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Knudson [Knudson, A. G. (1971) Proc. Natl. Acad. Sci. USA 68, 820-823] suggested that progression of retinoblastoma follows from two mutational events. Individuals who inherit one mutated gene copy should follow an age-onset pattern set by only a single rate-limiting step for transformation, whereas normal individuals should follow an age-onset pattern set by two rate-limiting events. Knudson's analysis of inherited and sporadic cases of retinoblastoma supported this prediction. However, retinoblastoma has a peculiar age-onset pattern concentrated in early life, because the retinal tissue completes most of its cell division by 5 years of age. Here, I compare age-specific incidences of inherited and sporadic forms of colon cancer, a much more typical form of human cancer. My simple mathematical analysis based on multistage theory explains the observed differences in age-onset patterns between inherited and sporadic cases. I also analyze recent retinoblastoma data and provide a mathematical analysis and interpretation. My analysis supports Knudson's two-hit theory but is much simpler and easier to understand than the original mathematical theory, which was based on a complicated model of cell division in the retina. My simpler theory for retinoblastoma makes clear the common basis for understanding multistage progression in tissues as different as the retina and colon.

Age-specific incidence of inherited versus sporadic cancers: A test of the multistage theory of carcinogenesis