Abstract

This study investigates the association between exposure to the PFOS alternative F-53B (6:2 Cl-PFESA) and cervical cancer risk in Chinese women, and elucidates its dual mechanisms of cervical toxicity and malignant progression. A case-control study (181 patients, 164 controls) measured plasma concentrations of 8 PFAS by UPLC-MS/MS, and logistic regression, WQS, and BKMR models were used to assess PFAS-cervical cancer associations. Human cervical epithelial cells (HcerEpic, HeLa, SiHa) were exposed to acute (425 μM) or long-term low-dose (1 μM) F-53B, followed by transcriptomics, ferroptosis phenotyping, functional assays, and protein/gene expression analyses. In vivo validation was performed using C57BL/6 mice (subacute exposure, metabolomics) and BALB/c nude mice (xenograft model). Epidemiological analysis identified F-53B as the predominant driver of cervical cancer risk within PFAS mixture exposure. Acute high-dose F-53B induced ferroptosis in cervical epithelial cells. At a concentration relevant to occupational exposure (1 μM), F-53B promoted malignant phenotypes by driving cell cycle progression, inhibiting apoptosis, enhancing migration/invasion, and inducing EMT. In vivo, F-53B caused cervical ferroptosis and systemic lipid metabolic reprogramming in C57BL/6 mice, and promoted xenograft growth and lymphatic metastasis in nude mice. This first multi-level evidence identifies F-53B, a widely used PFOS substitute, as an environmental risk factor for cervical cancer. It exerts acute toxicity via ferroptosis and drives malignant progression over the long term through multiple oncogenic phenotypes, underscoring the need for stringent risk assessment of emerging PFAS alternatives.