Targeting the Cancer Kinome Through Polypharmacology
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PERSPECTIVES components, such as KRAS or PTEN, which THERAPEUTIC RESISTANCE — OPINION enable the tumour to bypass the drug target20,21,30. Targeting the cancer kinome Overcoming these resistance mechanisms will require targeting tumour cells at multiple levels, through either single drugs that bind through polypharmacology to multiple proteins31 or cocktails of highly selective inhibitors32. The challenge for the Zachary A. Knight, Henry Lin and Kevan M. Shokat cancer research community is to learn how to predict the best combinations of targets and Abstract | Kinase inhibitors are the largest class of new cancer drugs. then prioritize those combinations for clini- However, it is already apparent that most tumours can escape from the cal testing. This is a daunting task, because inhibition of any single kinase. If it is necessary to inhibit multiple kinases, the number of possible target combinations how do we choose which ones? In this Opinion article, we discuss some of is almost limitless, but clinical trials are slow the strategies that are currently being used to identify new therapeutic and expensive. combinations of kinase targets. Targeting one kinase with multiple drugs If a tumour depends on the activity of a sin- More than 10,000 patent applications for cancer. Clinical trials show that the most gle kinase, then using multiple drugs to target kinase inhibitors have been filed since 2001 effective kinase inhibitors prolong survival that kinase can be effective. This was first in the United States alone1. This massive by only a few months for these cancers12–17. demonstrated in CML, in which early clinical investment has been fuelled by the realiza- Results have been improved by identifying trials showed that more than 90% of patients tion that kinases are intimately involved in markers for patients that are more likely with chronic phase disease responded to the cancer cell growth, proliferation and sur- to respond to kinase inhibitor therapy — BCR–ABL inhibitor imatinib5 (TABLE 1), but vival. Indeed, kinases and their direct regula- such as EGFR mutations in lung cancer18, that a subset of those patients relapsed while tors are among the most frequently mutated ERBB2 overexpression in breast cancer19, on the drug. Disease progression was associ- oncogenes and tumour suppressors2–4. Well and wild-type KRAS in lung and colorectal ated with the emergence of leukaemic cells known examples include the oncogenic cancer20,21 — but even among these sub- bearing mutations in BCR–ABL that block kinases PIK3CA (the p110α subunit of groups, relapse is inevitable for patients with imatinib binding22, suggesting that drugs PI3K), epidermal growth factor receptor disseminated disease. targeting these BCR–ABL mutants would be (EGFR) and BRAF; the Ras family of onco- Why has clinical progress been so chal- effective. Two second-generation BCR–ABL genes, which activate both PI3Ks and Raf; lenging? One reason is that most tumours inhibitors were developed (dasatinib and and the PTEN tumour suppressor, which can escape from the inhibition of any single nilotinib) that retain activity against most of inhibits PI3K signalling. kinase (FIG. 1). This first became clear when the more than 50 clinically observed BCR– Despite the excitement surrounding these resistance mutations in BCR–ABL were ABL resistance mutations, and these drugs targets, clinical progress has been uneven. discovered in patients with CML who were are highly effective against imatinib-resistant Kinase inhibitors have revolutionized the resistant to imatinib22; similar mutations disease33,34. However, a common BCR–ABL treatment of a select group of diseases, such have now been detected in other kinases fol- mutation (T315I) prevents the binding of as chronic myeloid leukaemia (CML) and lowing treatment with kinase inhibitors23–26. all three drugs, and this has emerged as the gastrointestinal stromal tumours (GIST), Alternatively, tumours can acquire drug default allele for many patients on long- which are driven by a single oncogenic resistance through mechanisms that do not term inhibitor therapy22,35. To address this kinase; for these conditions, kinase inhibi- involve mutation of the target (FIG. 1a). These problem, third-generation drugs have been tors have achieved multi-year increases in mechanisms include the activation of sur- developed that potently inhibit BCR–ABL survival5–7. Smaller but significant responses rogate kinases that substitute for the drug T315I. These agents are effective in preclini- have been observed for some cancers that target27 and the inactivation of phosphatases cal models of drug-resistant CML36–39, and are highly dependent on angiogenesis, and to amplify the residual kinase activity that four such compounds are currently in clini- therefore sensitive to inhibitors of vascular persists during drug treatment28. It is also cal trials. Some patients have now survived endothelial growth factor (VEGF) signalling, clear that many tumours possess intrinsic more than 10 years since starting treatment such as renal cell carcinoma8–11. resistance to kinase inhibitors at the time of by undergoing sequential therapy with three Kinase inhibitors have been least effec- initial therapy (FIG. 1b). This can result from generations of BCR–ABL inhibitors40, prov- tive in treating the types of cancer that have the activation of multiple, redundant kinase ing that it is possible to extend the therapeu- the highest mortality rates, such as lung, signalling pathways29 or the presence of acti- tic response in CML by repeatedly targeting breast, colorectal, pancreatic and prostate vating mutations in downstream pathway the same kinase. 130 | FEBRUARY 2010 | VOLUME 10 www.nature.com/reviews/cancer © 2010 Macmillan Publishers Limited. All rights reserved PERSPECTIVES A similar approach has been used to response. It is unclear how broadly this of an oncogene is much less dramatic than target the ERBB2 receptor tyrosine kinase in model applies, because it is unclear how the response in CML, in which even tran- breast cancer. Trastuzumab is a monoclonal many tumours are truly dependent on a sin- sient inhibition of BCR–ABL irreversibly antibody that binds to the extracellular gle oncogene (a state referred to as ‘oncogene commits cells to apoptosis44 (FIG. 2). In this domain of ERBB2, thereby both inhibiting addiction’ (REF. 41)). The strongest evidence respect, it is worth noting that the term ERBB2 signalling and recruiting immune in favour of this hypothesis is the discovery oncogene addiction gained widespread use cells to the tumour19; however, patients of resistance mutations after kinase inhibitor because it describes a paradox: inhibiting an with metastatic cancer who are treated with treatment in CML, GIST, lung cancer and a oncogene would be predicted to reverse the trastuzumab invariably relapse. The mecha- myeloproliferative disorder known as hyper- gain of function caused by the oncogene, not nism of trastuzumab resistance is not under- eosinophilic syndrome22–26. Such mutations kill all the tumour cells. It is only recently stood, but it is clear that resistant tumours are definitive proof that the mutated kinase that this term has been conflated with the remain dependent on ERBB2 signalling. was required for the survival of that tumour. idea that oncogenes should be expected to This is because patients with breast can- The oncogene addiction model is also sup- be required for tumour survival. For this cer who have progressed on trastuzumab ported by many preclinical studies showing reason, there is clearly a need to identify therapy nonetheless respond to lapatinib14, that tumour cell lines containing an activat- additional vulnerabilities in tumours beyond a small molecule inhibitor of the tyrosine ing mutation or amplification of a kinase can the genes that are directly mutated. kinase domain of ERBB2. Therefore, it is be more sensitive to inhibitors of that kinase possible to induce a second response in these in vitro42–44. Targeting nodes in a signalling network patients by targeting ERBB2 with a drug Conversely, the detection of an oncogenic Three sets of targets collectively account that binds to a different site on the protein. kinase mutation does not guarantee sensitiv- for a large proportion of current efforts in Unlike CML, however, the clinical response ity to the corresponding kinase inhibitor. For kinase inhibitor drug discovery. These are to lapatinib in metastatic breast cancer is example, mutations in PIK3CA or PTEN are the receptor tyrosine kinases (for example, brief, and disease progression typically poor predictors of the sensitivity of tumour EGFR, ERBB2, platelet-derived growth occurs within a few months14. cell lines to PI3K inhibitors31,45. Mutations in factor receptor (PDGFR) and VEGF These examples show that in certain cases KRAS do not, in general, sensitize tumour receptor 2 (VEGFR2)), the kinases in the sequential targeting of a single kinase with cells to inhibitors of Raf or Mek43,46. Indeed, MAPK pathway (for example, BRAF, MEK1 multiple drugs can prolong the therapeutic the response of most tumours to inhibition and MEK2) and the kinases in the PI3K pathway (for example, PIK3CA, Akt and mTOR). These three groups of targets are a Mutation that blocks Upregulation of Downregulation drug binding second kinase of phosphatase mechanistically linked because most recep- tor tyrosine kinases activate the MAPK and PI3K pathways as their primary signalling (FIG. 3) D Drug T315I D D D D function . There is a compelling biological