Several experimental and epidemiologic studies have shown that the antidiabetes drug metformin has antitumor properties. The report by Algire and colleagues in this issue of the journal (beginning on page 536) shows for the first time that metformin reduces mutagenesis induced by reactive oxygen species. This report offers new perspectives on metformin in cancer prevention and provides a new mechanism for the reduction of cancer risk in diabetic patients treated with this drug. Cancer Prev Res; 5(4); 503-6. Ó2012 AACR.Metformin (N 0 ,N 0 -dimethylbiguanide) belongs to the biguanide class of oral hypoglycemic agents. It is a widely used antidiabetes drug now prescribed to almost 120 million diabetic patients. In addition to its efficacy in lowering glucose levels, and consequently insulinemia, it has the clinical advantage of not inducing any risk of hypoglycemia at standard doses and of inducing few adverse secondary effects (1).Accumulating evidence from epidemiologic and experimental studies shows that metformin exerts antitumor and antiproliferative effects (reviewed in ref.2). Many epidemiologic studies have shown that metformin (compared with other antidiabetic drugs such as insulin or sulfonylureas) reduces the incidence of cancers in diabetic patients (2). It should be noted, however, that most of these studies have been retrospective and exclusively involved diabetic patients.At the cellular level, metformin induces cell-cycle arrest, autophagy, and cell death, depending on the cancer cell origin (3-5). It also affects cancer cell metabolism and inhibits the activity of the mitochondrial complex I in hepatocytes and cancer cells (Fig. 1; refs. 6,7). At the molecular level, metformin activates AMP-activated kinase (AMPK), a kinase regulated by liver kinase B1 (LKB1), a tumor suppressor gene. AMPK activation inhibits mTOR, which controls protein synthesis. Altogether, these observations suggest a direct action of metformin on cancer cell proliferation. Numerous preclinical studies have shown that metformin reduces tumor growth in mice models. Interestingly, an article by Vitale-Cross in this issue demonstrates that metformin prevents the development of oral squamous cell carcinoma (8). One of the disputed issues, however, is whether the in vivo effects of metformin are direct and/or indirect, that is, due to the associated decrease in insulin levels as a consequence of decreased hyperglycemia. Indeed, insulin as well as insulin-like growth factor-1 (IGF-1) are key factors in promoting cancer development (9, 10). Some preclinical studies in different mouse models found that decreased tumor growth was associated with a significant reduction of insulinemia (11,12). One of the most interesting of these preclinical studies was recently published in this journal by Memmott and colleagues (13). They show that metformin prevents carcinogenesis induced by 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), a wellknown tobacco-specific human lung carcinogen that is notorious for causing DNA damage. The ant...