INTRODUCTION

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Gene Therapy, experimental medical treatment that manipulates a gene or genes within
cells in order to produce proteins that change the function of those cells. Gene therapy
originated in efforts to treat and cure some of the more than 9,000 knowngenetic disorders,
most of which lack an effective therapy. In the United States 1 infant in every 28 is born with
a disorder caused by a defect in 1 or more of the estimated 31,000 genes found in the
human body. Thousands of children and adolescents die from these diseases each year, and
tens of thousands suffer lifelong disability. Although gene therapy is not an approved
medical therapy to treat disease, over 400 clinical trials, experiments testing the safety and
efficacy of this method on humans, have been conducted in the United States. Scientists
expect that within the first decades of the 21st century, gene therapy will offer
unprecedented opportunities to treat, cure, and ultimately prevent a vast range of diseases.
The original goal of gene therapy was to substitute a healthy gene for a defective one, or to
repair a faulty gene, thereby eliminating symptoms of disease. But researchers have moved
beyond inherited genetic disorders to treat other kinds of diseases. Today, nearly 75 percent
of all clinical trials involving gene therapy are aimed at treatments for cancer and acquired
immunodeficiency syndrome (AIDS). Cancer begins in genes and may be caused by an
inherited defect or a mutation (permanent alteration to a gene) that causes a cell to
malfunction. AIDS is caused by a virus that disrupts the genetic material of immune cells.
Other new gene therapy projects are targeted at conditions such as heart disease, diabetes
mellitus, arthritis, andAlzheimer's disease, all of which involve genetic susceptibility to
illness. Gene therapists hope to reduce or eliminate this susceptibility. Eventually, gene
therapy might help older people to regain strength in withered muscles and density in
thinned bones, and to increase pumping power in their aging hearts. Some researchers
predict that in the distant future the technology could be used to eliminate genetic defects
from families or even to produce “designer babies” with more muscle strength, higher
intelligence, sweeter dispositions, or whatever traits parents desire.
Although gene therapy offers seemingly limitless possibilities, researchers have been
thwarted by many technical problems. There has only been one successful clinical trial using
gene therapy—in April 2000 French researchers reported the successful use of gene therapy
to treat two female infants with severe combined immunodeficiency disease (SCID), a
deadly inherited disease that impairs the immune system. But even this success was marred
when each child later developed a rare leukemia-like illness, thought to be a result of gene
therapy. Most clinical trials of gene therapy have not resulted in enough improvement in the
patient’s underlying condition to consider it an unqualified success and to justify treating
large numbers of people. The extraordinary potential of gene therapy has also raised alarms
among critics who warn that the technology could go too far. They note, for example, that
gene therapy could offer wealthy families opportunities for genetic enhancement
unavailable to the poor. More troubling still for some critics is gene therapy's potential to
narrow the human gene pool, producing unknown, and possibly harmful, consequences.

THE NATURE OF GENES

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A gene is a long segment of the molecule deoxyribonucleic acid (DNA). This segment,
composed of minute subunits called nucleotide bases, serves as the blueprint for
manufacturing a single protein or enzyme needed for the structure or function of cells. In
humans, genes are compressed and bundled into a set of 23 pairs of chromosomes, which
stabilize and protect the DNA. Even a tiny error in the arrangement of a gene's nucleotide
bases can lead to the production of a protein or enzyme that works improperly, disrupting
cellular biology like a broken piston would wreak havoc in an automobile engine. Or the
needed compounds might not be produced at all.
Biologists have known about the importance of genes since the pioneering work of Austrian
monk Gregor Mendel. In a series of experiments beginning in the 1850s Mendel showed that
the traits of plants are inherited in a precise, predictable manner. But little was known about
the physical nature of genes until the 1950s when American biochemist James Watson and
British biophysicist Francis Crick developed their revolutionary model of DNA. Watson and
Crick showed that DNA is composed of two strands of nucleotides, linked to form a chain and
arranged in a structure resembling a twisted ladder, called a double helix. Another key
breakthrough came in the early 1970s when researchers discovered a series of enzymes
that made it possible to snip apart genes at predetermined sites along a molecule of DNA,
then glue them back together in a reproducible manner. These genetic advances set the
stage for the emergence of the genetic engineering industry, which has produced new
drugs, antibodies, and a host of other naturally occurring chemicals. The discoveries also
enabled scientists to contemplate gene therapy.

TYPES OF GENE THERAPY

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There are two distinctly different types of gene therapy: somatic-cell therapy and germ-line
therapy. In somatic-cell therapy, gene surgeons attempt to fix genetic malfunctions in
somatic (body) cells, such as blood cells and skin cells. This type of gene therapy is the only
one that has been performed on humans. Genetic alterations to somatic cells are restricted
to the person being treated and cannot be passed on to his or her offspring.
In germ-line therapy, genetic alterations are made to germ cells, such as sperm and eggs, in
order to treat inherited diseases. Germ-line therapy is highly controversial because such
changes would alter the genetic endowment of the unborn and could be passed on to future
generations. Germ-line experiments with laboratory animals have been performed since the
late 1980s. In countries that regulate gene therapy in clinical trials, germ-line therapy has
yet to be applied to humans. Nevertheless, U.S. researchers have submitted proposals to
conduct human germ-line experiments, and many experts predict the first of these
experiments will occur early in the 21st century.

METHODS
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In gene therapy, one or more genes are inserted into a cell, where they produce a missing
protein or enzyme. Researchers have developed several methods for transporting genes into
cells. The most common technique is to attach healthy genes to genetically modified
viruses. These infectious agents, known as vectors, carry the genes into a cell’s nucleus and
incorporate them into the genetic material of the infected cell. Another gene-delivery
method still under development is chimeraplasty, in which segments of DNA are inserted
into a cell’s nucleus. The DNA segment binds with a defective gene in a way that helps the
cell’s repair mechanisms identify and fix the defective gene.

Virus Vectors
A
About 15 years ago scientists demonstrated that viruses could be used as vectors for the
delivery of healthy genes. Scientists use four types of viruses in gene therapy experiments—
retroviruses, adenoviruses, adeno-associated viruses, and herpes simplex viruses.
 Retroviruse
A1
s

Retroviruses were the first viruses used as vectors in gene therapy experiments. They are
unusual because instead of using DNA to carry their genetic information to the cell’s protein-
making machinery, retroviruses use a related material called ribonucleic acid (RNA) as their
primary carrier of genetic information. When retroviruses invade a cell, they use an enzyme
called reverse transcriptase to make a DNA copy of their genes. Other enzymes then
incorporate this DNA copy into the infected cell's DNA.
In one application, scientists use a retrovirus that causes leukemia in mice but no known
disease in humans. The researchers remove the genes that cause disease and, in their
place, insert an RNA copy of a healthy gene into the virus. They also add a piece of genetic
information called a promoter. The promoter is, in effect, an “on/off switch” for a gene.
When it is turned on, usually with a drug, it tells the cell's protein-making machinery to
begin producing the inserted gene's protein.
Although retroviruses have been used in most gene therapy experiments so far, they still
present many problems. Retroviruses can invade only cells that are actively dividing,
limiting potential targets for therapy to blood cells, skin cells, stem cells, and other fast-
growing tissues. In addition, the viruses have no specific targets in the infected cells'
chromosomes. As a result, the genes they carry are inserted in a haphazard manner.
Ideally, retroviruses insert genes into the middle of a strand of DNA that does not contain
other genes. The genes might, however, be inserted smack in the middle of a crucial gene,
rendering it defective and blocking key cellular functions, causing more damage than repair.
Retroviruses could also integrate new genes into a stretch of DNA where they could cause
cancer. Despite the presence of promoters, moreover, the added genes typically do not
produce sufficient amounts of proteins to effectively treat disease. In addition, the patient’s
body generally recognizes retroviruses as foreign invaders, provoking adverse immune
responses.
Researchers approached the use of retroviruses with caution because of concerns that they
might attack inappropriate cells. To avoid this problem, researchers initially removed blood
or other target cells from the patient's body before treatment with the retrovirus. They then
monitored the cells to ensure the therapy was working properly before returning the cells to
the patient’s body.
As researchers have grown more confident, however, they have begun injecting altered
retroviruses directly into tissues where the corrected genes are needed and have, so far,
observed few problems. In clinical trials of patients with cystic fibrosis, a disease in which a
mutated gene impairs lung function, healthy genes are inserted directly into the lining of
bronchial tubes. In studies of animals, researchers have used retroviruses to inject genes
directly into muscle tissue to learn if the genes will produce normal muscle proteins.
Researchers hope this treatment will one day help people with muscular dystrophy.

Adenoviruse
A2
s

To avoid the problem of inserting genes at the wrong sites, some researchers have turned to
other types of viruses, such as the adenoviruses, which cause the common cold. Stripped of
their disease-causing genes, adenoviruses take healthy genes into the nucleus of cells,
where the DNA is located, but do not usually integrate them into a cell's DNA. Researchers
thus trade safety for impermanence, because the genes persist in the cell’s DNA only for
days to weeks. Adenoviruses can also infect a broader variety of cells than retroviruses do,
including cells that divide more slowly, such as lung cells. However, adenoviruses are also
more likely to be attacked by the patient's immune system, and the high levels of virus
required for treatment often provoke an undesirable inflammatory response. Despite these
drawbacks, adenoviruses have been used in attempts to treat cancers of the liver and
ovaries.

Adeno-Associated
A3
Virus

One of the most promising potential gene-delivery systems, or vectors, is a recently

discovered virus called the adeno-associated virus, which infects a broad range of cells,
including both dividing and nondividing cells. Researchers believe that most humans carry
adeno-associated viruses, which do not cause disease and do not provoke an immune
response. Scientists have demonstrated that the adeno-associated virus can be used to
correct genetic defects in animals. It is now being used in preliminary studies to
treat hemophilia, a hereditary blood disease, in humans.
The chief drawback of the adeno-associated virus is that it is small, carrying only two genes
in its natural state. Its payload is therefore relatively limited. It can produce unintended
genetic damage because the adeno-associated virus inserts its genes directly into the host
cell's DNA. Researchers have also had difficulties manufacturing large quantities of the
altered virus.

Herpes Simplex
A4
Virus

Scientists have found that the herpes simplex virus, the cause of the common cold sore, has
a very large genome compared to other virus vectors. This large genome enables scientists
to insert more than one therapeutic gene into a single virus, paving the way for the
treatment of disorders caused by more than one gene defect. The virus makes an ideal
vector because it can infect a wide variety of tissues, including muscle, tumor, liver,
pancreas, nerve, and lung cells.
One problem with using herpes simplex virus is that the virus is cytopathic—that is, it kills
the cells that it infects. In addition, the virus can cause encephalitis (inflammation of the
brain) if it replicates freely in the brain. Scientists are developing a form of herpes simplex
virus in which the genes that direct the virus’s replication and cell-killing abilities have been
removed.

Chimeraplast
B y
Some researchers believe that in the near future a process called chimeraplasty may make
it possible to fix defective genes within a cell directly, making it unnecessary to insert new
genes into cells. Researchers have developed short segments of DNA called oligomers,
whose nucleotide sequences complement those of a gene in which a defect occurs. When
inserted into the cell's nucleus, oligomers bind to the defective gene where the sequences
are correct, but they do not bind properly at defective sites. The cell's repair machinery sees
this “bump” in the DNA and interprets it as a signal to repair the defective gene.
Chimeraplasty has been successfully tested in animals, and investigators have recently
begun to test it in humans.

Clinical
C Trials
Once gene therapy methods have been developed in a laboratory and tested on animals,
scientists need to prove that they work in humans. Scientists approach any experiments in
humans with great care. Since gene therapy is a new technique that may have unforeseen
risks, they develop a proposed experiment, known as a protocol, that incorporates strict
safety guidelines.
In the United States, a gene therapy protocol must be reviewed and approved by the
Recombinant DNA Advisory Committee of the National Institutes of Health (NIH). If
approved, the protocol is then submitted to the Food and Drug Administration (FDA) for
approval. After the FDA gives permission for human testing to begin, they continue to
monitor the experiments. In the course of a clinical trial, researchers are required to report
any harmful side effects resulting from the gene therapy treatment under study. The FDA
has approved more than 400 clinical trials of gene therapy, although in early 2003 the FDA
placed a temporary ban on 30 of the clinical trials that used retrovirus vectors. The FDA took
this precautionary measure after the French gene therapy trial for SCID resulted in a life-
threatening disorder that may have been caused by the procedure. The FDA expects to
permit the U.S. trials to resume if safety measures are taken to minimize the risk of using
retrovirus vectors.

DEBATES ABOUT GENE THERAPY

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Most scientists are confident that technical problems associated with gene therapy will
eventually be overcome, allowing its use by a much larger number of people. That prospect
has prompted ethical and moral concerns about gene therapy, especially regarding
alterations to germ cells.
Critics and proponents all agree that the risks of gene therapy must not be substantially
larger than the potential benefits. For this reason, most of the early gene therapy
experiments have been on rare diseases that can cause intense suffering and for which no
treatment exists. Initial experiments using gene therapy in the treatment of cancer and AIDS
have been conducted primarily in patients for whom all other treatments have failed and
who are near death, so the risks are small. This is the same procedure used to test new
drugs against these diseases. But many people feel that because gene therapies use altered
genes and potentially dangerous viruses, these treatments should be more extensively
tested than drugs before being approved.
Critics have charged, for example, that the health risks exceeded the benefits in a case in
1999 that resulted in the first death linked to gene therapy. In that case, an 18-year-old
Arizona man received gene therapy for a rare genetic metabolic disorder called ornithine
transcarbamylase deficiency. He died from failure of his liver and other internal organs four
days after researchers at the University of Pennsylvania in Philadelphia infused a genetically
modified adenovirus into his liver to correct the defect. Many observers believe the man
should not have been treated because he had a mild form of the disease and drugs and diet
may have been able to control his symptoms.
The potential risks are also at the center of the more contentious debate about germ-line
therapy. Although the potential benefits of success are great—lifelong freedom from genetic
disease and the elimination of dangerous genetic legacies in families—the risks are also
much greater. For example, partial correction of a genetic defect might lead to the birth of a
severely deformed child. Without the intervention of gene therapy, such a pregnancy might
otherwise result in a miscarriage. The procedure might also bring unforeseen harm to the
mother, through either unpredicted spread of the virus vector or other problems associated
with the procedure.
Beyond scientific and medical risks, germ-line therapy opens thorny moral dilemmas. Critics
argue that, for example, people do not have the right to sculpt the genetic blueprint of
children—a decision in which the child has no voice. Others portray the experiments as the
first step down the slippery slope to designer babies. Critics fear that before too long, any
child who has not received enhancement through gene therapy and who does not measure
up to some arbitrary standard of health, behavior, or physique will be seen as flawed.
Few researchers endorse genetic enhancement of babies, and most think it is a bad idea.
For one thing, enhancement is a much more complex procedure than repairing a genetic
defect. Such apparently simple traits as blue eyes or brown hair are caused by complex
interactions among genes. Interfering with that interaction is likely to have unexpected
consequences, increasing the risks for health problems. Nevertheless, the concept of
enhancement received a boost from studies showing that mice can be made more intelligent
by adding a single gene to their genome and that they can be made more sociable by
adding a different gene—apparently, in both cases, without adverse effects.

CHALLENGES FOR GENE THERAPY

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Gene therapy is a powerful new technology, but many advances are necessary before it will
make a noticeable impact on the treatment of disease. Researchers must make vectors that
are more effective at invading large numbers of cells, must find new ways to manufacture
the vectors in large quantities, and must produce better promoters so that larger quantities
of proteins are produced.
Observers note that the field of gene therapy is still very young and the rules governing
gene therapy clinical trials are evolving as the field evolves. As a consequence, some safety
issues have not been fully addressed, which critics charge may have resulted in the
unnecessary death in the gene therapy clinical trial in 1999. That death provoked a detailed
review of the methods used in gene therapy trials, and the NIH and FDA developed plans for
increased oversight of safety and efficacy in gene therapy trials.
Despite some technical setbacks in the methods used in gene therapy and some procedural
problems in testing gene therapy in humans, most experts believe that use of gene therapy
in medicine is inevitable. Experts believe that within the next few decades, doctors will
routinely correct simple genetic defects, eliminating a number of diseases that now plague
humankind.