Efficacy of Saffron ( Crocus sativus L.) and Its Constituents on Breast Cancer,a Systematic Review of Preclinical Studies and Potential Therapeutic Mechanisms

Abstract

Background:

Breast cancer is the most common cancer and the main cause of death because of malignant tumors in women, worldwide. The impact of Crocus sativus on several cancers has been discussed. Recent studies provide evidence regarding the anticancer properties of C. sativus and its bioactive constituents against breast cancer. This study aims to systematically review the efficacy of this botanical drug and its constituents on breast cancer, and their mechanism of action for the first time. Due to the lack of human studies in this field, the present research focused on preclinical studies.

Methods:

In this systematic review, scientific databases, including PubMed, Web of Sciences, Google Scholar, Scopus, and Scientific Information Database were explored profoundly. Preclinical studies published until the end of 2024 that had investigated the therapeutic properties of C. sativus, or its bioactive constituents including crocin, crocetin, safranal, or picrocrocin against breast cancer were selected.

Results:

Forty-four studies examining the effect of C. sativus or its bioactive constituents against breast cancer were obtained. Preclinical in vitro and in vivo studies have demonstrated the potential and targeted anticancer properties of the metabolites found in saffron (C. sativus). These metabolites, such as crocin, crocetin, and safranal, exhibit their anticancer effects through various mechanisms, including induction of apoptosis, modulation of the cell cycle, and other pathways.

Conclusions:

C. sativus and its constituents exerts their anticancer activity with different mechanisms. A considerable number of the included studies highlight induction of apoptosis and modulation of the cell cycle. The findings of our study suggest that certain compounds, particularly crocin and crocetin, have significant anticancer properties. In particular, crocin provided the highest level of evidence of efficacy in preclinical research, indicating its potential for further investigation.

Keywords

breast cancer saffron traditional medicine herbal medicine

Introduction

Breast cancer is known as the most common cancer and the main cause of death because of malignant tumors in females.^1,2 Several factors such as genetics, and lifestyle affect the risk of breast cancer and would influence the rate of mortality.³ The nature of this disease is very heterogeneous with variations in proliferative index, immunohistochemistry, clinical presentation, and histological grade.⁴ The medicinal plan in patients suffering from breast cancer often depends on the cancer subtypes including Her 2 amplified, and hormone receptor-positive subtypes.⁵ The main therapeutic options for breast cancer patients at early stages are chemotherapy, radiotherapy, surgical resection, and hormone therapy.⁶ Surgery is now being recommended more frequently, particularly in cases where metastasis has occurred.^6,7 The prognosis of breast cancer is also influenced by the stage of the disease, which is determined by factors such as the primary tumor size, involvement of axillary lymph nodes, and the presence of distant metastasis.^6,8 The variability in presentation and response to treatment has led to a comprehensive and collaborative approach that incorporates the use of natural remedies to improve survival rates. These multifaceted approaches rely heavily on early diagnosis of the disease.⁹ Worldwide, individuals with persistent chronic conditions such as cancer and acquired immunodeficiency syndrome utilize complementary and alternative medicine including botanical drugs to enhance their quality of life and alleviate the psychosocial and medical challenges they face.^10,11

Natural remedies have shown promising potential as agents that combat tumors and cancer. They have also exhibit reduced toxicity compared to conventional hormonal targeting anti-cancer agents, which often encounter recurrent resistance (known as multi-drug resistance).^12,13 These benefits are attributed to the antioxidant and anti-inflammatory properties of botanical drugs, and their ability to modulate the immune system and induce anti-proliferative and apoptotic effects on neoplastic cells.^14
-16 This approach aims to provide a chemo-preventive quality that can serve both as a preventive measure and as a therapeutic option while ensuring long-term safety.^17,18 Several studies have presented evidence supporting the effectiveness of natural products, such as botanical drugs, in the development of anticancer medications and in mitigating the adverse effects induced by chemotherapy.^18
-21 Although most of the studies conducted so far on the effects of numerous botanical drugs such as Curcuma longa, Nigella sativa, Matricaria chamomilla, and also their constituents on various cancers, including breast cancer, are preclinical,^22
-26 some of the common drugs used in the treatment of breast cancer are extracted from medicinal plants.²⁷ The therapeutic potential and tolerability of various bioactive compounds derived from herbs or their semi-synthetic derivatives have been attempted in breast cancer treatment. Vinca rosea (vinblastine, vinorelbine), Taxus baccata (paclitaxel, docetaxel), Camptotheca acuminata (camptothecin), and Podophyllum peltatum (etoposide) are chemotherapeutic drugs originated from herbal medicine; their efficacy against breast cancer has been assessed in clinical trials.^27
-29

Crocus sativus is a botanical drug that belongs to the iris family (Iridaceae) and primarily grows in Iran, and certain regions of China, like Tibet, and India. The flower of C. sativus contains various chemical components that have therapeutic potential, leading to its extensive use as a traditional medicine over a significant period.³⁰ C. sativus is a well-known spice traditionally used for food coloring and flavoring. It comprises several metabolites, including crocin, crocetin, picocrocin, and safranal, each possessing distinct pharmacological effects. Crocin, a carotenoid compound, crocetin, a dicarboxylic acid, and safranal, an aldehyde compound, are the metabolites found in C. sativus.³¹ Apocarotenoids, such as crocetin (C20H24O4) and crocin (digentiobiosyl8, 80-diapocarotene-8, 80-oate; C44H64O24), are the metabolites responsible for the red color of C. sativus stigmas. Additionally, picrocrocin (4-[β-D glucopyranosyloxy] -2, 6, 6- trimethylcyclohex-1-ene- 1-carboxaldehyde; C16H26O7) gives C. sativus its bitter taste, while safranal (C10H14O7) contributes to its strong aroma.³²

Regarding medicinal properties, C. sativus exhibits sedative, antispasmodic, hepatoprotective, and immune system booster activities.^33
-35 Numerous studies have previously explored the potential anticancer effects of C. sativus in various cancer types, including gastrointestinal and gynecologic cancers.^36,37 Although considerable investigations have evaluated the effectiveness of C. sativus or its bioactive constituents in various diseases, such as depression, anxiety, dysmenorrhea, etc.,^38
-40 unfortunately, no clinical trial has examined the effectiveness of this herb in the treatment of any cancer. Based on preclinical research, C. sativus has demonstrated several antitumor mechanisms such as the induction of apoptosis, inhibition of angiogenesis, anti-inflammatory effects that lead to the reduction of inflammation in the tumor microenvironment, and thus the rate of tumor progression, and antioxidant activity to help neutralize free radicals and oxidative stress.^41,42 The objective of this review is to systematically gather and summarize literature regarding the effectiveness of C. sativus and its metabolites in the management of breast cancer.

Study Design

This systematic review has evaluated the efficacy of C. sativus and its constituents in breast cancer. The authors initially considered human studies for inclusion in the review; however, no eligible clinical trials were identified in the literature search. Thus, this review focused mostly on preclinical research (in vivo and in vitro).

The Strategy of Literature Review

To gather studies evaluating the impact of C. sativus and its constituents on breast cancer, a comprehensive search was conducted in scientific databases including PubMed, Web of Sciences, Google Scholar, Scopus, and Scientific Information Database. The search encompassed articles published from the inception of these databases up until the end of 2024. A combination of Medical Subject Headings (MeSH) and non-MeSH keywords was employed to ensure a thorough exploration of the databases. The names of the breast cancer cell lines commonly used in breast cancer research were also obtained from a review article.⁴³ Subsequently, a search strategy was designed as (Crocus sativus OR its main constituents) AND (breast OR different breast cancer cell lines). Supplemental File 1 presents the full search strategy and terms used.

Furthermore, a comprehensive examination of the references cited in the initially selected papers was performed to identify any potentially overlooked relevant studies.

Study Selection

All studies including in vivo, in vitro, and in clinical settings were considered. Unpublished reports, gray literature, editorial letters, review articles, books, and articles that were not available in English or Persian were excluded.

The PICOS criteria (Population, Intervention, Comparison, Outcome, Study design) was considered to select the eligible studies.

Population

For human studies, all breast cancer cases regardless of the cancer type were eligible for inclusion. For animal studies, all breast cancer models, regardless of how cancer was induced can be included. For in vitro researches, applying any of breast cancer cell lines including BT483, CAMA1, EFM19, HCC1428, HCC712, IBEP2, KPL1, LY2, MCF7, MDAMB134, MDAMB134VI, MDAMB175, MDAMB175VII, MDAMB415, T47D, ZR751, ZR75B, BSMZ, BT474, EFM192A, IBEP1, IBEP3, MDAMB330, MDAMB361, UACC812, ZR7527, ZR7530, 21MT1, 21MT2, 21NT, 21PT, AU565, HCC1008, HCC1569, HCC202, HCC2218, HH315, HH375, HCC1954, KPL-4, MDAMB453, OCUB-F, SKBR3, SKBR5, SUM190PT, SUM225CWN, UACC893, BT20, CAL148, DU4475, EMG3, HCC1143, HCC1187, HCC1599, HCC1806, HCC1937, HCC2157, HCC3153, HCC70, HMT3522, KPL-3C, MA11, MDAMB435, MDAMB436, MDAMB468, MFM223, SUM185PE, SUM229PE, BT549, CAL120, CAL51, CAL851, HCC1395, HCC1739, HCC38, HDQ-P1, Hs578T, MDAMB157, MDAMB231, SKBR7, SUM102P, SUM1315M02, SUM149PT, SUM159PT was acceptable for inclusion.

Intervention

Studies that had investigated the therapeutic properties of C. sativus, or its bioactive constituents including crocin, crocetin, safranal, or picrocrocin, regardless of the dosage and the method of administration were selected.

Comparison

Studies with any type of comparison group were considered eligible for inclusion.

Outcome

Researches that evaluated different outcomes related to breast cancer, such as tumor size, apoptosis rates, overall survival, and tumor-associated biomarkers were eligible for inclusion in the current review.

Study Design

Any in vivo and in vitro studies may be included in this review.

Review articles, gray literature, books, editorial letters, unpublished reports, and articles that were not available in full text in English or Persian were excluded from consideration.

Two reviewers independently assessed the suitability of primary studies based on their titles and abstracts (FSH, and MA). In cases of disagreement between the 2 reviewers, a third reviewer was consulted to reach a consensus.

Data Extraction

The authors adhered to established protocols for gathering and examining the data. They obtained and assessed information from chosen articles concerning the substances, animal models, cell lines, histological assessments, biochemical assays, and molecular mechanisms investigated in the studies.

Quality Assessment of the Studies

The bias risk of in vivo studies was determined using SYRCLE’s risk of bias tool for animal studies.⁴⁴ Several biased aspects of animal studies such as selection, performance, detection, attrition, and reporting biases were evaluated.

Data Analysis

Due to differences in the methodologies used in the studies, the meta-analyses were not applicable.

Studies Description

In this research, various studies were evaluated to investigate the effects of C. sativus and its main constituents on breast cancer. A total of 217 search results were initially obtained regarding the impact of C. sativus or its metabolites on the different breast cancer subtypes or breast cancer cell lines. After excluding 173 articles that were reviews, books, duplicate articles, indexes, and other irrelevant sources, 44 were selected for the current review (Figure 1). This systematic electronic search was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.⁴⁵

Figure 1.

Steps to select suitable articles based on the inclusion and exclusion criteria defined for this review.

Effects of C. sativus and Its Constituents Against Breast Cancer and the Proposed Mechanisms

The efficacy of C. sativus and its constituents against breast cancer has been demonstrated in several preclinical in vivo and in vitro researches. C. sativus extract and its metabolites including crocetin, crocin, and safranal have shown significant anticancer properties in animal breast cancer models and various breast cancer cell lines. Table 1 presents the beneficial effects of C. sativus and its metabolites in breast cancer, as well as some of the established mechanisms. Table 2 indicates the therapeutic properties of C. sativus and its metabolites in combination with chemotherapy agents or other therapeutic methods against breast cancer.

Table 1.

Therapeutic Effects of Crocus sativus and Its Constituents Against Breast Cancer.

Type of study	Intervened compound name	Cell lines/subjects	Route of administration	Intervention Dose Concentration duration	Outcome	Proposed mechanism	References
In vitro	Crocin	MCF-7 cell line	Adding to cell culture media	Measurement of mitochondrial membrane potential: 25, 50, 75, 100, 125, 150, 175, 200 µg/mL Crocin for 24 and 48 h Apoptosis assay: 10, 25, 50 µg/mL Crocin for 24 h Caspase activity assay: 50 µg/mL Crocin for 24 h	Inhibitory effect on cell proliferation in a time- and dose-dependent manner: at 24 h, the IC50 of Crocin was 60 µg/mL, while at 48 h, the IC50 was 12.5 µg/mL. Apoptosis induction at 10, 25, 50 µg/mL concentration. At 50 µg/mL the total percentage of apoptotic cells was significantly higher than the control group.	Caspase-8 activation, Bax upregulation Mitochondrial membrane potential disruption Cytochrome c release ↑p53 expression	Lu et al⁴⁶
In vitro	Crocin	MDA-MB-231 cell line	Adding to cell culture media	MTT assay: 0, 1, 2, 4, 8, and 16 mg/mL Crocin for 24, 48, and 72 h Establishment of the subcutaneous tumor model: 5 mg/mL crocin, every 2 d, for a total of 7 doses	Crocin changed the morphology, and decreased the cell number of MDA-MB-231 cells Inhibitory effect on cell proliferation in a dose-dependent manner The inhibitory effect at 48 h was stronger than that at 24 or 72 h IC50 value at 48 h was 5 mg/mL Apoptosis induction and cell cycle arrest at the G2/M phase in a dose-dependent manner tumor growth was slower in the 5 mg/mL Crocin group compared to the blank control group	↓ expression of CD34 and Ki-67	Chen et al⁴⁷
In vitro	Crocetin	MDA-MB-231 cell line	Adding to cell culture media	Tissue culture plates incubated with crocetin at concentrations of 1 and 10 μΜ for 24 h	Inhibiting proliferation and invasiveness at 1 and 10 µM Incubation with 10 µM crocetin for 24 h in serum-free conditions reduced pro-MMP-9 activity and pro-MMP-2/MMP-2 protein levels. Crocetin at 10 μΜ reduced gelatinase activity	MMPs downregulation	Chryssanthi et al⁴⁸
In vitro	Crocetin beta-d-glucosyl ester	MCF-7 cell line	Adding to cell culture media	MTT assay: 1.25, 62.5, 125, 250, 500, 1000 µg/mL for 72 h and observations were noted every 24 h	Inhibitory effect on cell proliferation in a dose dependent way with IC50 value of 628.36 ± 15.52 µg/mL Crocetin beta-d-glucosyl ester-treated MCF-7 cells have indicated cellular apoptotic characteristics	Affinity of Crocetin beta-d-glucosyl ester to histone deacetylase 2 and alpha estrogen receptors	Mir et al⁴⁹
In vitro	Crocin	HCC70 cells HCC1806 cells HeLa cells CCD1059sk cells	Adding to cell culture media	Tubulin Polymerization Assay: 0-50 μM concentration Cell Culture and Proliferation Assay: 0 to 1500 nM concentration for 24 h Cell Cycle Analysis: 1 and 2 μM concentration for 24 h Mitotic Index Analysis: 0 to 1500 nM concentration for 24 h	Inhibiting microtubule assembly, is more effective in higher concentration The IC50 values were 209 ± 5 nM for HCC1806, 275 ± 8 nM for HCC70, 380 ± 7 nM for HeLa, and, 660 ± 23 nM for CCD1059sk. 2 μM concentration was more effective in blocking cell cycle progression. Crocin treatment increases the mitotic index in cancer cells.	Microtubule network disruption (microtubule assembly inhibition, and induction of tubulin aggregation)	Hire et al⁵⁰
In vitro	Crocin	MDA-MB-231 cells MDA-MB-468 cells BT-549 cells MCF-7 cells	Adding to cell culture media	CCK-8 assay: 4 mg/mL Crocin for 48 h EdU incorporation assay: 4 mg/mL Crocin for 48 h RT-qPCR and ELISA assays: 4 mg/mL Crocin for 48 h	Crocin significantly inhibited cell viability, indicating its effectiveness in reducing cancer cell survival. Crocin significantly inhibited proliferation in breast cancer cells. Crocin treatment resulted in a significant reduction of inflammation.	↓ NF-κB activation due to ↓ PRKCQ expression ↓ Tumor necrosis factor-α ↓ Interleukin-1β	Xu et al⁵¹
In vitro	Safranal	MDA-MB-231 cell line	Adding to cell culture media	Western blot: 250 μg/mL for 24 h TUNEL assay: 250 μg/mL for 24 h Cell Cycle assay: 250 μg/mL for 2 and 24 h Immunofluorescence assay: 250 μg/mL for 0 min, 12, 24 h	Safranal can lead the cells into apoptosis and may causes DNA damage. It prevents repair by the hypo-acetylation of H4 and facilitates the transcription of proapoptotic genes by hyperacetylation of H3, which push the cells to the brink of death.	By affecting the phosphorylation of proteins associated to DNA repair and replication, translation, activated epidermal growth factor receptor activation/accumulation	Ashrafian et al⁵²
In vitro	Safranal	MDA-MB-231 cell line	Adding to cell culture media	MTT cell viability: Specific concentrations for this assay were not detailed Flow cytometry: Specific concentrations for this assay were not detailed Western blotting: Specific concentrations for this assay were not detailed	Inhibitory effect on cell proliferation Apoptosis induction	Mitochondrial dysfunction and metabolism inhibition Regulating DNA fragmentation proteins and mediators of apoptosis Alteration of glycoproteins sialylation affecting cell survival and metastasis	Zarrineh et al⁵³
In vitro	Crocin	T-47D cell line MDA-MB-231 cell line MCF-10A cell line	Adding to cell culture media	CCK-8 Assay: 0, 0.25, 0.5, 1, 2, or 4 mM Crocin for 48 h EdU Incorporation Assay: 1, 2, and 4 mM crocin for 48 h western blot analysis: 1, 2, and 4 mM crocin for 48 h Luciferase Reporter Assay: Specific concentrations for this assay were not detailed	The 2 mM concentration was identified as effective in demonstrating cytotoxicity against breast cancer cells. The 2 mM concentration was effective in inhibiting the protein expression of the proliferation biomarker PCNA in breast cancer cells miR-122-5p targeted SPRY2 and FOXP2, which are involved in breast cancer progression, indicating the relevance of crocin’s action through these targets	↓ miR-122-5p expression ↑ FOXP2 and SPRY2 expression	Jia et al⁵⁴
In vitro	Crocin	MCF-7 cell line	Adding to cell culture media	MTT assay: 2, 4, 6, 8, 10, 12, 14, 16, 18, and 20 mg/mL Crocin for 48 h Conventional telomere repeat amplification protocol assay: 1.25, 2.5, and 3.5 mg/mL Crocin Real-time quantitative telomere repeat amplification protocol: 1.25, 2.5, and 3.5 mg/mL Crocin	Anti-proliferative effect The IC50 values were reported 3.5 mg/mL for MCF7 cells	Inhibitory effect on telomerase activity in a dose-dependent manner	Kazemi Noureini et al⁵⁵
In vitro	Crocin	BT-474 cell line	Adding to cell culture media	MTT Assay: 0 to 5 mg/mL concentration for 24, 48, and 72 h Flow Cytometry: 3 mg/mL concentration for 6, 12, and 24 h	The IC50 value was found to be 3.5 mg/mL at 24 h The increase in early and late apoptotic cells was observed	↑ Expression of caspase-9 XBP1 gene splicing induction ↑ Unfolded protein response activation	Faridi et al⁵⁶
In vitro	Aqueous and methanolic extracts of C. sativus from several regions of Iran	MCF-7 cell line MDA-MB-231 cell line	Adding to cell culture media	Cell Viability Assays: 50, 100, 200, 400, 800, and 1000 μM/mL for 48 and 72 h	No cytotoxic activity against MDA-MB-231 cells Cytotoxic activity against MCF-7 cells in increased time and high concentration.	-	Sheidaei and Shakeri⁵⁷
In vitro	Crocin	MCF-7 cell line	Adding to cell culture media	MTT assay: 0, 1, 2, 4, and 8 mg/mL Crocin for 24 and 48 h Apoptosis assay: 2, 4, and 8 mg/mL	Apoptosis induction Decreasing in cell growth in a dose- and time-dependent manner The IC50 value was found to be 3 mg/mL at 24 h	↓VEGF expression	Saravani et al⁵⁸
In vitro	Crocin	MCF-7 cell line	Adding to cell culture media	MTT assay, DAPI staining and PCR were performed. Details regarding concentration and duration were not reported.	Inhibitory effect on cell proliferation Apoptosis induction	↑ expression of the PTEN gene ↓ expression of the Akt1 gene	Ghorbian and Hajizadeh⁵⁹
In vitro	Aqueous extract	MCF-7 cell line	Adding to cell culture media	Real time PCR: 100, 200, 400, and 800 mg/mL	↓ Expression of the vascular endothelial growth factor A in a dose dependent manner	-	Mousavi et al⁶⁰
In vitro	Alcoholic extract	MCF-7 cell line	Adding to cell culture media		Inhibitory effect on cell proliferation in a dose dependent manner	-	Vakili et al⁶¹
In vitro	Alcoholic extract	MCF-7 cell line	Adding to cell culture media	MTT assay: 200-2000 μM/mL concentrations for 24, 48 and 72 hApoptosis assay: 1600 μM/mL for 48 hInhibition of caspase activity assay: 1600 μM/mL for 48 h	Decreased cell viability of MCF-7 in a concentration- and time-dependent manner.Apoptosis induction	Induction of caspase-dependent pathway↑ Expression of Bax protein	Mousavi et al⁶²
In vitro	C. sativus extract	MCF-7 cell lineMCF-12a cell line	Adding to cell culture media	MTT assay: 100, 50, 25, 12.5, 6.25, 3.125, 1.56 mg/mL for 24 h	↓ Viability of MCF-7 cell line in a dose-dependent mannerNo cytotoxic effect on MCF12a cell line	-	Keskiner and Kocaman⁶³
In vitro	C. sativus aqueous extract	MCF-7 cell line	Adding to cell culture media	PCR analysis:100, 200, 400, and 800 µg/mL for 48 h	↓ Expression of VEGF-A in a dose dependent mannerCritical inhibitory effect of VEGFR-2 expression was in 400 µg/mLconcentration	-	Mousavi and Baharara⁶⁴
In vitro	Crocin	MCF-7 cell lineMDA-MB-231 cell line	Adding to cell culture media	MTT assay: Crocin: 0.5 to 6 mM for 24 hHoechst 33 258 staining:Crocin: 3 or 2.7 mM for 24 hApoptosis assay: Details not reportedCaspase 3 activity assay: Details not reportedWestern blot analysis: Details not reportedMitochondrial and cytoplasmic protein lysates: Details not reportedNuclear and cytoplasmic protein lysates: Details not reportedAntioxidant measurement: Details not reportedROS determination: Crocin: 3 or 2.7 mMImmunofluorescence: Crocin: 3 or 2.7 mM up to 24 hMeasurement of mitochondrial membrane potential: Crocin: 3 or 2.7 mM for 8 and 16 hColony formation assay: Crocin: 3 or 2.7 mM for 21 d	Apoptosis inductionThe IC50 of Crocin for MCF-7 cell linewas 3 mM and for MDA-MB-231 cell line was 2.7 mM at 24 h	↑ ROS production↑ FOXO3a expression↑ p-AKTexpression↑ Caspase-3 activation	Nasimian et al⁶⁵
In vitro	Crocin	Cancer cells isolated from tumors: Grade II, HER2-negative (C1 and C2)Grade III, HER2-positive (C3, C4, and C5)	Adding to cell culture media	MTT assay: Crocin: 1 to 5 mM at different time intervals of 0, 12, 24, 48 and 72 hFlow cytometry: IC50 value of Crocin (C1: 2.56, C2: 3.58, C3: 4.61, C4: 4.09, C5: 4.64 mM) for up to 24 hWestern blot: IC50 value of Crocin (C1: 2.56, C2: 3.58, C3: 4.61, C4: 4.09, C5: 4.64 mM) after 6, 12, and 24 h	Crocin significantly, enhanced stress responses, induced apoptosis, and inhibited the growth of breast cancer epithelial cells. It also reduced the metastatic markers expression and changed the levels of different proteins involved in apoptosis and cell cycle regulation.	Downregulation of EpCAM and CXCR4Endoplasmic reticulum stress leading to unfolded protein response activationAutophagy-related apoptosis inductionApoptosis due to pro-apoptotic proteins upregulation, and caspases activation	Bathaie et al⁶⁶
In vivoIn vitroIn silico	CrocetinCrocin	MiceMDA-MB-231 and MCF-7 cell lines	In mice: Intraperitoneal injectionIn vitro: Adding to cell culture media	MTT assay: Crocetin (0.1-0.8 mg/mL) or Crocin (2-5 mg/mL) for 24 hMDA-MB-231 treatment: Crocetin (0.7 mg/mL) or Crocin (4 mg/mL) for 6, 12 or 24 hMCF-7 cell line treatment: Crocetin (0.8 mg/mL) or Crocin (3.5 mg/mL) for 6, 12 or 24 hAnimal model treatment (intraperitoneal injection): Crocin: 150 mg/kg once a week, for 4 wkCrocetin: 100 mg/kg once a week, for 4 wk	MTT assay indicated the dose-dependent changes in the viability of both cell lines.↓ Triglyceride and cholesterol content in tumor, and cell lines (as an effective way to control cancer).Higher affinity of crocetin than simvastatin to binding to hydroxymethylglutaryl coenzyme A reductase active site	-	Hashemi et al⁶⁷
In vivoIn vitroIn silico	CrocetinCrocin	BALB/c miceMCF-7 cell line	In mice: Intraperitoneal injectionIn vitro: Adding to cell culture media	Kinetic study and SOD activity:Crocin: 150-700 μMCrocetin: 150-700 μMAnimal model treatment (intraperitoneal injection):Crocin: 150 mg/kg once a week, for 4 wkCrocetin: 100 mg/kg once a week, for 4 wkFluorescence measurements: Crocin: 0.85 mMCrocetin: 1.33 mMUV–Vis absorption measurement: Crocin: 0.42 mMCrocetin: 0.89 mMCircular dichroism spectrum measurement:Crocin: 0.3, 0.6, and 0.9 μMCrocetin: 0.4, 0.7, and 1.0 μM	In contrast to the in vitro data, both Crocin and Crocetin effectively increased SOD activity in breast tumors of BALB/c mice, after 1 mo of treatment.↓ Superoxide dismutase activity (in vitro)↑ Superoxide dismutase activity (in vivo)	The mechanisms of ↓ superoxide dismutase activity (in vitro):Crocin: superoxide radical scavengeCrocetin: influencing on the copper-binding site	Hashemi et al⁶⁸
In vivo	Crocin	Rat	In rat: Intraperitoneal injection	Crocin: 200 mg/kg once a week, for 4 wk (intraperitoneal injection)	Tumor growth suppression and cell cycle arrestment	Downregulation of p21^Cip1 and cyclin D1	Ashrafi et al⁶⁹
In vivo	CrocinCrocetin	Rat	In rat:Gavage	Crocin: 100 mg/kg once every 3 d up to 16 wkCrocetin: 100 mg/kg once every 3 d up to 16 wk	Protection against NUM-induced breast cancer (↓ tumor volume, ↓ tumor size, ↓ latency period)Efficacy of crocetin was more than crocin	Apoptosis via caspase activation, Bax/Bcl-2 ratio changes, disruption in cyclin D1, p53, and p21	Sajjadi and Bathaie⁷⁰
In vivo	Crocin	Female BALB/c mice (breast cancer induction with 4T1 cells injection)	In mice: Injection	Crocin: 200 mg/kg thrice a week, for 4 wk	In comparison to the control mice, the crocin-treated mice showed considerably higher survival ratesIn comparison to the control mice, the crocin-treated mice showed considerably lower metastatic colonies in the lungsThe average tumor volume in the treated group was remarkably less than in the control group the average tumor volume in the treated group was remarkably less than in the control group	↓ Wnt/β-catenin target genes expression	Arzi et al⁷¹
In vivo	Crocetin	Rat	Intraperitoneal injections	Crocetin: 100 mg/kg, for 4 wk	Significant decrease in tumor volume. The tumor growth rate was notably lower in the Crocetin-treated group compared to the untreated group	Cyclin D1 downregulation and p53 and p21 Cip1 upregulation, leading to cell cycle arrest and contributing to apoptosis induction in cancer cells	Bathaie et al⁷²

Abbreviations: PRKCQ, protein tyrosine kinase C theta isoform; DNA, deoxyribonucleic Acid; NF-Κb, nuclear factor kappa-light-chain-enhancer; FOXP2, forkhead box protein P2; SPRY2, sprouty RTK signaling antagonist 2; XBP1, X-box binding protein 1; VEGF, vascular endothelial growth factor; VEGFR, vascular endothelial growth factor receptor; PTEN, phosphatase and tensin homolog; Akt1, AKT Serine/Threonine Kinase 1; Bcl-2m, B-cell lymphoma protein 2; ROS, reactive oxygen species; FOXO, forkhead box transcription factor class O; MMPs, matrix metalloproteinases; EDU, 5-ethnyl-2′-deoxyuridine; CCK-8, cell counting kit-8; TUNEL, terminal deoxynucleotidyl transferase dUTP nick end labeling.

Table 2.

Therapeutic Effects of Crocus sativus and Its Constituents in Combination With Other Therapeutic Methods Against Breast Cancer.

Type of study	Intervened compound name	Cell lines/subjects	Rout of administration	Intervention Dose Concentration duration	Outcome	Proposed mechanism	References
In vitro	Crocin + paclitaxelCrocin + gamma radiation	MCF-7 cell line	Adding to cell culture media	Crocin: 2.5 mg/mLGamma radiation: 2 Gy gamma radiationPaclitaxel: 0.01 μM/mLThe duration of different therapies was varied from 24 to 72 h	Combination of crocin with gamma radiation or paclitaxel leads to ↑ apoptosis	↑ expression of the p53, PARP, caspase-7 and caspase-9	Vali et al⁷³
In vitro	C. sativus aqueous extractC. sativus ethanolic extractPaclitaxelCombination of ethanolic extract + paclitaxelCombination of aqueous extract + paclitaxel	4T1 cell line	Adding to cell culture media	Paclitaxel: 0.001 to 10 μM/mL for 48 and 72 hC. sativus aqueous extract: 200 to 100 mg/mLC. sativus ethanolic extract: 250-2000 mg/mLThe duration of different therapies was 48 and 72 h	The cytotoxicity property and apoptogenic changes in combination groups especially in aqueous extract + paclitaxel were more than in other groups.	-	Hamta et al⁷⁴
In vitro	Crocetin + fluorouracilfluorouracil	MCF-7 cell line	Adding to cell culture media	Fluorouracil: 10 µmol/LCrocetin: 50 µmol/LThe duration of different therapies was 24, 48, and 72 h	Crocetin enhanced fluorouracil suppressive effect on growth of breast cancer cellCrocetin shifted the autophagic cell survival to death	↓ Beclin-1 levels↑ ATG1 levels	Zhang and Li⁷⁵
In vitro	CrocinCrocin-coated magnetite nanoparticles	MCF-7 cell line	Adding to cell culture media	Crocin: 0 to 32 mg/mLCrocin-coated magnetite nanoparticles: 0 to 32 mg/mLThe duration of different therapies was 24 and 48 h	The apoptosis ability of crocin-coated magnetite nanoparticles was more than free crocin	↓ VEGF expression in crocin-coated magnetite nanoparticles administration was more than free crocin	Saravani et al⁷⁶
In vitro	Crocetin + Indocyanine Green + near infrared laserCrocetin-loaded poly lactic-co-glycolic acid nanoparticles + Indocyanine Green + near infrared laser	MCF-7 cell line	Adding to cell culture media	Cytotoxicity assay: Crocetin: 0-400 µM for 24 and 48 hCrocetin-loaded poly lactic-co-glycolic acid nanoparticles: the same amount of Crocetin and Indocyanine Green (0-250 µM) for 24 and 48 h	Combination of Crocetin-Loaded PLGA Nanoparticles + Indocyanine Green was more efficient in improvement of Photodynamic therapy	-	Soudmand Salarabadi et al⁷⁷
In vitro	CrocinCrocin + hyperthermia	MDA-MB-468 cell line	Adding to cell culture media	Crocin: 0-5 mg/mL for 0-72 h	The apoptosis and antiproliferative ability of crocin + hyperthermia was more than Crocin alone	↑ expression of the Hsp27, Hsp70, and Hsp90, ↑ LDH, and ↑ Bax/Bcl-2 ratio in crocin + hyperthermia was more than Crocin	Mostafavinia et al⁷⁸
In vitro	CrocinPaclitaxelCrocin+ paclitaxel	MCF-7 cell lineMCF-7/PTX cell line	Adding to cell culture media	CCK-8 assay: Crocin: 0, 0.25, 0.5, 1, 2, 4, and 8 mM for 48 hPaclitaxel: 0, 2.5, 5, 10, 20, 40, and 80 nM) for 48 hTUNEL assay: 1 mM crocin or/and2.5 nM Paclitaxel for 48 hWestern blot: 4 mM crocin or/and 10 nM Paclitaxel for 48 h	Crocin increased Paclitaxel-induced cytotoxicity by decreasing cell viability and enhancing apoptosis in Paclitaxel-sensitive (MCF-7) and Paclitaxel-resistant (MCF-7/PTX) cells.	Depletion of BIRC5 by crocin made cells more sensitive to Paclitaxel.	Jia et al⁷⁹
In vitroIn vivo	CrocinMetforminCombination of them	4T1 cell lineFemale BALB/c mice (breast cancer induction with 4T1 cells injection)	Adding to cell culture media	MTT assay:Crocin: 0-4.5 mM for 0-72 hMetformin: 0-20 mM for 0-72 hCell migration wound healing assay:Crocin: 2, 4.5 mM for 12-24 hMetformin: 8, 16 mM for 12-24 hCell–matrix adhesion assay:Crocin: 2, 4.5 mMMetformin: 8, 16 mMTheir combinations in every test were in various dosages in the above-mentioned range.Animal model treatment:Crocin: 200 mg/kg, thrice per week for 4 wkMetformin: 150 mg/kg, thrice per week for 4 wk	Crocin and metformin and their combination reduced the tumor volume size and enhanced the animal survival rate and decreased the cell adhesionCrocin and metformin but not their combinations delay wound healing in 4T1 cells	VEGF and MMP9 down-regulation	Farahi et al⁸⁰
In vitro	C. sativus aqueous extractLow frequency electromagnetic fieldCombination of them	MCF-7 cell line	Adding to cell culture media	C. sativus aqueous extract: 100, 200, 400, and 800 μg/mL up to 5 dExposing to ElectromagneticField: 50 Hz, 0.04 T EMF for 1 h	↓ VEGFR2 gene expression in all groups especially in the combination of aqueous extract with low frequency electromagnetic field	-	Mousavi et al⁸¹
In vitro	C. sativus aqueous extractLow frequency electromagnetic fieldCombination of them	MCF-7 cell line	Adding to cell culture media	C. sativus aqueous extract: 100, 200, 400, and 800 µg/mL for 48 hExposing to ElectromagneticField: 50 Hz, 0.04 T	↓ MMP gene expression in all groups especially in the combination of aqueous extract with low frequency electromagnetic field	-	Asadi-Samani et al⁸²
In vitro	C. sativus aqueous extractLow frequency electromagnetic fieldCombination of them	MCF-7 cell line	Adding to cell culture media	C. sativus aqueous extract: 100, 200, 400, and 800 µg/mL for 48 hExposing to ElectromagneticField: 50 Hz, 0.004 T	↓ VEGF-A gene expression in all groups especially in the combination of aqueous extract with low frequency electromagnetic field	-	Mousavi and Baharara⁸³
In vitro	Crocin-loaded liposomes + doxorubicinCrocin + doxorubicinDoxorubicin	MDA-MB 231 cell line	Adding to cell culture media	Crocin: 1.5-6 μM for 24 and 48 hDoxorubicin: 0.25-6 μM for 24 and 48 hCrocin (2.5 μM) + doxorubicin (0.25-2 μM) for 24 hCrocin loaded liposome (containing 2.5 μM crocin) + doxorubicin (0.25-2 μM) for 24 h	Crocin enhanced the doxorubicin cytotoxicity, crocin-loaded liposomes much more increased the doxorubicin cytotoxicity.	Crocin-loaded liposomes + doxorubicin:↑ Cell number in Sub-G1 and G2/M phases, downregulation of surviving, cyclin-B1, Bcl-xl mRNA levels, upregulation of Bax and Bid mRNA levels.	Chavoshi et al⁸⁴
In vitro	CrocinCrocin-loaded on HA-Cd-NC	MDA-MB-468MDA-MB-231BT-474MCF-7	Adding to cell culture media	Crocin: 0.2, 0.4, 0.6, 0.8, and 1 mg/mLCrocin-loaded on HA-Cd-NC: 1 mg HA-Cd-NC+different amounts of Crocin (0.1, 0.2, 0.3, 0.4, and 0.5 mg	IC50 of crocin was significantly decreased when loaded on HA-Cd-NC, especially in MDA-MB-468 with a higher degree of CD44 at the surface, indicating enhanced efficacy.The HA-Cd-NC showed improved delivery of crocin, leading to increased toxicity against breast cancer cells.	The functionalization of Cd-NC with hyaluronic acid HA allows for targeted delivery to CD44-expressing cancer cells, enhancing the therapeutic effect of crocin.	Jafarisani et al⁸⁵
In vivo	High-intensity interval trainingC. sativus aqueous extractCombination of them	Female BALB/c mice (breast cancer induction with 4T1 cells injection)	Gavage	C. sativus aqueous extract: 200 mg/kg thrice a week, for 4 wk	High-intensity interval training group: ↑ expression of SIRT-1 than other onesC. sativus extract increased hTERT expression, high-intensity interval training much more enhanced hTERT expression.C. sativus extract group: ↑ p53 expression than other groups	-	Nezamdoost et al⁸⁶
In vivo	High-intensity interval trainingC. sativus aqueous extractCombination of them	Female BALB/c mice (breast cancer induction with 4T1 cells injection)	Gavage	C. sativus aqueous extract: 200 mg/kg thrice aweek, for 4 wk	The mRNA level of SIRT1 in combination group was more than other groupsThe mRNA level of p53 in High-intensity interval training group was higher than other groupsThe mRNA level of hTERT has no changes in different groups	-	Nezamdoost et al⁸⁷
In vivo	High-intensity interval trainingC. sativus aqueous extractCombination of them	Female BALB/c mice (breast cancer induction with 4T1 cells injection)	Gavage	C. sativus aqueous extract: 200 mg/kg thrice aweek, for 4 wk	The volume of tumor was lower in intervened groups than control.The improvement in apoptotic induction was seen only in high-intensity interval training and C. sativus aqueous extract groups	Caspase-3 protein level and Bax/Bcl-2 ratio in high-intensity interval training and C. sativus aqueous extract groups was higher than other ones.Bcl-2 protein level in combination group was higher than other ones.	Ahmadabadi et al⁸⁸
In vivo	High-intensity interval trainingC. sativus aqueous extractCombination of them	Female BALB/c mice (breast cancer induction with 4T1 cells injection)	Gavage	C. sativus aqueous extract: 200 mg/kg thrice aweek, for 4 wk	High-intensity interval training or C. sativus extract groups: ↓ muscle wasting and ↓ apoptosis indices in gastrocnemius muscleNo improvement in muscle mass was observed in combination group.	High-intensity interval training or C. sativus extract groups:↓ caspase-3 level↓ Bax level↑ Bcl-2 level↑ Bcl-2/Bax ratioCombination group:↓ Bcl-2/Bax ratio	Ahmadabadi et al⁸⁹

Abbreviations: PTEN, phosphatase and tensin homolog; VEGF, vascular endothelial growth factor; Bcl-2m, B-cell lymphoma protein 2; ATG1, autophagy-related 1; Hsp, heat shock protein; LDH, lactate dehydrogenase; MMP, matrix metalloproteinase; VEGFR2, vascular endothelial growth factor receptor; mRNA, messenger ribonucleic acid; SIRT-1, silent information regulator sirtuin 1; hTERT, human telomerase reverse transcriptase; HA-Cd-NC, hyaluronic acid- cadmium-nanocluster; CCK-8, cell counting kit-8; TUNEL, terminal deoxynucleotidyl transferase dUTP nick end labeling.

Tables 1 and 2 illustrate the molecular mechanisms through which C. sativus exerts its anti-breast cancer properties. The anti-cancer mechanisms of C. sativus and its constituents have been categorized as following:

Induction of Apoptosis

Apoptosis is a crucial mechanism for eliminating cancer cells. C. sativus and its constituents, including crocetin, crocin, and safranal, have been shown to induce apoptosis in breast cancer cells through different pathways:

• Bcl-2 family proteins: The Bcl-2 family proteins have an important role in apoptosis regulation, consisting of both anti-apoptotic proteins (eg, Bcl-xL, Bcl-2), and pro-apoptotic proteins (eg, Bak, Bax).⁹⁰ The balance between these proteins indicates the cell’s fate to die or survive. Studies have shown that metabolites of C. sativus are effective options for modulating the level of this protein family expression.^70,78

a) Reduced of anti-apoptotic proteins expression: The metabolites of C. sativus have demonstrated the downregulation of the anti-apoptotic proteins expression like Bcl-2, so decreasing the resistance of cell to pro-apoptotic signals. This action is important for the apoptotic process promotion, as enhanced Bcl-2 levels often contribute to cancer cell proliferation and survival.

b) Enhancement of pro-apoptotic factors expression: The metabolites of C. sativus increase the pro-apoptotic proteins expression such as Bax, associating with a shift in the balance of pro-apoptotic/anti-apoptotic. Bax induces mitochondrial membrane permeabilization favors the release of cytochrome C into the cytosol. Cytochrome C release then proceeds to activate a cascade of events favoring apoptosis through the intrinsic apoptotic pathway.

c) Mitochondrial membrane permeabilization: The reduced levels of Bcl-2 and elevated levels of Bax lead to pore formation in the mitochondrial membranes, thereby permitting the passage of apoptosis-inducing factors to initiate an activation of downstream caspases.^70,78

• Activation of executioner caspases: Caspases form the family of cysteine proteases, crucially involved in the apoptotic execution phase; For instance, caspase-3 is an executioner caspase the activation of which commits a cell to apoptosis. Induction of caspase-3 activity is therefore also needed for dismantling cellular components and amplifying the apoptotic signal through a positive feedback mechanism. The caspase-3 activation proteolytically cleaves different cellular substrates and causes morphological changes in apoptosis, including membrane blebbing, chromatin condensation, and DNA fragmentation.⁹¹ It has been documented that C. sativus can enhance the activity of these types of caspases thereby accelerating the apoptotic event in breast cancer cells. This action is very important in targeting cancerous cells and halting tumor progression.^62,65

Inhibition of Cell Proliferation

In recent times, much attention has been paid to the anti-proliferative effects of C. sativus and its constituents, particularly concerning breast cancer. The phenomenon prohibits cancer cell proliferation through several interconnected pathways. Two important mechanisms in this regard are cell cycle arrest and regulation of oncogenes and tumor suppressor genes.

Cell cycle arrest: C. sativus and its active constituents, have been indicated to induce apoptosis in several tumoral cells such as breast cancer cells. Apoptosis clears damaged or unwanted cells and also prevents their proliferation. Researchers demonstrated that crocin triggers apoptotic pathways, which are essential for stopping the cell cycle in cancerous cells, consequently contributing to its anticancer actions. Crocin notably affects key regulators of the cell cycle, especially p21Cip1 and cyclin D1. In N-Nitroso-N-Methylurea-induced breast cancer models, treatment with crocin caused the downregulation of cyclin D1, a protein that promotes cell cycle progression. Concurrently, it suppressed the p21Cip1 expression, a cyclin-dependent kinase inhibitor that can stop the cell cycle. These actions contribute to cell cycle arrest, especially in the G1 phase, consequently tumor growth inhibition. The mechanisms by which crocin causes cell cycle arrest include different signaling pathways modulation. For instance, crocin has been reported to inhibit telomerase activity and downregulation of NF-kB expression, both of which participate in survival and cell proliferation. By interfering with these pathways, crocin efficiently leads to apoptosis and cell cycle arrest in breast cancer cells.^47,50

Regulation of oncogenes and tumor suppressors: The regulation of tumor suppressor genes and oncogenes is an important dimension of cancer biology. The p53 gene is commonly described as the “guardian of the genome” because of its significant function in controlling the cell cycle and genomic integrity. It is a tumor suppressor because it inhibits the growth of tumors by cell cycle arrest to permit repair of the DNA and by inducing apoptosis if the cell is stressed or damaged. If p53 is inactivated or mutated, cancer cells are then permitted to grow without control.⁹² Crocin was found to be able to increase the expression of p53 in cancer cells. In breast cancer, that is, in MCF-7 cells, crocin treatment results in a remarkable increase in the p53 levels, indicating that crocin is expected to restore or increase the tumor-suppressing activity of p53. This is crucial because p53 activation may result in apoptosis induction and thus inhibit cancer cell growth. Crocin triggers apoptosis by mitochondrial signaling pathways. Crocin triggers caspase-8, which has been shown to cause Bax conformational change, a pro-apoptotic protein. Bax activation leads to mitochondrial membrane permeabilization, cytochrome c release, and downstream caspase activation, culminating in the death of cells through programed mechanisms. The event is greatly affected by p53, which can regulate the expression and activity of Bax.⁴⁶

Anti-Inflammatory Properties

Chronic inflammation is increasingly being identified as an important factor in the development of different cancer types. Chronic inflammation may result in a tumorigenic microenvironment, which is induced by a perpetual cycle of tissue damage and repair, in which inflammation leads to genetic changes and increases the proliferation of cells.⁹³ Inflammatory cells, including neutrophils and macrophages, infiltrate the tumor microenvironment and release growth factors, reactive oxygen species (ROS), and various pro-inflammatory cytokines. Their presence may induce DNA damage and thereby enhance the risk of mutations that would lead to cancer progression. For example, the generation of ROS by inflammation has been implicated in oxidative stress, a condition shown to initiate carcinogenic pathways.^93,94 Among other factors, C. sativus’s antiinflammatory characteristics are central to its anti-cancer action:

Cytokine modulation: Research has indicated that C. sativus and its constituents inhibit the production of pro-inflammatory cytokines, including Tumor Necrosis Factor alpha (TNF-α), and so on. The reduction of these inflammatory mediators impacts the likelihood of tumor growth.⁵¹

Suppression of inflammatory pathways: It is also possible that C. sativus and its constituents have a suppressive effect on vital inflammatory mechanisms such as the NF-κB pathway. The anticancer effect of C. sativus is thereby increased as it inhibits the transcription of genes involved in inflammation and cancer progression.⁵¹

Angiogenesis Inhibition

Angiogenesis, the formation of new blood vessels from pre-existing vessels, is one of the biological processes that is very important for tumor growth and metastasis. The continuous need for oxygen and nutrients to support the fast growth of tumors fosters the process of angiogenesis.⁹⁵ In physiological conditions, angiogenesis is strictly regulated. However, in cancer, this regulation is usually lost, and there is rampant angiogenesis that supports tumor growth. The tumor microenvironment secretes a number of pro-angiogenic factors, one of the most significant of which is vascular endothelial growth factor (VEGF). VEGF promotes the proliferation and tube formation of endothelial cells, a process through which tumors can grow beyond a minimal size. The importance of angiogenesis in oncology is highlighted by its association with tumor growth. The developing tumor can release other factors to induce angiogenesis as well as lymphangiogenesis (formation of lymph vessels), which further increases its capability to invade local tissues and metastasize to distant locations.^95,96 Several studies have proved that C. sativus has the potential to inhibit the angiogenesis of tumoral cells in different ways and potentially inhibit the growth of tumors:

VEGF and VEGFR2 regulation: It has been reported that C. sativus and its constituents can downregulate the expression levels of VEGF and its relevant receptor VEGFR2. This type of inhibition causes the regression of the blood supply needed for the expansion of a tumor, denying it the nutrients transported by blood vessels.^58,64

Matrix metalloproteinases (MMPs): Modern medicine offers C. sativus as a possible therapy against matrix metalloproteinases, which facilitate the degradation of the extracellular matrix as well as advanced angiogenesis. Inhibition of MMPs by C. sativus and its constituents may be yet another way to limit the level of angiogenesis in tumors.^48,80

Modulation of Signaling Pathways

The anticancer properties of C. sativus and its constituents are also attributable to the modulation of various signaling pathways:

PTEN/AKT1 pathway: PTEN (Phosphatase and Tensin Homolog) is a tumor suppressor gene that functions as a negative regulator of the AKT1 pathway. Where PTEN is present, it inhibits the AKT1 signaling, with the downstream effect of promoting apoptosis and inhibiting uncontrolled cell growth. However, in the majority of cancers, as well as in breast cancer, PTEN is either mutated or downregulated, leading to elevated AKT1 activity and promoting cell survival. A recent study highlights the fact that crocin is a potent inhibitor of the PTEN/AKT1 signaling pathway. The study reveals that crocin treatment induces overexpression of the PTEN gene and underexpression of the AKT1 gene in MCF7 breast cancer cells, thereby reducing cell growth and enhancing apoptosis in breast cancer cells.⁵⁹

Synergistic Effects With Other Therapies

Combining C. sativus with other medications in the treatment of breast cancer opens a new horizon of possibilities. Studies indicate that C. sativus can improve the outcomes of standard treatments including chemotherapy and radiotherapy and there were cases emphasizing that:

Chemosensitization: Chemotherapy agents are known to have restricted use in certain cases due to high toxicity profiles. To this effect, C. sativus has been shown to chemosensitize breast cancer cells to certain chemotherapeutics, allowing for lower doses with fewer side effects. This positive outcome may be dependent on the capacity of C. sativus to modulate drug resistance mechanisms.^73,84

Combination with high-intensity interval training: Interestingly, based on the results of some studies, the combination of high-intensity interval training with the aqueous extract of C. sativus showed less therapeutic effects in some breast cancer indexes than high-intensity interval training alone.^86
-89 For example, Ahmadabadi et al indicated the crocin effect on elevating the Bax/Bcl-2 ratio and the activation of caspase of 4T1 breast cancer-bearing mice. While the combination of high-intensity interval training with C. sativus aqueous extract showed a positive effect on tumor volume reduction, no synergistic effect was observed in apoptotic indices when both strategies were implemented. It is worth noting that the levels of pro- and anti-apoptotic proteins in tumor tissue were found to be lower and higher, respectively, following the combined treatment compared to either high-intensity interval training or C. sativus aqueous extract treatment alone. Collectively, these results suggest that in this study, the combination of high-intensity interval training with C. sativus aqueous extract exhibited higher levels of pro-apoptotic proteins (caspase-3 and Bax) and a decrease in the anti-apoptotic protein Bcl-2 compared to the C. sativus aqueous extract group. This indicates the potential significance of antioxidant supplementation in enhancing antioxidant defenses and acting as a scavenger for exercise-induced reactive oxygen species.⁸⁸ Likewise, a recent study showed that administering pomegranate juice as antioxidant supplementation reduced Bcl-2 expression in tumor tissue and enhanced enzymatic antioxidant defenses in skeletal muscle of Copenhagen rats with prostate tumors. However, when combined with exercise training, this effect was prevented.⁹⁷ Additionally, another study found that high-intensity interval training improved the anti-inflammatory index (IL-10/TNF-α ratio) in the gastrocnemius skeletal muscle of mice with breast cancer. However, when high-intensity interval training was combined with selenium nanoparticles as antioxidant supplementation, no significant effect on this ratio was observed.⁹⁸ Taken together, these findings may support observation of increased pro-apoptotic protein (caspase-3 and Bax) and reduced level of anti-apoptotic Bcl-2 in the HIIT + SAE group compared to the SAE group in this study, suggesting the importance of antioxidant supplementation on the antioxidant defenses as a scavenger of exercise training induced-ROS. C. sativus and its constituents have a high lethal dose (LD50) against normal cells, indicating low toxicity. In conclusion, emerging evidence suggests that C. sativus extract, along with crocin, crocetin, and safranal, selectively targets cancer cells and may possess cancer-preventive properties. Moreover, C. sativus and its constituents are considered non-toxic when administered orally.⁹⁹

Toxicology Assessment and Some Reported Side Effects Regarding Consumption of C. sativus and Its Constituents

Although the evaluation of clinical trial studies is not the subject of the current study, and the animal studies included in this review did not report any specific side effects regarding applying C. sativus and its constituents, there are some other studies that have addressed concerns about the safety of this medicinal plant usage,^100,101 and also numerous interventional researches that reported whether any adverse events had occurred.^102
-111

In a subchronic investigation, the safety of ethanolic extract of C. sativus was evaluated in mice at different doses up to 5 g/kg body weight for 8 weeks continuously. This research indicated that this herbal extract was non-toxic, as no any hepatic or renal toxicity and no mortality was observed.¹⁰⁰ The safety of C. sativus (400 mg/day for 7 days) was evaluated in healthy subjects. The results of the study showed that while applying C. sativus caused changes in biochemical and hematological parameters, these changes were within normal limits and there were no clinical complications.¹⁰¹

Several clinical trials are evaluating the efficacy of C. sativus against different disorders in which side effects were reported. based on these studies the most commonly reported adverse events were usually self-limiting, minor, and restricted to gastrointestinal disturbances such as digestive problems, nausea, constipation, vomiting, and diarrhea, some limited neurological or psychological problems like headache, dizziness, and insomnia and some other complications such as dry mouth, and increased urination.^102
-106 However, there are a considerable number of trials that have reported no side effects associated with C. sativus consumption.^107
-111

Conclusion

In the present systematic review, the potential of C. sativus and its constituents in the treatment of breast cancer has been comprehensively assessed. The findings of our study suggest that certain compounds, particularly crocin and crocetin, have significant anticancer properties. In particular, crocin at (150-200 mg/kg once a week for 4 weeks in animal models) provided the highest level of evidence of efficacy in preclinical research, indicating its potential for further investigation.

The primary mechanisms proposed for the anticancer activities of C. sativus and its constituents are induction of apoptosis, which causes programed cell death in cancer cells, and modulation of the cell cycle, which is effective in suppressing cancer cell growth. In addition, the anti-inflammatory activity of C. sativus helps decrease inflammation in the tumor microenvironment, which can lead to reduced tumor growth. These mechanisms represent the different ways in which saffron exerts its anticancer activity.

Given the promising findings of preclinical research, clinical trials are warranted to evaluate the therapeutic potential of C. sativus in the treatment of breast cancer. This review not only emphasizes the potential of saffron as an anticancer agent, but also supports the necessity of further research efforts to identify optimal dosing schedules and treatment regimens. In summary, C. sativus is a potential candidate in the treatment of breast cancer, and further studies are necessary to fully elucidate its therapeutic effects and mechanisms of action.

Methodological Quality Assessment

Our quality assessment of in vivo studies, as depicted in Figure 2, reveals that the most commonly identified biases are related to blinding, randomization, and detection areas that receive insufficient attention in animal studies.

Figure 2.

Classification based on different types of bias incorporated in the included animal research.

Limitations, Future Research Needs and Priorities

A major limitation identified is the lack of clinical trials. All studies included in the review were preclinical, focusing on in vitro and in vivo research. This absence highlights the urgent need for well-structured clinical trials to assess the efficacy and safety of C. sativus and its metabolites in human populations. The reviewed studies displayed considerable variability in methodologies, complicating the comparison of results. Future research should aim for standardized protocols to ensure consistency and reliability in findings. This includes establishing clear definitions for optimal dosages and treatment regimens for C. sativus extracts. The review emphasizes the importance of determining optimal effective doses from both therapeutic and economic perspectives. Future studies should incorporate cost-effectiveness analyses to evaluate the viability of C. sativus and its constituents as a treatment option in clinical settings, ensuring that it is not only effective but also economically feasible. Future research should also emphasize comparative studies of C. sativus and its bioactive constituents with other well-studied natural products, such as ginger (6-gingerol) and resveratrol, to determine relative efficacy, mechanisms of action, and potential therapeutic interactions in cancer models. It should be noted that this systematic review has not been registered in the International Prospective Register of Systematic Reviews (PROSPERO).

Supplemental Material

sj-docx-1-ict-10.1177_15347354251361450 – Supplemental material for Efficacy of Saffron (Crocus sativus L.) and Its Constituents on Breast Cancer, a Systematic Review of Preclinical Studies and Potential Therapeutic Mechanisms

Supplemental material, sj-docx-1-ict-10.1177_15347354251361450 for Efficacy of Saffron (Crocus sativus L.) and Its Constituents on Breast Cancer, a Systematic Review of Preclinical Studies and Potential Therapeutic Mechanisms by Fatemeh Sadat Hasheminasab and Maryam Azimi in Integrative Cancer Therapies

Footnotes

ORCID iDs

Fatemeh Sadat Hasheminasab

Maryam Azimi

Author Contributions

Both authors have contributed to the research conception and design. Selection of articles, and extracting study data were performed by H FS, and A M. H FS wrote the first draft of the manuscript. Both authors commented on previous versions of the manuscript and approved the final version.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All acquired data are included in this paper and supplementary file. Further information can be directed to the corresponding author.

Supplemental Material

Supplemental material for this article is available online.

References

Azamjah

Soltan-Zadeh

Zayeri

Global trend of breast cancer mortality rate: a 25-year study. Asian Pac J Cancer Prev. 2019;20(7):2015-2020.

Smolarz

Nowak

Romanowicz

Breast Cancer-epidemiology, classification, pathogenesis and treatment (review of literature). Cancers. 2022;14(10):2569.

Byrne

Boyle

Ahmed

Lee

Benyamin

Hyppönen

Lifestyle, genetic risk and incidence of cancer: a prospective cohort study of 13 cancer types. Int J Epidemiol. 2023;52(3):817-826.

Chen

Zeng

Clinicopathological classification and traditional prognostic indicators of breast cancer. Int J Clin Exp Pathol. 2015;8(7):8500-8505.

Voduc

Cheang

Tyldesley

Gelmon

Nielsen

Kennecke

Breast cancer subtypes and the risk of local and regional relapse. J Clin Oncol. 2010;28(10):1684-1691.

Gradishar

Moran

Abraham

, et al Breast cancer, version 3.2022, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2022;20(6):691-722.

Kunkler

Williams

Jack

WJL

Cameron

Dixon

JM.

Breast-conserving surgery with or without irradiation in early breast cancer. N Engl J Med. 2023;388(7):585-594.

Falato

Schettini

Pascual

Brasó-Maristany

Prat

Clinical implications of the intrinsic molecular subtypes in hormone receptor-positive and HER2-negative metastatic breast cancer. Cancer Treat Rev. 2023;112:102496.

Wörmann

Breast cancer: basics, screening, diagnostics and treatment. Med Monatsschr Pharm. 2017;40(2):55-64.

10.

Mosavat

Pasalar

Joulaei

, et al Complementary and alternative medicine use among people living with HIV in Shiraz, Southern Iran. Front Public Health. 2023;11:1206665.

11.

Dehghan

Ghaedi Heidari

Malakoutikhah

Mokhtarabadi

Complementary and alternative medicine usage and its determinant factors among Iranian patients with cancer. World Cancer Res J. 2019;6:e1382.

12.

Kumar

Jaitak

Natural products as multidrug resistance modulators in cancer. Eur J Med Chem. 2019;176:268-291.

13.

Bonofiglio

Giordano

De Amicis

Lanzino

Andò

Natural products as promising antitumoral agents in breast cancer: mechanisms of action and molecular targets. Mini Rev Med Chem. 2016;16(8):596-604.

14.

Alyasin

Nabavizadeh

Esmaeilzadeh

, et al Efficacy of oral supplementation of whey protein in patients with contact dermatitis: a pilot randomized double-blind placebo-controlled clinical trial. Dermatol Ther. 2020;33(6):e14260.

15.

Safari

Hoseinifar

Van Doan

Dadar

The effects of dietary Myrtle (Myrtus communis) on skin mucus immune parameters and mRNA levels of growth, antioxidant and immune related genes in zebrafish (Danio rerio). Fish Shellfish Immunol. 2017;66:264-269.

16.

Maqbool

Awan

Malik

Hadi

Shehzadi

Tariq

In-vitro anti-proliferative, apoptotic and antioxidative activities of medicinal herb Kalonji (Nigella sativa). Curr Pharm Biotechnol. 2019;20(15):1288-1308.

17.

Safarzadeh

Sandoghchian Shotorbani

Baradaran

Herbal medicine as inducers of apoptosis in cancer treatment. Adv Pharm Bull. 2014;4(Suppl 1):421-427.

18.

McGrowder

Miller

Nwokocha

, et al Medicinal herbs used in traditional management of breast cancer: mechanisms of action. Medicines. 2020;7(8):47.

19.

Hasheminasab

Hashemi

Dehghan

, et al Effects of a Plantago ovata-based herbal compound in prevention and treatment of oral mucositis in patients with breast cancer receiving chemotherapy: a double-blind, randomized, controlled crossover trial. J Integr Med. 2020;18(3):214-221.

20.

Hasheminasab

Sharififar

Hashemi

Setayesh

An evidence-based research on botanical sources for oral mucositis treatment in traditional persian medicine. Curr Drug Discov Technol. 2021;18(2):225-234.

21.

Tavakoli

Miar

Majid Zadehzare

Akbari

Evaluation of effectiveness of herbal medication in cancer care: a review study. Iran J Cancer Prev. 2012;5(3):144-156.

22.

Adinew

Taka

Mochona

, et al Therapeutic potential of thymoquinone in triple-negative breast cancer prevention and progression through the modulation of the tumor microenvironment. Nutr. 2021;14(1):79.

23.

Korak

Ergül

Sazci

Nigella sativa and cancer: A review focusing on breast cancer, inhibition of metastasis and enhancement of natural killer cell cytotoxicity. Curr Pharm Biotechnol. 2020;21(12):1176-1185.

24.

Nikseresht

Kamali

Rahimi

, et al The hydroalcoholic extract of Matricaria chamomilla suppresses migration and invasion of human breast cancer MDA-MB-468 and MCF-7 cell lines. Pharmacogn Res. 2017;9(1):87-95.

25.

Ranjbari

Alibakhshi

Arezumand

, et al Effects of Curcuma longa extract on telomerase activity in lung and breast cancer cells. Zahedan J Res Med Sci. 2014;16(10):1-6.

26.

Yang

D-S

Yang

S-J

. Effects of Curcuma longa L. On MDA-MB-231 human breast cancer cells and DMBA-induced breast cancer in rats. The Journal of Korean Obstetrics and Gynecology. 2013;26(3):44-58.

27.

Richard

Kamdje

AHN

Mukhtar

Medicinal plants in breast cancer therapy. J Dis Med Plants. 2015;1:19-23.

28.

Gailani

Armstrong

Carbone

Tan

Holland

JF.

Clinical trial of vinleurosine sulfate (NSC-90636): a new drug derived from Vinca rosea Linn. Cancer Chemother Rep. 1966;50:95-103.

29.

Yan-Hua

Jia-Wang

Xiao-Li

Research progress on the source, production, and anti-cancer mechanisms of paclitaxel. Chin J Nat Med. 2020;18(12):890-897.

30.

Mohtashami

Amiri

Ramezani

Emami

Simal-Gandara

. The genus Crocus L.: a review of ethnobotanical uses, phytochemistry and pharmacology. Ind Crops Prod. 2021;171:113923.

31.

Avila-Sosa

Nevárez-Moorillón

Ochoa-Velasco

, et al Detection of saffron’s main bioactive compounds and their relationship with commercial quality. Foods. 2022; 11(20):3245.

32.

Sui

Kiser

Lintig

Palczewski

Structural basis of carotenoid cleavage: from bacteria to mammals. Arch Biochem Biophys. 2013;539(2):203-213.

33.

Azimi

Hasheminasab

Mokaberinejad

Qaraaty

Mojahedi

A review of prevention and adjuvant therapy in acute respiratory syndrome caused by covid-19 from the perspective of Persian medicine. J Babol Univ Med Sci. 2021;23(1):177-188.

34.

Hasheminasab

Tajadini

Setayesh

An evidence-based study on pharmacological treatments of non-alcoholic fatty liver disease based on traditional persian medicine. Curr Tradit Med. 2020;6(3):188-202.

35.

Roshanravan

Ghaffari

The therapeutic potential of Crocus sativus Linn.: a comprehensive narrative review of clinical trials. Phytother Res. 2022;36(1):98-111.

36.

Lambrianidou

Koutsougianni

Papapostolou

Dimas

Recent advances on the anticancer properties of saffron (Crocus sativus L.) and its major constituents. Molecules. 2020;26(1):86.

37.

Colapietro

Mancini

D’Alessandro

Festuccia

Crocetin and crocin from saffron in cancer chemotherapy and chemoprevention. Anticancer Agents Med Chem. 2019;19(1):38-47.

38.

Akhondzadeh

Tahmacebi-Pour

Noorbala

et al. Crocus sativus L. in the treatment of mild to moderate depression: a double-blind, randomized and placebo-controlled trial. Phytother Res. 2005;19(2):148-151.

39.

Kumar

Kaur

Wadhwa

. Clinical evidence on the effects of saffron (Crocus sativus L.) in anxiety and depression. World J Tradit Chin Med. 2022;8(2):181-187.

40.

Azimi

Abrishami

Comparison of the effects of Crocus sativus and mefenamic acid on primary dysmenorrhea. J Pharmaceut Care. 2016;4(3-4):75-78.

41.

Naeimi

Shafiee

Kermanshahi

, et al Saffron (Crocus sativus) in the treatment of gastrointestinal cancers: current findings and potential mechanisms of action. J Cell Biochem. 2019;120(10):16330-16339.

42.

Patel

Sarwat

Khan

. Mechanism behind the anti-tumour potential of saffron (Crocus sativus L.): the molecular perspective. Crit Rev Oncol Hematol. 2017;115:27-35. doi:10.1016/j.critrevonc.2017.04.010

43.

Dai

Cheng

Bai

Breast cancer cell line classification and its relevance with breast tumor subtyping. J Cancer. 2017;8(16):3131-3141.

44.

Hooijmans

Rovers

de Vries

, et al SYRCLE’s risk of bias tool for animal studies. BMC Med Res Methodol. 2014;14(1):1-9.

45.

Moher

Liberati

Tetzlaff

Altman

DG.

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264-269.

46.

Lin

, et al Antitumor effects of crocin on human breast cancer cells. Int J Clin Exp Med. 2015;8(11):20316-20322.

47.

Chen

S-S

, et al Antiangiogenic effect of crocin on breast cancer cell MDA-MB-231. J Thorac Dis. 2019;11(11): 4464-4473.

48.

Chryssanthi

Dedes

Karamanos

Cordopatis

Lamari

FN.

Crocetin inhibits invasiveness of MDA-MB-231 breast cancer cells via downregulation of matrix metalloproteinases. Planta Med. 2011;77(2):146-151.

49.

Mir

Ganai

Mansoor

, et al Isolation, purification and characterization of naturally derived crocetin beta-d-glucosyl ester from Crocus sativus L. against breast cancer and its binding chemistry with ER-alpha/HDAC2. Saudi J Biol Sci. 2020;27(3):975-984. doi:10.1016/j.sjbs.2020.01.018

50.

Hire

Srivastava

Davis

Kumar Konreddy

Panda

Antiproliferative activity of crocin involves targeting of microtubules in breast cancer cells. Sci Rep. 2017;7(1):44984.

51.

Jia

Xiong

Crocin attenuates NF-κB-mediated inflammation and proliferation in breast cancer cells by down-regulating PRKCQ. Cytokine. 2022;154:155888. doi:10.1016/j.cyto.2022.155888

52.

Ashrafian

Zarrineh

Jensen

, et al Quantitative phosphoproteomics and acetylomics of safranal anticancer effects in triple-negative breast cancer cells. J Proteome Res. 2022;21(11):2566-2585.

53.

Zarrineh

Ashrafian

Jensen

, et al Comprehensive proteomics and sialiomics of the anti-proliferative activity of safranal on triple negative MDA-MB-231 breast cancer cell lines. J Proteomics. 2022;259:104539.

54.

Jia

Yang

, et al Crocin suppresses breast cancer cell proliferation by down-regulating tumor promoter miR-122-5p and up-regulating tumor suppressors FOXP2 and SPRY2. Environ Toxicol. 2023;38:1597-1608.

55.

Kazemi Noureini

Khosrojerdi

Nabiuni

. Telomerase activity in breast cancer cells under treatment with crocin. J Sabzevar Univ Med Sci. 2014;19(3):267-277.

56.

Faridi

Heidarzadeh

Mohagheghi

Bathaie

SZ.

BT-474 breast cancer cell apoptosis induced by crocin, a saffron carotenoid. Basic Clin Cancer Res. 2019;11(1):5-15.

57.

Sheidaei

Shakeri

The comparison of anticancer properties of collected saffron from different region of Iran on human breast cancer cells. Exp Anim Biol. 2022;11(1):11-22.

58.

Saravani

Sargazi

Rabbani

Saravani

Evaluation of VEGF gene expression levels and induction of apoptosis in crocin-treated MCF-7 breast cancer cells. Original article. J Shahid Sadoughi Univ Med Sci. 2019;26(10):845-856. doi:10.18502/ssu.v26i10.474

59.

Ghorbian

Hajizadeh

Study of crocin (saffron component) on apoptosis or survival of MCF7 breast cancer cells lines) PTEN/AKT1 signaling pathway. J Ilam Univ Med Sci. 2022;30(4):47-55.

60.

Mousavi

Baharara

Shahrokhabadi

Balanejad

Effect of saffron extract on VEGF-A expression in MCF7 cell line. J Kermanshah Univ Med Sci. 2014;17(12):749-758.

61.

Vakili

Toroghian

Torshizi

ME.

Saffron extract feed improves the antioxidant status of laying hens and the inhibitory effect on cancer cells (PC3 and MCF7) growth. Vet Med Sci. 2022;8(6):2494-2503.

62.

Mousavi

Tavakkol-Afshari

Brook

Jafari-Anarkooli

Role of caspases and Bax protein in saffron-induced apoptosis in MCF-7 cells. Food Chem Toxicol. 2009;47(8):1909-1913.

63.

Keskiner

Kocaman

Determination of the saffron on MCF-7 and MCF-12a cell lines. Sabuncuoglu Serefeddin Health Sci. 2023;4(3):47-55.

64.

Mousavi

Baharara

. Effect of Crocus sativus L. on expression of VEGF-A and VEGFR-2 genes (angiogenic biomarkers) in MCF-7 cell line. Zahedan J Res Med Sci. 2014;16(12):9-15.

65.

Nasimian

Farzaneh

Tamanoi

Bathaie

SZ.

Cytosolic and mitochondrial ROS production resulted in apoptosis induction in breast cancer cells treated with crocin: the role of FOXO3a, PTEN and AKT signaling. Biochem Pharmacol. 2020;177:113999.

66.

Bathaie

Faridi

Hydrazideh

, et al Crocin induces apoptosis in primary cancer epithelial cells isolated from human breast tumors via different mechanisms in HER2-negative or positive cells: a preliminary study. 2024.

67.

Hashemi

Bathaie

Mohagheghi

MA.

Crocetin and crocin decreased cholesterol and triglyceride content of both breast cancer tumors and cell lines. Avicenna J Phytomed. 2020;10(4):384-397.

68.

Hashemi

Karami

Bathaie

SZ.

Saffron carotenoids change the superoxide dismutase activity in breast cancer: in vitro, in vivo and in silico studies. Int J Biol Macromol. 2020;158:845-853.

69.

Ashrafi

Bathaie

Abroun

Azizian

Effect of crocin on cell cycle regulators in N-nitroso-N-methylurea-induced breast cancer in rats. DNA Cell Biol. 2015;34(11):684-691. doi:10.1089/dna.2015.2951

70.

Sajjadi

Bathaie

Comparative study on the preventive effect of saffron carotenoids, crocin and crocetin, in NMU-induced breast cancer in rats. Cell J. 2017;19(1):94-101. doi:10.22074/cellj.2016.3901

71.

Arzi

Farahi

Jafarzadeh

, et al Inhibitory effect of crocin on metastasis of triple-negative breast cancer by interfering with Wnt/β-catenin pathway in murine model. DNA Cell Biol. 2018;37(12):1068-1075.

72.

Bathaie

Ashraf

Azizian

Khademian

Abroun

Crocetin regulates cell cycle progression in N-nitroso-nmethylurea(NMU)-induced breast cancer in rat: cyclin D1 suppression, p21Cip1 and p53 induction. Acta Biochim Iran. 2024;2(1):22-30.

73.

Vali

Changizi

Safa

Synergistic apoptotic effect of crocin and paclitaxel or crocin and radiation on MCF-7 cells, a type of breast cancer cell line. Int J Breast Cancer. 2015;2015:139349.

74.

Hamta

Soleimani

Darvishi

Comparison of the cytotoxicity of aqueous and ethanolic extracts of saffron (Crocus sativus L) with paclitaxel as a chemotherapy drug in breast cancer cell line (4T1). J Adv Med Biomed Res. 2014; 22(94):83-95.

75.

Zhang

Crocetin shifts autophagic cell survival to death of breast cancer cells in chemotherapy. Tumor Biol. 2017;39(3):1010428317694536.

76.

Saravani

Sargazi

Saravani

, et al Newly crocin-coated magnetite nanoparticles induce apoptosis and decrease VEGF expression in breast carcinoma cells. J Drug Deliv Sci Tech. 2020;60:101987.

77.

Soudmand Salarabadi

Hashemi

Sazgarnia

. The role of crocetin-loaded PLGA nanoparticles as a pre-treatment agent on indocyanine-photodynamic therapy of breast cancer cell. Iran J Med Phys. 2022;19(1):58-65.

78.

Mostafavinia

Khorashadizadeh

Hoshyar

Antiproliferative and proapoptotic effects of crocin combined with hyperthermia on human breast cancer cells. DNA Cell Biol. 2016;35(7):340-347.

79.

Jia

Yang

, et al Crocin enhances the sensitivity to paclitaxel in human breast cancer cells by reducing BIRC5 expression. Chem Biol Drug Des. 2024;103(2):e14467.

80.

Farahi

Abedini

Javdani

, et al Crocin and metformin suppress metastatic breast cancer progression via VEGF and MMP9 downregulations: in vitro and in vivo studies. Mol Cell Biochem. 2021;476(9):3341-3351.

81.

Mousavi

Baharara

Shahrokhabadi

. The synergic effects of Crocus sativus L. and low frequency electromagnetic field on VEGFR2 gene expression in human breast cancer cells. Avicenna J Med Biotechnol. 2014;6(2):123.

82.

Asadi-Samani

Mousavi

Baharara

The synergic effect of low-frequency electromagnetic field and saffron extract on MMP gene expression in MCF-7 cell line. J Chem Pharm Res. 2015;7(6):680-686.

83.

Mousavi

Baharara

Reduction VEGF-A expression induced by saffron aqua extract with low frequency electromagnetic field in MCF-7 cell line. J Gene Microbes Immun. 2014;2014:1-10.

84.

Chavoshi

Taheri

Wan

MLY

Sabzichi

Crocin-loaded liposomes sensitize MDA-MB 231 breast cancer cells to doxorubicin by inducing apoptosis. Process Biochem. 2023;130:272-280.

85.

Jafarisani

Hashemi

Faridi

Mousavi

Bathaie

SZ.

Cadmium nanocluster as a safe nanocarrier: biodistribution in BALB/c mice and application to carry crocin to breast cancer cell lines. Explor Target Antitumor Ther. 2024;5(3):522-542.

86.

Nezamdoost

Saghebjoo

Hoshyar

Hedayati

Sadeghi Tabas

The effect of high-intensity interval training and saffron extract on the expression of some cachexia-related genes in the skeletal muscle of female mice carrying breast cancer cell line. Sport Physiol. 2020;12(48):83-104.

87.

Nezamdoost

Saghebjoo

Hoshyar

Hedayati

Keska

High-intensity training and saffron: effects on breast cancer-related gene expression. Med Sci Sports Exerc. 2020;52(7):1470-1476.

88.

Ahmadabadi

Saghebjoo

Hedayati

Hoshyar

Huang

C-J.

Treatment-induced tumor cell apoptosis following high-intensity interval training and saffron aqueous extract in mice with breast cancer. Physiol Int. 2021;108(1):19-26.

89.

Ahmadabadi

Saghebjoo

Huang

C-J

Saffari

Zardast

The effects of high-intensity interval training and saffron aqueous extract supplementation on alterations of body weight and apoptotic indices in skeletal muscle of 4T1 breast cancer-bearing mice with cachexia. Appl Physiol Nutr Metab. 2020;45(5):555-563.

90.

Zhou

Yang

Xing

Bcl-2 and Bcl-xll play important roles in the crotalk betwen autophagy and apoptosis. FEBS J. 2011;278(3):403-413.

91.

Cohen

GM.

Caspases: the executioners of apoptosis. Biochem J. 1997;326(Pt 1):1-16.

92.

Rusin

The p53 protein – not only the guardian of the genome. Poste̢p Biochem. 2024;70(1):71-87.

93.

Gonda

Wang

TC.

Chronic inflammation, the tumor microenvironment and carcinogenesis. Cell Cycle. 2009;8(13):2005-2013.

94.

Multhoff

Molls

Radons

Chronic inflammation in cancer development. Front Immunol. 2011;2:98.

95.

Folkman

Role of angiogenesis in tumor growth and metastasis. Semin Oncol. 2002;29:15-18.

96.

Paduch

The role of lymphangiogenesis and angiogenesis in tumor metastasis. Cell Oncol. 2016;39:397-410.

97.

Gueritat

Lefeuvre-Orfila

Vincent

, et al Exercise training combined with antioxidant supplementation prevents the antiproliferative activity of their single treatment in prostate cancer through inhibition of redox adaptation. Free Radic Biol Med. 2014;77:95-105.

98.

Shamsi

Chekachak

Soudi

, et al Combined effect of aerobic interval training and selenium nanoparticles on expression of IL-15 and IL-10/TNF-α ratio in skeletal muscle of 4T1 breast cancer mice with cachexia. Cytokine. 2017;90:100-108.

99.

Milajerdi

Djafarian

Hosseini

. The toxicity of saffron (Crocus sativus L.) and its constituents against normal and cancer cells. J Nutr Intermed Metab. 2016;3:23-32.

100.

Ramadan

Soliman

Mahmoud

Nofal

Abdel-Rahman

RF.

Evaluation of the safety and antioxidant activities of Crocus sativus and propolis ethanolic extracts. J Saudi Chem Soc. 2012;16(1):13-21.

101.

Modaghegh

M-H

Shahabian

Esmaeili

H-A

Rajbai

Hosseinzadeh

Safety evaluation of saffron (Crocus sativus) tablets in healthy volunteers. Phytomedicine. 2008;15(12):1032-1037.

102.

Kashani

Aslzadeh

Shokraee

, et al Crocus sativus (saffron) in the treatment of female sexual dysfunction: a three-center, double-blind, randomized, and placebo-controlled clinical trial. Avicenna J Phytomed. 2022;12(3):257-268.

103.

Kazemi

Mollaei

Takhviji

, et al The anti-dyslipidemia property of saffron petal hydroalcoholicextract in cardiovascular patients: a double-blinded randomized clinical trial. Clin Nutr ESPEN. 2023;55:314-319.

104.

Lopresti

Smith

Drummond

PD.

An investigation into an evening intake of a saffron extract (affron®) on sleep quality, cortisol, and melatonin concentrations in adults with poor sleep: a randomised, double-blind, placebo-controlled, multi-dose study. Sleep Med. 2021;86:7-18.

105.

Esalatmanesh

Biuseh

Noorbala

, et al Comparison of saffron and fluvoxamine in the treatment of mild to moderate obsessive-compulsive disorder: a double blind randomized clinical trial. Iran J Psychiatry. 2017;12(3):154-162.

106.

Ghajar

Neishabouri

Velayati

, et al Crocus sativus L. versus citalopram in the treatment of major depressive disorder with anxious distress: a double-blind, controlled clinical trial. Pharmacopsychiatry. 2017;50(4):152-160.

107.

Bahrami

Pour

Hassanpour

, et al The effect of saffron and corrective exercises on depression and quality of life in women with multiple sclerosis: a randomized controlled clinical trial. Multiple Scler Relat Disord. 2023;79:105038.

108.

Roghani

Jalili

Emtiazi

, et al S932 safron: a promising adjuvant therapy in ulcerative colitis - a trial evaluating clinical and laboratory outcomes. Am J Gastroenterol. 2023;118(10S):S698-S699.

109.

Sahebari

Heidari

Nabavi

, et al A double-blind placebo-controlled randomized trial of oral saffron in the treatment of rheumatoid arthritis. Avicenna J Phytomed. 2021; 11(4):332-342.

110.

Tajaddini

Roshanravan

Mobasseri

, et al Saffron improves life and sleep quality, glycaemic status, lipid profile and liver function in diabetic patients: a double-blind, placebo-controlled, randomised clinical trial. Int J Clin Pract. 2021;75(8):e14334.

111.

Zilaee

Hosseini

Jafarirad

, et al An evaluation of the effects of saffron supplementation on the asthma clinical symptoms and asthma severity in patients with mild and moderate persistent allergic asthma: a double-blind, randomized placebo-controlled trial. Respir Res. 2019;20(1):39.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.01 MB