The role of DNA methylation in ovarian cancer chemoresistance: A narrative review

BACKGROUND AND AIMS: Ovarian cancer (OC) is the most lethal gynecological cancer. In 2018, it was responsible for over 180,000 deaths worldwide. The high mortality rate is the culmination of a lack of early diagnosis and high rates of chemotherapy resistance, which is synonymous with disease recurrence. Over the last two decades, an increasingly significant role of epigenetic mechanisms, in particular DNA methylation, has emerged. This review will discuss several of the most significant genes whose hypo/hypermethylation profiles are associated with chemoresistance. Aside from functionally elucidating and evaluating these epimutations, this review will discuss recent trials of DNA methyltransferase inhibitors (DNMTi). Finally, we will propose future directions that could enhance the feasibility of utilizing these candidate epimutations as clinical biomarkers. METHODS: To perform this review, a comprehensive literature search based on our keywords was conducted across the online databases PubMed and Google Scholar for identifying relevant studies published up until August 2022. RESULTS: Epimutations affecting MLH1, MSH2, and Ras‐association domain family 1 isoform A (DNA damage repair and apoptosis); ATP‐binding cassette subfamily B member 1 and methylation‐controlled J (drug export); secreted frizzled‐related proteins (Wnt/β‐catenin signaling), neurocalcin delta (calcium and G protein‐coupled receptor signaling), and zinc finger protein 671 all have potential as biomarkers for chemoresistance. However, specific uncertainties relating to these epimutations include histotype‐specific differences, intrinsic versus acquired chemoresistance, and the interplay with complete surgical debulking. DNMTi for chemoresistant OC patients has shown some promise; however, issues surrounding their efficacy and dose‐limiting toxicities remain; a personalized approach is required to maximize their effectiveness. CONCLUSION: Establishing a panel of aberrantly methylated chemoresistance‐related genes to predict chemoresponsiveness and patients' suitability to DNMTi could significantly reduce OC recurrence, while improving DNMTi therapy viability. To achieve this, a large‐scale prospective genome‐wide DNA methylation profile study that spans different histotypes, includes paired samples (before and after chemotherapy), and integrates transcriptomic and methylomic analysis, is warranted.