Current Cancer Drug Targets - Volume 9, Issue 3, 2009

It was with great pleasure that I accepted the invitation to be Guest Editor for this issue of Current Cancer Drug Targets. This volume collates reviews by experts on a wide range of research topics relevant to anti-cancer drug sensitivity and resistance, considering both traditional chemotherapeutic agents and newer, targeted therapies. The use of chemotherapy to treat cancer began in 1943 following the observation of leukopenia in those exposed to mustard gas (alkylating agent) after the explosion of a battle ship in Bari harbour during World War II. This alkylating agent was adapted for i.v. application and it produced dramatic, if short-lived, responses in lymphoma and leukaemia patients. Advancing on this, an extensive range of anti-cancer chemotherapeutic agents have been developed and are used in the oncology clinic. Such anti-cancer drugs aim to destroy cancer cells by stopping them from growing or multiplying. Unfortunately, due to the relative non-specific effects of some of these drugs, healthy cells (especially those that divide quickly) can also be harmed, resulting in undesirable side-effects. Based on our increasing understanding of normal versus cancer cells, in recent years the specific design and targeting of anti-cancer treatment is becoming increasingly sophisticated. The initially crude chemotherapy poisons which have since been continuously fine-tuned to increase efficacy and reduce side-effects and the newer “targeted agents” (which more specifically target features of cancer cells, with more limited side-effects) are set to revolutionise cancer treatment. Most types of cancer show some response to traditional chemotherapy and/or newer targeted agents, but only a limited number of forms of cancer can be completely cured by these approaches. In fact, the successful treatment of cancers varies greatly depending upon the specific malignancy. Some cancers, such as testicular seminoma, leukaemias and malignant lymphomas, are highly responsive to anti-cancer treatment; others are devastating diseases, showing limited, if any, response to currently available therapies. Unfortunately, intrinsic and acquired resistance to anti-cancer agents still represents a serious obstacle to success as patients refractory to treatment often exhibit resistance to multiple anti-cancer agents of differing structures and, often, differing functions. This clinical resistance, comparable to the experimental phenomenon termed multiple drug resistance (MDR), is likely to be multifactorial and heterogeneous, with many molecular mechanisms potentially contributing to the drug resistance phenotype. This resistance -whether inherent or acquired- of cancer cells to the effects of such agents is a serious problem, which we need to better understand and overcome. Studies on mechanisms of cancer drug resistance have yielded, and continue to yield, important information about how to circumvent this problem to improve response. Applying both basic and advanced analytical technologies, genome-wide studies correlating drug response phenotypes with large DNA, RNA, and miRNA microarray and proteomic datasets are being performed to identify the genes, RNAs, and proteins involved in drug sensitivity or resistance. The goal is to identify panels of sensitive- and/or resistance-associated genes, that are predictive of treatment response, for each anti-cancer agent/treatment regime. The hope is that such emerging panels of biomarkers will offer the potential for the selection of optimal treatment regimens for individual patients and also for the identification of novel therapeutic targets to overcome drug resistance.

Protein kinase inhibitors (PKI) are becoming key agents in modern cancer chemotherapy, and combination of PKIs with classical chemotherapeutic drugs may help to overcome currently untreatable metastatic cancers. Since chemotherapy resistance is a recurrent problem, mechanisms of resistance should be clarified in order to help further drug development. Here we suggest that in addition to PKI resistance based on altered target structures, the active removal of these therapeutic agents by the MDR-ABC transporters should also be considered as a major cause of clinical resistance. We discuss the occurring systemic and cellular mechanisms, which may hamper PKI efficiency, and document the role of selected MDR-ABC transporters in these phenomena through their interactions with these anticancer agents. Moreover, we suggest that PKI interactions with ABC transporters may modulate overall drug metabolism, including the fate of diverse, chemically or target-wise unrelated drugs. These effects are based on multiple forms of MDR-ABC transporter interaction with PKIs, as these compounds may be both substrates and/or inhibitors of an ABC transporter. We propose that these interactions should be carefully considered in clinical application, and a combined MDR-ABC transporter and PKI effect may bring a major advantage in future drug development.

Drug resistance is a serious limitation to the effective treatment of a number of common malignancies. Thirty years of laboratory and clinical research have greatly defined the molecular alterations underlying many drug resistance processes in cancer. Based on this knowledge, strategies to overcome the impact of resistance and increase the efficacy of cancer treatment have been translated from laboratory models to clinical trials. This article reviews laboratory and, in particular, clinical attempts at drug resistance circumvention from early forays in the inhibition of cellular efflux pumpmediated drug resistance through to more selective circumvention agent strategies and into inhibition of the other important mechanisms which can allow cancer cells to survive therapy, such as apoptosis resistance. Despite some promising results to date, resistance inhibition strategies have largely failed due to poor understanding of the pharmacology, dynamics and complexity of the resistance phenotype. With the realisation that new molecularly-targeted agents can also be rendered ineffectual by the actions of resistance mechanisms, a major focus is once again emerging on identifying new strategies/pharmaceuticals which can augment the activity of the arsenal of more conventional cytotoxics and newer targeted anti-cancer drugs. Future tactical directions where old and new resistance strategies may merge to overcome this challenge are discussed.

P-glycoprotein (Pgp), coded for by the mdr1 gene, is one of the ABC transporters held responsible for the phenomenon of multidrug resistance (mdr), which is reflected by a rapidly escalating failure of chemotherapy with different classes of cytotoxic agents: anthracyclins, vinca alkaloids, taxanes, epipodophylotoxins. Although overcoming resistance conveyed by Pgp alone may not be sufficient for reaching effective treatment, the abundance of observations available for this paradigmatic multidrug transporter at both in vitro and in vivo setting is a tempting ground for an updated assessment of the main currents of mdr research. In this review we attempt to help keep track of the features of Pgp-mediated drug transport that serve as the major starting points for ongoing efforts of mdr reversal. We will analyze the slowly narrowing gaps that prevail between our ever increasing understanding at the protein, cell and organism level, focusing on the molecular interactions involving Pgp.

Over the past two decades, a number of chemical entities have been investigated in the continuing quest to reverse P-glycoprotein (P-gp) mediated multidrug resistance (MDR) in cancer cells and some have undergone clinical trials, but currently none are in clinical use. Unfortunately, most of these agents suffer clinically from their intrinsic toxicity or from undesired effects on the pharmacokinetics of the accompanying anti-cancer drugs. An acridonecarboxamide (GF120918), Imidazo acridone (C1311) and timethylene acridone derivative 1,3-bis(9-oxoacridin-10-yl)-propane (PBA) have already been shown to be among the group of compounds known to modify P-gp mediated MDR in cancer. In the recent past it has been identified that various N10-substituted acridones can reverse the multidrug resistance (MDR) in cancer by selectively inhibiting the multidrug resistance associated protein (MRP) and calmodulin dependent cyclic AMP phosphodiesterase. This article envisages the various drugs being developed for treating MDR in cancer cells and especially the acridone derivatives which are being developed by the author.

Resistance to chemotherapy is a major obstacle in the treatment of cancer. Despite the advent of new chemotherapies and molecular-targeted therapies, approximately 90% of patients with metastatic cancer succumb to their disease. Drug resistance, either acquired or intrinsic, often prevents tumour cells from undergoing sufficient levels of programmed cell death or apoptosis, resulting in cancer cell survival and treatment failure. In pre-clinical disease models, agents that target the apoptotic pathway have been shown to sensitize tumour cells to chemotherapy and radiotherapy. Such therapies include small molecule inhibitors and antisense strategies that inhibit the activity of anti-apoptotic proteins, or treatment with recombinant pro-apoptotic proteins or antibodies that can activate the apoptotic pathway. This review will discuss apoptosis and the mechanisms by which it can become dysregulated in human cancer. In addition, novel therapeutic strategies that target key components of the apoptotic machinery will be discussed.

Drug resistance remains a major clinical challenge for cancer treatment. One mechanism by which tumor cells develop resistance to cytotoxic agents and radiation is related to resistance to apoptosis. Apoptosis is a well-organised process of cell death pre-programmed inside the cell. Apoptosis can be initiated either by activation of death receptors on the cell surface membranes (extrinsic pathway) or through a series of cellular events primarily processed at mitochondria (intrinsic pathway). Apoptosis has been shown to be important for tumorigenesis and cancer treatment. Defects in apoptosis can result in the expansion of a population of neoplastic cells. However, because the death of tumor cells induced by chemotherapy and radiotherapy is largely mediated by activation of apoptosis, inhibition of apoptosis will make tumor cells resistant to anti-tumor treatment. Herein, we will review the molecular changes that have the potential to cause apoptotic dysregulation, including activation of antiapoptotic factors (Bcl-2, BCLXL, Bfl1/A1 etc.), inactivation of pro-apoptotic effectors (p53, p53 pathway), and /or reinforcement of survival signals (Survivin, FLIP, NF-κB etc). Furthermore, we will discuss therapeutic intervention and/or strategies that can lower the threshold for apoptosis of tumor cells that could became useful approaches to treat cancer with special emphasis placed on the important priority to develop new cancer therapeutics toward tumor stem cells.

Bleomycin, a widely used anti-tumor agent, is well-known to cause single- and double-strand breaks in cellular DNA in vivo and in vitro leading finally to genomic instability of damaged cells. Bleomycin causes an increase of reactive oxygen species resulting in oxidative stress and pulmonary fibrosis. Further, bleomycin induces apoptosis and senescence in epithelial and non-epithelial cells of the lung. Caveolin-1 is a scaffold protein of caveolae, which are particularly abundant in alveolar epithelial type I cells, in endothelial and smooth muscle cells, and in fibroblasts of lung tissue. Caveolin-1 directly interacts with signaling molecules and effects diverse signaling pathways regulating cell proliferation, apoptosis, differentiation and growth. In this review we discuss aspects of bleomycin resistance. We summarize recent data about the effects of bleomycin in terms of lung cell biology and emphasize that bleomycin-induced injury of lung cells is accompanied by altered expression levels of caveolin-1. Caveolin-1 is involved in bleomycin-induced apoptosis and senescence of normal and lung cancer cells. Investigating the role of caveolin-1 may provide new tools for therapeutic interventions in lung disease and for the understanding of tumor biology.

A systematic review of cell models of acquired drug resistance not involving genetic manipulation showed that 80% of cell models had an inverse resistance relationship between cisplatin and paclitaxel [1]. Here we systematically review genetically modified cell lines in which the inverse cisplatin/paclitaxel resistance phenotype has resulted. This will form a short list of genes which may play a role in the mechanism of the inverse resistance relationship as well as act as potential markers for monitoring the development of resistance in the clinical treatment of cancer. The literature search revealed 91 genetically modified cell lines which report toxicity or viability/apoptosis data for cisplatin and paclitaxel relative to their parental cell lines. This resulted in 26 genes being associated with the inverse cisplatin/paclitaxel phenotype. The gene with the highest number of genetically modified cell lines associated with the inverse resistance relationship was BRCA1 and this gene is discussed in detail with reference to chemotherapy response in cell lines and in the clinical treatment of breast, ovarian and lung cancer. Other genes associated with the inverse resistance phenotype included dihydrodiol dehydrogenase (DDH) and P-glycoprotein. Genes which caused cross resistance or cross sensitivity between cisplatin and paclitaxel were also examined, the majority of these genes were apoptosis associated genes which may be useful for predicting cross resistance. We propose that BRCA1 should be the first of a panel of cellular markers to predict the inverse cisplatin/paclitaxel resistance phenotype.

Anthracyclines are an important reagent in many chemotherapy regimes for treating a wide range of tumors. One of the primary mechanisms of anthracycline action involves DNA damage caused by inhibition of topoisomerase II. Enzymatic detoxification of anthracycline is a major critical factor that determines anthracycline resistance. Natural product, daunorubicin a toxic analogue of anthracycline is reduced to less toxic daunorubicinol by the AKR1B10, enzyme, which is overexpressed in most cases of smoking associate squamous cell carcinoma (SCC) and adenocarcinoma. In addition, AKR1B10 was discovered as an enzyme overexpressed in human liver, cervical and endometrial cancer cases in samples from uterine cancer patients. Also, the expression of AKR1B10 was associated with tumor recurrence after surgery and keratinization of squamous cell carcinoma in cervical cancer and estimated to have the potential as a tumor intervention target colorectal cancer cells (HCT-8) and diagnostic marker for non-small-cell lung cancer. This article presents the mechanism of daunorubicin action and a method to improve the effectiveness of daunorubicin by modulating the activity of AKR1B10.

When treating cancer, cytotoxic agents are intended to exert their effect on rapidly proliferating cancer cells. However, often cancer chemotherapies lack specificity which can lead to toxicity and undesirable side affects. Many approaches have been designed to target tumors. Selective chemotherapies can be established by focusing on distinctive physiological, morphological and environmental differences between tumor and healthy tissue. For example, agents targeting nuclear receptors over-expressed in tumors can hone in on malignant tissue and result in improved chemotherapeutic treatments. In hormone-dependent cancers, such as certain breast cancers, a number of structurally varied estrogen receptor ligand conjugates have been investigated attempting to take advantage of the presence of over-expressed estrogen receptor. Estrogen receptor ligand conjugates containing a variety of cytotoxic agents, photodynamic therapeutic agents and radioligands have been reported. In addition, studies to improve the pharmaceutical properties of certain estrogen receptor ligand conjugates have shown promising results. In this review, developments in these specific types of estrogen receptor targeting approaches are discussed which highlight the potential advantages of these conjugates in the discovery of more effective cancer chemotherapy agents.

Despite major improvements in the surgical management the prognosis for patients bearing malignant gliomas is still dismal. Malignant gliomas are notoriously resistant to treatment and the survival time of patients is between 3-8 years for low-grade and anaplastic gliomas and 6 - 12 month for glioblastoma. Increasing malignancy of gliomas correlates with an increase in cellularity and a poorly organized tumor vasculature leading to insufficient blood supply, hypoxic areas and ultimately to the formation of necrosis, a characteristic of glioblastoma. Hypoxic/necrotic tumors are more resistant to chemotherapy and radiation. Hypoxia induces either directly or indirectly (through the activation of transcription factors) changes in the biology of a tumor and its microenvironment leading to increased aggressiveness and tumor resistance to chemotherapy and radiation. This review is focused on hypoxia-induced molecular changes affecting glioma biology and therapy.

Melanoma is the most aggressive form of skin cancer and advanced stages are inevitably resistant to conventional therapeutic agents. In particular, the inability of undergo apoptosis in response to chemotherapy and other external stimuli poses a selective advantage for tumor progression, metastasis formation as well as resistance to therapy in melanoma. Herein, we will review the molecular mechanisms of sensitivity and/or resistance of the most important drugs used in the treatment of melanoma. Furthermore, the novel strategies to overcome tumor chemoresistance will also be discussed. In particular, we will review the cancer stem cell hypothesis and how the failure of MDR reversal agents might increase the therapeutic index of substrate antineoplastic agents.

Breast cancer is the second leading cause of cancer deaths. This disease is estimated to be diagnosed in over one million people worldwide and to cause more than 400,000 deaths each year. This is a significant health problem in terms of both morbidity and mortality. Chemotherapy forms part of a successful treatment regime in many cases; however, as few as half of the patients treated may benefit from this, as a result of intrinsic or acquired multiple drug resistance (MDR). A range of mechanisms of MDR has been identified using in vitro cell culture models; many, if not all, of which may contribute to breast cancer resistance in the clinical setting. This phenomenon is complicated by the heterogenous nature of breast cancer and the likely multi-factorial nature of clinical resistance. It has been very well established that a “one treatment fits all” approach is not relevant and significant advances have been made through identifying and appropriately treating sub-groups of patients; particularly with newer rationally-targeted therapies, such as the HER2-targeted monoclonal antibody, Trastuzumab, and the dual HER2 and EGFR tyrosine kinase inhibitor, Lapatinab. Furthermore, large defined collaborative studies, using standardised global profiling approaches to study mRNA, microRNAs and proteins, followed by functional genomics studies, by ourselves and others, are underway in order to definitively establish the degree of complexity contributing to drug resistance. The overall vision is to identify the optimum therapeutic regime for individual patients -possibly involving novel targeted therapies, drug resistance modulators, and chemotherapy- to overcome breast cancer.

Amplification of the HER-2 gene occurs in approximately 25% of breast cancers, causing up-regulation of key signaling pathways which control cell growth and survival. In breast cancer patients, HER-2 overexpression correlates with an aggressive phenotype and poor prognosis. HER-2, therefore, has become the focus of many anti-cancer therapeutic approaches. Trastuzumab (Herceptin™), a humanized monoclonal antibody directed against the extracellular domain of HER-2, was the first FDA-approved HER-2-targeted therapy for the treatment of metastatic breast cancer. However, not all HER-2-overexpressing patients respond to trastuzumab and most that initially respond develop resistance within one year of treatment. Trastuzumab resistance has been studied in cell line models of resistance and several mechanisms of resistance have been proposed. More recent anti-HER-2 strategies involve targeting its tyrosine kinase domain; for example, lapatinib (Tykerb™) is a dual HER-2 and EGFR tyrosine kinase inhibitor and has shown efficacy as a single agent and in combination with other therapeutics. A number of novel HER-2 antagonists are currently in preclinical or clinical development, including both monoclonal antibodies and small molecule inhibitors. Increased understanding of HER-2 signaling in breast cancer, and of response and resistance to HER-2 antagonists, will aid the development of strategies to overcome resistance to HER-2 targeted therapies.

The phosphatidylinositol 3-kinase/protein kinase B/mammalian target of rapamycin-pathway (PI3K/AKT/mTOR-pathway) plays a role in the regulation of cell proliferation, cell survival, angiogenesis and resistance to anti-tumor treatments. In many tumor types the PI3K/AKT/mTOR-pathway is found activated through several different underlying mechanisms. Since this pathway is believed to largely drive the malignant behavior of several of these tumors, mTOR-inhibition is considered an attractive means to apply as anti-tumor treatment. Currently, four mTOR-inhibitors are explored for clinical use: rapamycin, temsirolimus (CCI-779), everolimus (RAD001) and deforolimus (AP23573). As monotherapy, mTOR-inhibitors yield interesting anti-tumor activity against various tumor types at the expense of relatively mild toxicities. This recently resulted in the registration of two mTOR-inhibitors for patients with metastatic renal cell carcinoma (RCC) while randomized studies in other tumors are currently in progress. Furthermore, mTOR-inhibitors are well-suited drugs to combine with other anti-tumor drugs as in preclinical models mTOR-inhibition overcomes chemoresistance. Consequently, mTOR-inhibitor-containing multidrug regimens are subject to clinical studies. As holds true for all anti-tumor therapies, identification of patients who are likely to respond to mTOR-inhibitorcontaining therapies is of utmost importance to avoid over- or undertreatment. Preliminary results suggest that several factors reflecting activation of mTOR in tumors may be used for this purpose. This review addresses the mechanism of action and current clinical experience with mTOR-inhibitors as well as their role in overcoming resistance to conventional therapies. Additionally, potential predictors of outcome to mTOR-inhibition are discussed.