellular proliferation was not identified. More research is required to establish the response-response relationship between these two events.

Information regarding the approximate time-scale of the changes in KEdownstream relative to changes in KEupstream (i.e., do effects on KEdownstream lag those on KEupstream by seconds, minutes, hours, or days?). More help

Although the time scale is not well-established for this KER, there are a few studies that have examined how cellular proliferation changes overtime in the presence of mutations. In Cul9-/- mouse embryonic fibroblasts, a higher proliferation rate relative to Cul9+/+ cells was evident by 3 days in culture (Li and Xiong 2017). A similar relationship was observed in mouse embryonic fibroblasts with p53 manipulations. Increased proliferation in p53-/-, p53 515A/+ and p53 515A/515A relative to p53+/- and p53+/+ cells was present by the fourth day in culture (Lang et al. 2004).  Examination of population doublings in various cell lines found that Cul9-/- and Cul9 mutant cells had higher population doublings than wild-type cells by approximately passage 7; Arf-/-, p53-/-, and Cul9-/-p53-/- cells, however, displayed even higher rates of population doublings by passage 6  (Li and Xiong 2017). Additionally, tumour growth in mice inoculated with lung epithelial cells engineered with LT (suppresses p53 and pRB) and an activated oncogene (either EGFR or KRAS) was monitored over 40 days post-injection. Relative to mice inoculated with either LT-lung epithelial cells or activated oncogene-lung epithelial cells, mice inoculated cells containing both mutations had detectable tumours by approximately day 10 - 12 post-injection; the volumes of these tumours continued increasing until the end of the experiment (Sato et al. 2017).

There were also differences in the rate of DNA synthesis over time, which could possibly indicate higher rates of cell division. In all cell types examined (p53-/-, p53+/- and p53+/+, p53 515A/+, and p53 515A/515A), DNA synthesis declined over the first 6 days in culture, though the mutant p53 lines always had higher synthesis rates than p53-/-, p53+/- and p53+/+ cells. During culture days 6 - 10, DNA synthesis in the mutant p53 lines drastically increased, while the other p53 lines remained at the same relatively low level of synthesis (Lang et al. 2004).  

Known Feedforward/Feedback loops influencing this KER
Define whether there are known positive or negative feedback mechanisms involved and what is understood about their time-course and homeostatic limits. More help

Proliferation increases the likelihood that existing DNA damage will result in mutation and creates new mutations through errors in replication.

It is generally accepted that proliferation increases the risk of mutation and cancer (Preston-Martin, Pike et al. 1990). DNA damage that has not been completely or correctly repaired when a cell undergoes mitosis can be fixed in the genome permanently as a mutation, to be propagated to future daughter cells. Incomplete DNA repair can also cause additional DNA damage when encountered by replicative forks. Therefore, in the presence of any DNA damage (and there is a background rate of damage in addition to any other genotoxic stimuli) mutations will increase with cell division (Kiraly, Gong et al. 2015). Mutation-prone double strand breaks can also arise from replicative stress in hyperplastic cells including hyperplasia arising from excess growth factor stimulation (Gorgoulis, Vassiliou et al. 2005). This relationship between proliferation and mutation is thought to drive a significant portion of the risk of cancer from estrogen exposure since breast cells proliferate in response to estrogen or estrogen plus progesterone and risk increases with cumulative estrogen exposure (Preston-Martin, Pike et al. 1990).

Not all proliferating tissue shows replicative stress and DSBs - tissue with a naturally high proliferative index like colon cells don’t show any sign of damage (Halazonetis, Gorgoulis et al. 2008). Additional factors are therefore required beyond replication for damage and mutation from replicative stress, but replication is essential for the expression of these factors.

Domain of Applicability

A free-text section of the KER description that the developers can use to explain their rationale for the taxonomic, life stage, or sex applicability structured terms. More help

The domain of applicability pertains to all multicellular organisms, as cell proliferation and death regulate tissue homeostasis (Pucci et al. 2000).


List of the literature that was cited for this KER description. More help

Adjei, A.A. (2001), "Blocking Oncogenic Ras Signaling for Cancer Therapy.", Journal of the National Cancer Institute, 93(14):1062–1074. doi:10.1093/jnci/94.13.1032

Bertram, J.S. (2001), "The molecular biology of cancer.", Mol. Aspects. Med. 21:166–223. doi:10.1016/S0098-2997(00)00007-8.

Danesi, R. et al. (2003), "Pharmacogenetics of Anticancer Drug Sensitivity in Non-Small Cell Lung Cancer." 55(1):57-103. doi:10.1124/pr.

Duan, W. et al. (2008), "Lung specific expression of a human mutant p53 affects cell proliferation in transgenic mice.", Transgenic Res. 17(3):355–366. doi:10.1007/s11248-007-9154-3.

Fernandez-Antoran, D. et al., (2019), Outcompeting p53-mutant cells in the normal esophagus by redox manipulation., Cell Stem Cell. 25(3):329-341. doi: 10.1016/j.stem.2019.06.011.

Forbes, S.A. et al. (2011), "COSMIC: Mining Complete Cancer Genomes in the Catalogue of Somatic Mutations in Cancer.", Nucleic Acids Res., 39(Database issue):945–950. doi:10.1093/nar/gkq929.

Geng, C. et al. (2017), "SPOP regulates prostate epithelial cell proliferation and promotes ubiquitination and turnover of c-MYC oncoprotein.", Oncogene. 36(33):4767–4777. doi:10.1038/onc.2017.80.

Hanahan, D. & R.A. Weinberg (2011), "Review Hallmarks of Cancer: The Next Generation.", Cell. 144(5):646–674. doi:10.1016/j.cell.2011.02.013.

Hundley, J.E. et al. (1997), "Increased Tumor Proliferation and Genomic Instability without Decreased Apoptosis in MMTV- ras Mice Deficient in p53.", Mol. Cell. Biol. 17(2):723–731. doi:10.1128/MCB.17.2.723.

Iwakuma, T. & G. Lozano (2007), "Crippling p53 activities via knock-in mutations in mouse models.", Oncogene, 26(15):2177–2184. doi:10.1038/sj.onc.1210278.

Jancik, S. et al. (2010), "Clinical Relevance of KRAS in Human Cancers", J. BioMed. & BioTech. 2010. doi:10.1155/2010/150960.

Jarvis, E.M., J.A. Kirk & C.L. Clarke (1998), "Loss of Nuclear BRCA1 Expression in Breast Cancers Is Associated with a Highly Proliferative Tumor Phenotype.", Cancer Genet Cytogenet. 101(97):101–115. doi:10.1016/S0165-4608(97)00267-7.

Kim, M.P. & G. Lozano (2018), "Mutant p53 partners in crime.", Nat Publ Gr. 25(1):161–168. doi:10.1038/cdd.2017.185.

Lang, G.A. et al. (2004), "Gain of Function of a p53 Hot Spot Mutation in a Mouse Model of Li-Fraumeni Syndrome.", Cell. 119(6):861–872. doi:10.1016/j.cell.2004.11.006.

Larsen, J.E. & J. Minna (2011), "Molecular Biology of Lung Cancer: Clinical Implications.", Clin. Chest Med., 32(4):703–740. doi:10.1016/j.ccm.2011.08.003.

Levine, M. S., & A. J. Holland, A. J. (2018),. “The impact of mitotic errors on cell proliferation and tumorigenesis.”, Genes & development, 32(9-10):, 620–638. 

Li, Z. & Y. Xiong (2017), "Cytoplasmic E3 ubiquitin ligase CUL9 controls cell proliferation, senescence, apoptosis and genome integrity through p53.", Oncogene, 36(36):5212–5218. doi:10.1038/onc.2017.141.

Lodish, H. et al. "Molecular Cell Biology.", 4th edition. New York: W. H. Freeman; 2000. Available from:

Loewe, L. & W.G. Hill (2010), "The population genetics of mutations: Good, bad and indifferent." Philos Trans R Soc B Biol Sci. 365(1544):1153–1167. doi:10.1098/rstb.2009.0317.

López-lázaro M. (2018), "The stem cell division theory of cancer.", Crit. Rev. Oncol. Hematol. 123:95–113. doi:10.1016/j.critrevonc.2018.01.010.

Muller, P.A., K.H. Vousden & J.C. Norman (2011), "p53 and its mutants in tumor cell migration and invasion.", J. Cell. Biol. 192(2):209–218. doi:10.1083/jcb.201009059.

NIHa,  EGFR gene epidermal growth factor receptor Normal. 2018. Genetics Home Reference EGFR gene.

NIHb, KRAS proto-oncogene, GTPase Normal. 2018. Genetics Home Reference KRAS gene.

NIHc, TP53 gene tumor protein p53 Normal. 2018. Genetics Home Reference TP53 gene.

Beir V. 1999. Health Effects of Exposure to Radon. National Academies Press.

Panov, S.Z. (2005), "Molecular biology of the lung cancer.", Radiology and Oncology 39(3):197–210.

Pucci, B., M. Kasten & A. Giordano (2000), "Cell Cycle and Apoptosis 1", Neoplasia, 2(4):291–299.doi: 10.1038/sj.neo.7900101

Sanders, H.R. & M. Albitar (2010), "Somatic mutations of signaling genes in non-small-cell lung cancer.", Cancer Genet Cytogenet. 203(1):7–15. doi:10.1016/j.cancergencyto.2010.07.134.

da Cunha Santos, G., F.A. Shepherd & M.S. Tsao (2010), "EGFR Mutations and Lung Cancer.", Annu Rev. Pathol., doi:10.1146/annurev-pathol-011110-130206.

Sato, T. et al. (2017), "Ex vivo model of non-small cell lung cancer using mouse lung epithelial cells.", Oncol. Lett. :6863–6868. doi:10.3892/ol.2017.7098.

Schabath, M.B. et al. (2016), "Differential association of STK11 and TP53 with KRAS.", Oncogene, 35(24):3209–3216. doi:10.1038/onc.2015.375.

Shostak, A. (2017), "Circadian Clock, Cell Division, and Cancer: From Molecules to Organism.", Int. J. Mol. Sci., doi:10.3390/ijms18040873.

Ventura, A. et al. (2007), "Restoration of p53 function leads to tumour regression in vivo.", Nature 445(7128):661-5. doi:10.1038/nature05541.

Vogelstein, B. & K.W. Kinzler (2004), "Cancer genes and the pathways they control.", Nat. Med, 10(8):789–799. doi:10.1038/nm1087.

Welcker, M. & B.E. Clurman (2008), "FBW7 ubiquitin ligase: a tumour suppressor at the crossroads of cell division, growth and differentiation.", Nature Publishing Group. doi:10.1038/nrc2290.