| Summary: | <p>Despite a decade of publications investigating the effect of germline polymorphisms on both toxicity related to treatment with 5-fluorouracil-based (5-FU) chemotherapy and prognosis following diagnosis with colorectal cancer (CRC), few genetic biomarkers have been identified convincingly. For 5-FU toxicity and CRC prognosis, in four results chapters, this thesis aims to validate previously-reported genetic biomarkers, identify new markers, determine the mechanistic basis of associated polymorphisms, and expand upon methods in the field.</p> <p>The first three results chapters investigate genetic biomarkers for the prediction of toxicity caused by 5-FU-based treatment, particularly for the 5-FU prodrug capecitabine (Xeloda®, Roche). In the first, a systematic review and meta-analysis is performed for all variants that have been previously studied for an association with toxicity caused by any 5-FU-based drug regimen. 16 studies are analysed, including 36 previously-studied variants. Four variants show strong evidence of affecting a patient’s risk of global (any) 5-FU-related toxicity upon analysis of both the existing data and over 900 patients from the QUASAR2 trial of capecitabine +/- bevacizumab (Avastin®, Roche/Genentech): <em>DPYD</em> 2846, <em>DPYD</em> *2A, <em>TYMS</em> 5’VNTR and <em>TYMS</em> 3’UTR. Next, 1,456 polymorphisms in 25 genes involved in the activation, action or degradation of 5-FU are investigated in 1,046 patients from QUASAR2. At a Bonferroni-corrected p-value threshold of 3.43e-05, three novel associations with capecitabine-related toxicity are identified in <em>DPYD</em> (rs12132152, rs7548189, A551T) and the previously-identified <em>TYMS</em> 5’VNTR and 3’UTR toxicity polymorphisms are refined to a tagging SNP (rs2612091) downstream of <em>TYMS</em> and intronic to the adjacent <em>ENOSF1</em>, the latter of which appears to be functional. Finally, a genome-wide investigation of 4.77 million directly genotyped or imputed SNPs identifies one variant (rs2093152 on chr20) as significantly associated with capecitabine-related diarrhoea (p<5e-08), though no associations meet this threshold for global toxicity.</p> <p>In the study of CRC prognosis, a severe left truncation to the VICTOR trial is defined and shown to probably reduce statistical power but not bias effect estimates. Applying standard and novel genome-wide analysis approaches, a set of 43 SNPs are prioritised for future work.</p> <p>With over one million new CRC cases annually, this work helps define biomarkers that could become broadly applicable in the clinical setting.</p>
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