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Most textbooks attribute cancer-causing mutations to two major sources. Inherited and environmental factors. A recent study highlighted the prominent role in cancer of replicative mutations that arise from a third source. Unavoidable errors associated with deoxyribonucleic acid replication. Tomasetti et alia developed a method for determining the proportions of cancer-causing mutations that result from inherited, environmental, and replicative factors - see the Perspective by Nowak and Waclaw. They found that a substantial fraction of cancer driver gene mutations are indeed due to replicative factors. The results are consistent with epidemiological estimates of the fraction of preventable cancers.

Cancers are caused by mutations that may be inherited, induced by environmental factors, or result from deoxyribonucleic acid replication errors. We studied the relationship between the number of normal stem cell divisions and the risk of 17 cancer types in 69 countries throughout the world. The data revealed a strong correlation - median = 0.80 - between cancer incidence and normal stem cell divisions in all countries, regardless of their environment. The major role of replicative mutations in cancer etiology was supported by an independent approach, based solely on cancer genome sequencing and epidemiological data, which suggested that replicative mutations are responsible for two-thirds of the mutations in human cancers. All of these results are consistent with epidemiological estimates of the fraction of cancers that can be prevented by changes in the environment. Moreover, they accentuate the importance of early detection and intervention to reduce deaths from the many cancers arising from unavoidable replicative mutations.

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