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Chemotherapy and CDK4/6 Inhibitors: Unexpected Bedfellows Patrick J

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Chemotherapy and CDK4/6 Inhibitors: Unexpected Bedfellows Patrick J Published OnlineFirst June 16, 2020; DOI: 10.1158/1535-7163.MCT-18-1161 MOLECULAR CANCER THERAPEUTICS | REVIEW Chemotherapy and CDK4/6 Inhibitors: Unexpected Bedfellows Patrick J. Roberts1, Vishnu Kumarasamy2, Agnieszka K. Witkiewicz2,3, and Erik S. Knudsen2,4 ABSTRACT ◥ Cyclin-dependent kinases 4 and 6 (CDK4/6) have emerged as ation between CDK4/6i and chemotherapy. Furthermore, the com- important therapeutic targets. Pharmacologic inhibitors of these bination of CDK4/6i and chemotherapy is being tested in clinical kinases function to inhibit cell-cycle progression and exert other trials to both enhance antitumor efficacy and limit toxicity. Exploi- important effects on the tumor and host environment. Because of tation of the noncanonical effects of CDK4/6i could also provide an their impact on the cell cycle, CDK4/6 inhibitors (CDK4/6i) have impetus for future studies in combination with chemotherapy. been hypothesized to antagonize the antitumor effects of cytotoxic Thus, while seemingly mutually exclusive mechanisms are at play, chemotherapy in tumors that are CDK4/6 dependent. However, the combination of CDK4/6 inhibition and chemotherapy could there are multiple preclinical studies that illustrate potent cooper- exemplify rational medicine. CDK4/6 in Cell-cycle Progression phosphorylate many substrates, CDK4/6 has a very limited repertoire of targets (18). CDK4 and CDK6 selectively phosphorylate the RB Cyclin dependent kinases (CDK) are serine/threonine kinases that tumor suppressor protein and additional members of the RB regulate the sequential progression of the cell cycle in eukaryotic family (18–21). RB-family proteins function as transcriptional cor- organisms. The molecular functions of these kinases in different epressors and limit the expression of E2F target genes that include phases of the cell cycle have been well characterized (1, 2). The multiple genes required for cell-cycle progression, DNA replication, cell-cycle machinery in higher eukaryotes is tightly regulated by the and mitotic progression (22, 23). The phosphorylation of RB, which is presence of more than 10 proteins in the CDK family that can have initiated by CDK4 or CDK6 serves to limit transcriptional repression overlapping and distinct functions (2). Cell-cycle initiation occurs in and enable progression through latter phases of the cell cycle defining G phase, which is conventionally governed by the activation of CDK4 1 the canonical CDK4/6-RB pathway (Fig. 1A). and CDK6 kinases that are downstream of mitogenic signals (3–5). The requirement for CDK4/6 in cell division has been interrogated The catalytic activity of CDK4 and CDK6 is positively regulated by the utilizing multiple approaches and has illustrated important features of binding of D-type cyclins (D1, D2, and D3). Expression of D-type the cell cycle. The inhibition of CDK4/6 by the expression of endog- cyclins is induced in response to mitogenic stimuli and remains high as enous inhibitors (e.g., p16INK4A) potently arrests cells that contain a the cells progress to the G –S phase boundary (6). Therefore, unlike 1 functional RB protein and subsequently limits gene expression con- other cyclins and CDKs that are regulated by other components of the trolled by RB/E2F (Fig. 1A). Multiple experimental methods (e.g., cell-cycle machinery, the expression of D-type cyclins, and by exten- antibody injection, RNAi, etc.) have further suggested that D-type sion, CDK4/6-associated kinase activity, largely depend on mitogenic cyclins and/or CDK4/6 activity are generally important for progres- signaling pathways (7, 8). Transcription of D-type cyclins is intimately sion from G1/S in normal cells as well as multiple cancer models (24). linked to multiple pathways that coalesce to lead to the accumulation of These findings contrast with studies in mouse models that clearly transcripts (7, 9, 10). Mitogenic signaling pathways also regulate the demonstrate that the cell cycle can proceed with genetic deletion of stability and localization of these proteins (11, 12). Importantly, a host CDK4 and 6 or deletion of all D-type cyclins (25, 26). In this context, of growth-inhibitory mechanisms also impact CDK4/6 activity, adaptation occurs in many tissues by enabling CDK2 or CDK1 activity including the induction of endogenous CDK4/6-specific inhibitors to drive cell cycle entry. However, genetic suppression of CDK4/6 with specific stresses (e.g., CDKN2A which encodes p16INK4A), and activity can limit or block tumor development in select models (27–30). active mechanisms of cyclin D1 degradation (13, 14). Thus, CDK4/6 This was clearly shown in the context of HER2-driven breast cancer activity acts as a sensor linking multiple signaling pathways to the where CDK4/6 activity is required both for tumor etiology and initiation of the cell cycle (15–17). maintenance (31). CDK4/6 regulates the cell cycle through phosphorylation of key substrates. Unlike the prototypical CDK1 and CDK2, which can Pharmacologic Inhibitors of CDK4/6— Mechanisms of Action and Resistance 1 2 G1 Therapeutics, Research Triangle Park, North Carolina. Center for Person- Because of the function of CDK4/6 in coordinating cell division, alized Medicine, Roswell Park Cancer Institute, Buffalo, New York. 3Department 4 pharmacologic inhibitors have been developed as anticancer drugs. of Pathology, Roswell Park Cancer Institute, Buffalo, New York. Department of fi Molecular and Cellular Biology, Roswell Park Cancer Institute, Buffalo, New York. There are ve selective CDK4/6 inhibitors (CDK4/6i); palbociclib (PD0332991), ribociclib (LEE011), abemaciclib (LY2835219), trilaci- Corresponding Author: Erik S. Knudsen, Roswell Park Cancer Center, Elm and clib (G1T28), and lerociclib (G1T38; refs. 32–38). Currently, three of Carlton Streets, Buffalo, NY 14263. Phone: 716-845-1224; Fax: 716-845-5908; þ E-mail: [email protected] these drugs are FDA-approved for the treatment of ER metastatic breast cancer based on multiple randomized clinical trials (palbociclib, Mol Cancer Ther 2020;19:1575–88 ribociclib, abemaciclib). While all of these compounds are selective doi: 10.1158/1535-7163.MCT-18-1161 for CDK4/6, palbociclib, ribociclib, abemaciclib, and lerociclib are Ó2020 American Association for Cancer Research. formulated for oral long-term dosing. Trilaciclib was formulated AACRJournals.org | 1575 Downloaded from mct.aacrjournals.org on September 26, 2021. © 2020 American Association for Cancer Research. Published OnlineFirst June 16, 2020; DOI: 10.1158/1535-7163.MCT-18-1161 Roberts et al. A Co-repressors Cyc D RB1 CDK4/6 E2F P P RB1 S-phase E2F Mitosis DNA-repair B Cyc D Co-repressors CDK4/6-inhibitor RB1 CDK4/6 E2F G1-arrest C Deregulated oncogenic pathways Co-repressors CDK4/6-inhibitor 2 Cyc E 1 CDK2 Cyc D CDK4/6 E2F P P RB1 S-phase E2F Mitosis Cytokinesis Figure 1. Different cell cycle states in cancer. A, The Canonical G1/S regulatory circuit: CDK4/6 kinase activity is stimulated downstream of mitogenic/oncogenic signals to initiate the phosphorylation of RB and related proteins. Phosphorylation facilitates the derepression of E2F-family of transcription factors that drive the expression of many genes required for DNA replication, mitosis, and cell division. B, CDK4/6 dependent cells: in cells, tumors, or tissues that are dependent on CDK4/6 activity treatment with pharmacological inhibitors yields the robust activation of RB. This event limits other CDK activities and represses the expression of essential genes for cellular division resulting in a G1–G0–like arrest. C, CDK4/6-independent cells: there are clearly two distinct states that yield CDK4/6 independent proliferation. (1) Loss of RB as occurs in a subset of human tumors removes the down-stream target and as such inhibition of CDK4/6 has minimal efficacy in controlling cell cycle. (2) Through various mechanisms RB phosphorylation can remain during pharmacologic inhibition. This cell-cycle plasticity can be generated through either CDK4/6 or CDK2 complexes and is prevalent in a number of tumor types that retain the RB tumor suppressor. specifically for intravenous delivery and short half-life with the activation (Fig. 1B) and suppress the expression of genes that are intended goal of preventing chemotherapy-induced host toxicities. conventionally regulated by the E2F family of transcription fac- Consistent with their mechanism of action, all CDK4/6i have cytostatic tors (39, 40). Because many of these genes are involved in core – activity that is associated with RB-dependent suppression of the G1 S functions of DNA replication and mitotic progression, and are con- transition (32, 36). Pharmacologic CDK4/6i mimic the effect of RB sidered essential for proliferation, the magnitude of transcriptional 1576 Mol Cancer Ther; 19(8) August 2020 MOLECULAR CANCER THERAPEUTICS Downloaded from mct.aacrjournals.org on September 26, 2021. © 2020 American Association for Cancer Research. Published OnlineFirst June 16, 2020; DOI: 10.1158/1535-7163.MCT-18-1161 Chemotherapy and CDK4/6 Inhibitors: Unexpected Bedfellows repression downstream from CDK4/6 inhibition is critical for cyto- prevent chemotherapy-induced cellular damage of normal cells that static activity. harbor an intact RB pathway (refs. 54, 55; Fig. 2A). One of the common Multiple determinants of response to CDK4/6 inhibition are being side effects of chemotherapy is myelosuppression, that can lead to the elucidated through both preclinical investigation and the analysis of exhaustion of hematopoietic stem and progenitor cells (HSPCs;
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