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The Goal of Geroscience Is Life Extension www.oncotarget.com Oncotarget, 2021, Vol. 12, (No. 3), pp: 131-144 Research Perspective The goal of geroscience is life extension Mikhail V. Blagosklonny1 1Roswell Park Cancer Institute, Buffalo, NY 14263, USA Correspondence to: Mikhail V. Blagosklonny, email: [email protected], [email protected] Keywords: aging; longevity; rapamycin; mTOR; metformin Received: December 23, 2020 Accepted: January 13, 2021 Published: February 02, 2021 Copyright: © 2021 Blagosklonny. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. ABSTRACT Although numerous drugs seemingly extend healthspan in mice, only a few extend lifespan in mice and only one does it consistently. Some of them, alone or in combination, can be used in humans, without further clinical trials. INTRODUCTION healthspan without lifespan (e.g., resveratrol), and discuss how to proceed with clinical application of lifespan- “Although we do not know everything about extending drugs. aging, we now know enough to start its pharmacologic suppression using clinically approved drugs.” Published Failure of anti-oxidants in 2010, these opening words of the paper entitled “Increasing healthy lifespan by suppressing aging in our The goal of longevity research is life extension. lifetime: preliminary proposal” are still relevant today Instead, most studies are focused on life-shortening. Many [1]. The proposal was based on hyperfunction theory things can shorten lifespan without causing normal aging. that aging is a continuation of development, driven in For example, car accidents shorten lifespan, but they do part by growth-promoting pathways, such as mTOR [2]. not cause aging. Knockout of antioxidant enzymes can Hyperfunction (inappropriate activation) of these signaling shorten lifespan. But antioxidants do not extend lifespan pathways directly drive all age-related diseases, which are [3–12]. Furthermore, antioxidants increase mortality manifestations of aging. We just need clinically available in humans [13–17]. Clinical trials of antioxidants inhibitors (drugs) of these signaling pathways to extend have been terminated because of increased cancer both healthspan and lifespan, by slowing aging. incidence [13–17]. In agreement, antioxidants promote Here I discuss a practical approach as to how cancer in mice [18, 19]. Yet, thousands of publications to make the current generation of adults live longer describe mechanisms of life extension by the exact and healthier, without conducting lifelong randomized same antioxidants that do not extend lifespan. To study clinical trials. Even if such trials would be started, only mechanisms of life extension, there must be life extension the next generation may benefit. But such clinical trials at least. are not needed anymore. For practical purposes, it is Certainly, reactive oxygen species (ROS) cause both necessary and sufficient that a drug consistently and molecular damage, and this damage would eventually significantly extend lifespan in mice (and other mammals, kill the organism. But no organism lives long enough if tested) and be already approved for any indication in to die from accumulation of molecular damage because humans. Given that no proof of life extension in humans hyperfunctional (in part, mTOR-driven) aging terminates (and other long-lived mammals) can be available in our life first [9]. If artificially accelerated by knocking out lifetime, we need strong evidence in rodents. I will discuss genes, molecular damage may become life limiting. But that the requirement of life extension must be strict. A in normal animals and humans, it is not. We cannot extend mere extension of healthspan is not enough: drugs that life by targeting a non-life-limiting process. fail to extend lifespan in mice will fail to extend lifespan in humans, if used as a monotherapy. Yet, in rational The goal of geroscience combinations with life-extending drugs, “healthspan-only” drugs may extend lifespan further. Here I will review The goal of geroscience is extension of lifespan drugs that extend lifespan and healthspan in mammals by extending healthspan. Standard medical interventions (e.g., rapamycin), in contrast to those that may affect only can prolong lifespan without extending healthspan (e.g., www.oncotarget.com 131 Oncotarget using a ventilator in comatose patient) but anti-aging of healthspan is subjective, because pre-diseases progress interventions increase lifespan by slowing aging and thus slowly towards diseases (Figure 1A: gray zone). Besides, delaying age-related diseases (extending healthspan). it’s not one disease but the sum of all diseases. In mice, One of the notions of hyperfunction theory is that age- diseases are difficult to diagnose until animal death. related diseases can be prevented and treated by slowing Given this, why not then measure healthspan and lifespan down aging with anti-aging drugs, such as rapamycin, as simultaneously? discussed in 2006–2012 [2, 20–22] and later named the So why has healthspan become so popular in animal geroscience hypothesis [23–26]. studies? The reason is that only a few drugs were shown to extend lifespan in mammals. Other drugs seemingly Lifespan vs healthspan increase healthspan but do not extend lifespan. This is considered an acceptable and even desirable effect [27]. But Healthspan is a period of life without age-related it is not. Increased healthspan must automatically increase diseases [27]. It is disease-free survival. (Note: A patient lifespan (Figure 1A and 1B), if healthspan represents good may view healthspan as a symptom-free survival, a health. Animals, including humans, do not die from good subjective well-being, but this definition is not used in health, they die from age-related diseases. If diseases are animal studies.) Since animals and humans die from age- delayed, an animal will live longer. (Symptomatic treatment related diseases, an increase in healthspan is expected to (e.g., opioids for pain) and placebo may prolong subjective increase lifespan. For example, in centenarians, healthspan well-being of humans without extending lifespan, but such is increased (this is why they are centenarians) [28]. treatments are not a subject of geroscience). Calorie restriction (CR) delays diseases and thus extends Consider a scenario in which lifespan is not lifespan in rodents [29]. So healthspan is a surrogate for increased, while healthspan is increased. To keep lifespan lifespan. constant, while increasing healthspan, diseases must be However, in comparison with lifespan, healthspan compressed (Figure 1C): start later but kill faster. For is difficult to measure, especially in animals [27]. The end example, in this scenario, cancer kills an organism in a Figure 1: Extension of healthspan extends lifespan. (A) Healthspan is the period of life without diseases. Diseases (black color) terminate lifespan. Subclinical aging (white color) progresses to pre-diseases (gray) and diseases (black). X axis: age. Y axis: loss of health (a sum of diseases) in log scale. (B) Longevity intervention slows aging and extends healthspan, automatically extending lifespan. (C) Unrealistic scenario “Healthspan without lifespan”. Compressed morbidity (black). Either diseases progress instantly, or animals die from “health” rather than from diseases. www.oncotarget.com 132 Oncotarget matter of minutes, instead of months. This is impossible monkeys [32, 33]. CR must extend lifespan in humans (Note: One apparent exception is the illusion of disease because it delays all age-related diseases in humans [29]. compression in centenarians due to poor diagnostics and Still it is debated whether it would extend life in humans. lack of medical treatment at the oldest age, as discussed Some gerontologists think that it will not [34]. Imagine, if later). Otherwise, an increase of healthspan must increase CR would not increase lifespan in any mammal including at least median lifespan (Figure 1B). mice. Would we then think that it may mysteriously extend So how is it possible that some senolytics, NAD life in humans? No. But then why are drugs that do not boosters and resveratrol, increase healthspan without extend life in mice still being considered to extend life lifespan? The simplest explanation is that they do not in humans. To reasonably expect that a drug will extend increase healthspan at all, because such studies use lifespan in humans, a drug must extend medium and irrelevant or ambiguous markers of health. Ambiguous maximum lifespan in genetically heterogeneous mice, parameters can be associated with either good or bad multiple strains of mice, and cancer-prone mice. (Note: health, depending on the underlying cause. For example, Cancer is delayed when aging is slow. For example, cancer similar changes in insulin signaling are associated with is rare in long-lived naked mole rats and centenarians). either slow or fast aging, depending on the mTOR activity [30]. Resveratrol The second explanation is that some diseases are not deadly, so that their treatment does not extend lifespan Three studies in mice failed to show life extension but improve quality of life. Yet, healthspan should not be by resveratrol [35–37]. In one of them, resveratrol measured by non-deadly diseases only. After all, aging is improved health without extending lifespan [35]. an exponential increase of death with age and
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