Abstract Background Cancer arises through coordinated disruption of genome integrity, epigenetic regulation, and cellular metabolism, producing heterogeneous phenotypes that enable uncontrolled growth, immune evasion, invasion, and metastasis. Because these processes operate as an interconnected system rather than isolated pathways, an integrated synthesis is needed to clarify how tumors evolve and why resistance emerges across diverse clinical contexts. Main body This review synthesizes key molecular events that initiate and sustain carcinogenesis, emphasizing mechanistic coupling among genomic instability, epigenetic remodeling, and metabolic adaptation. Defects in cell-cycle checkpoints, telomere maintenance, and DNA repair accelerate mutational accumulation and clonal diversification. Epigenetic control of gene expression is examined through DNA methylation, histone modifications, chromatin remodeling, and regulatory non-coding RNAs, including how epigenetic drift can stabilize malignant transcriptional programs and modulate DNA damage responses. Metabolic reprogramming is discussed beyond aerobic glycolysis, focusing on context-dependent shifts between glycolysis and oxidative phosphorylation shaped by hypoxia-inducible factor signaling, mitochondrial dysfunction, and mitochondrial DNA alterations. The resulting changes in redox balance and metabolite availability influence chromatin-modifying enzymes and genome maintenance pathways, creating feedback loops that support survival under microenvironmental stress. These molecular programs are linked to tumor progression through angiogenic signaling and epithelial–mesenchymal transition, in which loss of E-cadherin and transcriptional reprogramming promote dissemination. Translational implications are outlined through representative therapeutic classes, including next-generation targeted agents, anti-angiogenic strategies, immunotherapies, epigenetic modulators, and metabolism-directed interventions, with emphasis on rationale for combination approaches that constrain adaptive escape. Conclusion Establishing that carcinogenesis operates through coupled genetic, epigenetic, and metabolic mechanisms provides a coherent framework for interpreting tumor heterogeneity and therapy resistance. Organizing evidence around shared interaction nodes supports more mechanism-driven biomarker selection and more durable, context-aware therapeutic strategies.
Aziz et al. (2026) studied this question.