Skip to main content

FOXM1 mediates GDF-15 dependent stemness and intrinsic drug resistance in breast cancer



Stemness, a key component of breast cancer (BC) heterogeneity, is responsible for chemoresistance. Growth differentiation factor-15 (GDF-15) induces drug resistance and stemness in BC cells. In this study, the expressions and interactions of GDF-15, FOXM1, and stemness (OCT4 and SOX2), and drug resistance (ABCC5) markers were evaluated in BC.

Methods and results

40 diagnosed BC patients and 40 healthy controls were included in this study. Serum GDF-15 was significantly raised (p < 0.001) in BC patients. Expressions of GDF-15, OCT4, SOX2, and FOXM1 in BC tissue and cell lines (MCF-7 and MDA-MB-231) were determined by RT-PCR, while phosphorylated AKT (p-AKT) was analyzed by Western blot. Not only were the fold change expressions higher in cancer tissue as compared to surrounding control tissue, but a higher expression was observed for all the genes along with p-AKT in MDA-MB-231 cells compared to MCF-7. Tissue GDF-15 was significantly associated with ABCC5 (p < 0.001), OCT4 (p = 0.002), SOX2 (p < 0.001), and FOXM1 (p < 0.001). To further analyze the signaling pathway involved in stemness and drug resistance in BC, GDF-15 knockdown was performed, which reduced the expression of p-AKT, FOXM1, OCT4 and SOX2, and ABCC5, whereas recombinant GDF-15 treatment reversed the same. In silico analyses in UALCAN revealed a similar picture for these genes to that of BC tissue expression.


GDF-15 promotes stemness and intrinsic drug resistance in BC, possibly mediated by the p-AKT/FOXM1 axis.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Data availability

The data related to this article can be accessed by contacting the corresponding author.



ATP-binding cassette


Breast cancer


Breast cancer stem cells


Cancer stem cells


Estrogen receptor


Forkhead box M1


Growth Differentiation Factor-15


Human epidermal growth factor receptor


Octamer-binding transcription factor 4


Progesterone receptor


Sex determining region Y-box 2


Transforming growth factor-β


Triple negative breast cancer


  1. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F (2021) Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 71(3):209–249.

    Article  PubMed  Google Scholar 

  2. Foulkes WD, Smith IE, Reis-Filho JS (2010) Triple-negative breast cancer. N Engl J Med 363(20):1938–1948.

    Article  CAS  PubMed  Google Scholar 

  3. Al-Thoubaity FK (2019) Molecular classification of breast cancer: a retrospective cohort study. Ann Med Surg 49:44–48.

    Article  Google Scholar 

  4. Kulkarni A, Kelkar DA, Parikh N, Shashidhara LS, Koppiker CB, Kulkarni M (2020) Meta-analysis of prevalence of triple-negative breast cancer and its clinical features at incidence in Indian patients with breast cancer. JCO Glob Oncol 6:1052–1062.

    Article  PubMed  Google Scholar 

  5. Sridharan S, Howard CM, Tilley AMC, Subramaniyan B, Tiwari AK, Ruch RJ, Raman D (2019) Novel and alternative targets against breast cancer stemness to combat chemoresistance. Front Oncol 9:1003.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Cho Y, Kim YK (2020) Cancer stem cells as a potential target to overcome multidrug resistance. Front Oncol 10:764.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Chen Y, Song J, Jiang Y, Yu C, Ma Z (2015) Predictive value of CD44 and CD24 for prognosis and chemotherapy response in invasive breast ductal carcinoma. Int J Clin Exp Pathol 8(9):11287–11295

    PubMed  PubMed Central  Google Scholar 

  8. Desmedt S, Desmedt V, De Vos L, Delanghe JR, Speeckaert R, Speeckaert MM (2019) Growth differentiation factor 15: a novel biomarker with high clinical potential. Crit Rev Clin Lab Sci 56(5):333–350.

    Article  PubMed  Google Scholar 

  9. Roy D, Purohit P, Modi A, Khokhar M, Shukla RKG, Chaudhary R, Sankanagoudar S, Sharma P (2021) Growth differentiation factor-15 as a biomarker of obese pre-diabetes and type 2 diabetes mellitus in Indian subjects: a case-control study. Curr Diabetes Rev.

    Article  PubMed  Google Scholar 

  10. Modi A, Dwivedi S, Roy D, Khokhar M, Purohit P, Vishnoi J, Pareek P, Sharma S, Sharma P, Misra S (2019) Growth differentiation factor 15 and its role in carcinogenesis: an update. Growth Factors 37(3–4):190–207.

    Article  CAS  PubMed  Google Scholar 

  11. Modi A, Purohit P, Gadwal A, Roy D, Fernandes S, Vishnoi JR, Pareek P, Elhence P, Misra S, Sharma P (2021) A combined analysis of serum growth differentiation factor-15 and cancer antigen 15–3 enhances the diagnostic efficiency in breast cancer. EJIFCC 32(3):363–376

    PubMed  PubMed Central  Google Scholar 

  12. Peake BF, Eze SM, Yang L, Castellino RC, Nahta R (2017) Growth differentiation factor 15 mediates epithelial mesenchymal transition and invasion of breast cancers through IGF-1R-FoxM1 signaling. Oncotarget 8(55):94393–94406.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Sasahara A, Tominaga K, Nishimura T, Yano M, Kiyokawa E, Noguchi M, Noguchi M, Kanauchi H, Ogawa T, Minato H, Tada K, Seto Y, Tojo A, Gotoh N (2017) An autocrine/paracrine circuit of growth differentiation factor (GDF) 15 has a role for maintenance of breast cancer stem-like cells. Oncotarget 8(15):24869–24881.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Joshi JP, Brown NE, Griner SE, Nahta R (2011) Growth differentiation factor 15 (GDF15)-mediated HER2 phosphorylation reduces trastuzumab sensitivity of HER2-overexpressing breast cancer cells. Biochem Pharmacol 82(9):1090–1099.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Roy D, Tomo S, Modi A, Purohit P, Sharma P (2020) Optimising total RNA quality and quantity by phenol-chloroform extraction method from human visceral adipose tissue: a standardisation study. MethodsX 7:101113.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Livak KJ, Schmittgen TD (2001) Analysis of relative gene expression data using real-time quantitative PCR and the 2(-Delta Delta C(T)) method. Methods 25(4):402–408.

    Article  CAS  PubMed  Google Scholar 

  17. Szklarczyk D, Morris JH, Cook H, Kuhn M, Wyder S, Simonovic M, Santos A, Doncheva NT, Roth A, Bork P, Jensen LJ, von Mering C (2017) The STRING database in 2017: quality-controlled protein-protein association networks, made broadly accessible. Nucleic Acids Res 45(D1):D362–D368.

    Article  CAS  PubMed  Google Scholar 

  18. Shannon P, Markiel A, Ozier O, Baliga NS, Wang JT, Ramage D, Amin N, Schwikowski B, Ideker T (2003) Cytoscape: a software environment for integrated models of biomolecular interaction networks. Genome Res 13(11):2498–2504.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Raudvere U, Kolberg L, Kuzmin I, Arak T, Adler P, Peterson H, Vilo J (2019) g:Profiler: a web server for functional enrichment analysis and conversions of gene lists (2019 update). Nucleic Acids Res 47(W1):W191–W198.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Chandrashekar DS, Bashel B, Balasubramanya SAH, Creighton CJ, Ponce-Rodriguez I, Chakravarthi BVSK, Varambally S (2017) UALCAN: a portal for facilitating tumor subgroup gene expression and survival analyses. Neoplasia 19(8):649–658.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Windrichova J, Fuchsova R, Kucera R, Topolcan O, Fiala O, Finek J, Slipkova D (2017) MIC1/GDF15 as a bone metastatic disease biomarker. Anticancer Res 37(3):1501–1505.

    Article  CAS  PubMed  Google Scholar 

  22. Lee KL, Kuo YC, Ho YS, Huang YH (2019) Triple-negative breast cancer: current understanding and future therapeutic breakthrough targeting cancer stemness. Cancers 11(9):1334.

    Article  CAS  PubMed Central  Google Scholar 

  23. Nedeljković M, Damjanović A (2019) Mechanisms of chemotherapy resistance in triple-negative breast cancer-how we can rise to the challenge. Cells 8(9):957.

    Article  CAS  PubMed Central  Google Scholar 

  24. Ricardo S, Vieira AF, Gerhard R, Leitão D, Pinto R, Cameselle-Teijeiro JF, Milanezi F, Schmitt F, Paredes J (2011) Breast cancer stem cell markers CD44, CD24 and ALDH1: expression distribution within intrinsic molecular subtype. J Clin Pathol 64(11):937–946.

    Article  PubMed  Google Scholar 

  25. Ma F, Li H, Li Y, Ding X, Wang H, Fan Y, Lin C, Qian H, Xu B (2017) Aldehyde dehydrogenase 1 (ALDH1) expression is an independent prognostic factor in triple negative breast cancer (TNBC). Medicine 96(14):e6561.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Saigusa S, Tanaka K, Toiyama Y, Yokoe T, Okugawa Y, Ioue Y, Miki C, Kusunoki M (2009) Correlation of CD133, OCT4, and SOX2 in rectal cancer and their association with distant recurrence after chemoradiotherapy. Ann Surg Oncol 16(12):3488–3498.

    Article  PubMed  Google Scholar 

  27. Yang S, Zheng J, Xiao X, Xu T, Tang W, Zhu H, Yang L, Zheng S, Dong K, Zhou G, Wang Y (2015) SOX2 promotes tumorigenicity and inhibits the differentiation of I-type neuroblastoma cells. Int J Oncol 46(1):317–323.

    Article  CAS  PubMed  Google Scholar 

  28. Abd El-Maqsoud NM, Abd El-Rehim DM (2014) Clinicopathologic implications of EpCAM and Sox2 expression in breast cancer. Clin Breast Cancer 14(1):e1–e9.

    Article  CAS  PubMed  Google Scholar 

  29. Liu P, Tang H, Song C, Wang J, Chen B, Huang X, Pei X, Liu L (2018) SOX2 promotes cell proliferation and metastasis in triple negative breast cancer. Front Pharmacol 9:942.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Yeom YI, Fuhrmann G, Ovitt CE, Brehm A, Ohbo K, Gross M, Hübner K, Schöler HR (1996) Germline regulatory element of Oct-4 specific for the totipotent cycle of embryonal cells. Development 122(3):881–894

    Article  CAS  PubMed  Google Scholar 

  31. Liu CG, Lu Y, Wang BB, Zhang YJ, Zhang RS, Lu Y, Chen B, Xu H, Jin F, Lu P (2011) Clinical implications of stem cell gene Oct-4 expression in breast cancer. Ann Surg 253(6):1165–1171.

    Article  PubMed  Google Scholar 

  32. Cai S, Geng S, Jin F, Liu J, Qu C, Chen B (2016) POU5F1/Oct-4 expression in breast cancer tissue is significantly associated with non-sentinel lymph node metastasis. BMC Cancer 16:175.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Zhang JM, Wei K, Jiang M (2018) OCT4 but not SOX2 expression correlates with worse prognosis in surgical patients with triple-negative breast cancer. Breast Cancer 25(4):447–455.

    Article  PubMed  Google Scholar 

  34. Wang D, Lu P, Zhang H, Luo M, Zhang X, Wei X, Gao J, Zhao Z, Liu C (2014) Oct-4 and Nanog promote the epithelial-mesenchymal transition of breast cancer stem cells and are associated with poor prognosis in breast cancer patients. Oncotarget 5(21):10803–10815.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Gwak JM, Kim M, Kim HJ, Jang MH, Park SY (2017) Expression of embryonal stem cell transcription factors in breast cancer: Oct4 as an indicator for poor clinical outcome and tamoxifen resistance. Oncotarget 8(22):36305–36318.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Liu Y, Hock JM, Van Beneden RJ, Li X (2014) Aberrant overexpression of FOXM1 transcription factor plays a critical role in lung carcinogenesis induced by low doses of arsenic. Mol Carcinog 53(5):380–391.

    Article  CAS  PubMed  Google Scholar 

  37. Hou Y, Zhu Q, Li Z, Peng Y, Yu X, Yuan B, Liu Y, Liu Y, Yin L, Peng Y, Jiang Z, Li J, Xie B, Duan Y, Tan G, Gulina K, Gong Z, Sun L, Fan X, Li X (2017) The FOXM1-ABCC5 axis contributes to paclitaxel resistance in nasopharyngeal carcinoma cells. Cell Death Dis 8(3):e2659.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Xie Z, Tan G, Ding M, Dong D, Chen T, Meng X, Huang X, Tan Y (2010) Foxm1 transcription factor is required for maintenance of pluripotency of P19 embryonal carcinoma cells. Nucleic Acids Res 38(22):8027–8038.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Bergamaschi A, Madak-Erdogan Z, Kim YJ, Choi YL, Lu H, Katzenellenbogen BS (2014) The forkhead transcription factor FOXM1 promotes endocrine resistance and invasiveness in estrogen receptor-positive breast cancer by expansion of stem-like cancer cells. Breast Cancer Res 16(5):436.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Kwok JM, Peck B, Monteiro LJ, Schwenen HD, Millour J, Coombes RC, Myatt SS, Lam EW (2010) FOXM1 confers acquired cisplatin resistance in breast cancer cells. Mol Cancer Res 8(1):24–34.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Jabbarzadeh Kaboli P, Salimian F, Aghapour S, Xiang S, Zhao Q, Li M, Wu X, Du F, Zhao Y, Shen J, Cho CH, Xiao Z (2020) Akt-targeted therapy as a promising strategy to overcome drug resistance in breast cancer—a comprehensive review from chemotherapy to immunotherapy. Pharmacol Res 156:104806.

    Article  CAS  PubMed  Google Scholar 

  42. Yu G, Zhou A, Xue J, Huang C, Zhang X, Kang SH, Chiu WT, Tan C, Xie K, Wang J, Huang S (2015) FoxM1 promotes breast tumorigenesis by activating PDGF-A and forming a positive feedback loop with the PDGF/AKT signaling pathway. Oncotarget 6(13):11281–11294.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


This work was supported by the Intramural Funding of AIIMS, Jodhpur under Grant Number (AIIMS/RES/2019/3056) and Department of Biotechnology, Ministry of Science and Technology under Grant Number (DBT/2018/AIIMS-J/994).

Author information

Authors and Affiliations



Conception, organization and execution: AM, PP1; Data collection and analysis: AM, PP1, DR; Manuscript drafting: AM, PP1, DR; Data visualization: AM, DR; Review and critique of the manuscript: PP1, JRV, PP2, PE, PS1, SS, PS2, SM; Supervision of the project: PP1; All authors agreed to the final version of the manuscript.

Corresponding author

Correspondence to Purvi Purohit.

Ethics declarations

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 1967 KB)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Modi, A., Purohit, P., Roy, D. et al. FOXM1 mediates GDF-15 dependent stemness and intrinsic drug resistance in breast cancer. Mol Biol Rep 49, 2877–2888 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Breast cancer
  • GDF-15
  • Stemness
  • Drug resistance
  • FOXM1
  • Triple negative breast cancer