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Paradigm shift in solid cancer and
the need for antimetastatic drugs
Assoc. Prof. Jan Brábek, Ph.D.
Charles University, Faculty of Science
Deparment of Cell Biology and BIOCEV
Jan Brábek, Charles University and BIOCEV 1st April 2020
In 2019, the problems with solid cancer are:
ineffective, unsafe, and unaffordable
medicines!
Do cancer drugs improve survival or quality of life?
You don’t need to know, according to our broken regulatory system
Vinay Prasad
• between 2008 and 2013 both FDA and EMA mostly approved cancer drugs without evidence of
prolonged survival or improved quality of life
• less than 15% were shown later to improve survival
• the median improvement in survival among patients treated with 71 drugs for solid cancer was
just 9 weeks!
Tab. 1. Mortality rates (years 1950-2008) for infectious, heart, cerebrovascular diseases (From
American Cancer Society (ACS) 2010 Cancer Facts & Figures; Atlanta, USA, 2008, modified).
Estimation of the Percentage of US Patients With Cancer Who Benefit
From Genome-Driven Oncology
John Marquart, BA; Emerson Y. Chen, MD; Vinay Prasad, MD, MPH
Question How many US patients with cancer benefit from genome-targeted therapies?
Findings
• in 2006 - 5% of patients were eligible, in 2018 - 8%
• In 2006 - less than 1% of patients responded, in 2018 - 5%
In 2019, the problems with solid cancer are:
ineffective, unsafe, and unaffordable
medicines!
It seems as if we are now entering into the WE KNEW IT
ALL ALONG phase of the cancer paradigm shift. Not long
ago, the author of the Commentary was defending just the
opposite view. This is called "re-positioning" oneself. Good
sign...Carlos Sonnenschein, personal communication
Cancer, checkpoint inhibitors, and confusion.
Fernandes M, Brábek J.
Lancet Oncol. 2017 18(11):e632.
Compared to chemotherapy, serious broad spectrum toxicity is unpredictable.
In 2019, the problems with solid cancer are:
ineffective, unsafe, and unaffordable
medicines!
In 2019, the problems with solid cancer are:
ineffective, unsafe, and unaffordable
medicines!
Affordable cancer care.
Fernandes M, Brábek J.
Lancet Oncol. 2012 13(1):e2-3.
Affordable cancer care: pipedream or achievable reality?
Collingridge D, Sullivan R.
Lancet Oncol. 2014 15(3):257-8.
Continuing failure despite:
• excellent scientists
• advanced technology
• generous funding
WHY?
Not focused on central issue:
Invasion and metastasis!
Pharma companies don’t concentrate on solving the problem
of metastasis (the thing that kills people); they focus on
devising drugs that shrink tumors (the things that don’t).
In contrast to hematopoetic malignancies, solid
cancer is predominantly a disease of invasion
and metastasis, not an uncontrolled proliferation!
x
Virchows Archiv B
December 1978, Volume 29, Issue 1,
pp 145–150 | Cite as
Tumors as clonal proliferation
•Authors
•Authors and affiliations
•Peter C. Nowell
Cancer; a definition
A growth (enlargement) composed of a clonal population
of cells that has acquired the ability to expand in defiance
of the checks and balances that would normally control
the proliferation and survival of normal cells (neo-plastic).
https://link.springer.com/journal/443https://link.springer.com/journal/443/29/1/page/1https://link.springer.com/article/10.1007/BF02899348#citeashttps://link.springer.com/article/10.1007/BF02899348#authorshttps://link.springer.com/article/10.1007/BF02899348#authorsandaffiliations
In solid cancer, does ongoing metastatic activity
negate the “benefit” of tumor shrinkage?
YES!
METASTASES
➢ according to WHO - 9 millions of cancer deaths per year
(more than 10% of all deaths)
➢ metastases responsible for 90 % of deaths in cancer patients
(Steeg, 2016)
(adopted from (Hanahan a Weinberg, 2011))
HALLMARKS OF CANCER
Sustaining proliferative
signaling
Evading growth
suppressors
Enabling replicative
immortalityResisting cell death
Inducing angiogenesisActivating invasion
and metastasis
Avoiding immune
destruction
Deregulating cellular
energetics
Tumor-promoting
inflammation
Genome instability
and mutation
- Sustaining proliferative signaling
- Evading growth suppressors
- Resisting cell death
- Enabling replicative immortality
- Inducing angiogenesis
- Activating invasion and metastasis
MALIGNANT TRANSFORMATION
(Adapted from (Hanahan a Weinberg, 2000))
➢ invasion and metastasis - the only real
cancer hallmark
(prof. Y. Lazebnik)
➢ understanding the mechanisms of
invasion and metastasis critical for the
development of effective anti-cancer
treatment
➢ change in regulations required - criteria
of effectiveness for antimetastatic
drugs(Brábek and Fernandes, The Lancet Oncology, 2012)
METASTASES
© EU, 2016
(Pantel and Brakenhoff, 2004)
METASTATIC CASCADE
ECMBM
intravasation
invasionvessel
primary tumor
METASTATIC CASCADE
I. Invasion – from primary tumor into the
surrounding tissue.
II. Intravasation – into blood or lymphatic vessel.
III. Transport to the secondary site and survival in
the bloodstream.
IV. Extravasation at the secondary site.
V. Proliferation at the secondary site,
formation of metastases.
vessel
extravasation
vessel
dormancy metastasis
IndividualCollective
Mesenchymal
Amoeboid
MODES OF CANCER CELL INVASIVENESS
HT1080 cells
MESENCHYMAL INVASIVENESS
➢ elongated shape
➢ proteolytic degradation of ECM
➢ formation of invadopodia
➢ actomyosin stress fibers
➢ Rac signalization
➢ migration speed 0,1-1 µm/min
(Tolde, unpublished results)
DAPI actin p-paxillin
DAPI actin p-paxillin
Podosomes and invadopodia – ECM degradation(Mitra et al., 2005)
Focal adhesions – adhesions to ECM
(Block et al., 2008)
CELL STRUCTURES IMPORTANT FOR
ADHESION AND INVASIVENESS
(Tolde et al., 2010)
PODOSOME COMPONENTS
(Brunton et al., 2004)
INVADOPODIA – STRUCTURE
2D (glass):
F-actin
p-Tyr
3D – acellular dermis
Tolde 2010
(Tolde et al., 2010)
INVADOPODIA
(Tolde et al., 2010)
10 μm 10 μm
+ GM6001
+GM6001
DAPI
F-actin
FITC-dermis
0 -10 -20 -30 -40 µm
MESENCHYMAL INVASIVENESS IS DEPENDENT
ON PROTEOLYTIC ECM DEGRADATION
(Tolde et al., 2010)
AMOEBOID INVASIVENESS
➢ round shape
➢ ECM proteases-independent
➢ elevated traction forces
➢ cortical actomyosin
➢ Rho/ROCK signalization
➢ migration speed 2-25 µm/min
(Gandalovičová, unpublished results)
HT1080-iRhoA (G14V)
AMOEBOID INVASIVENESS
Elevated Rho/ROCK signaling results in elevation
of traction forces in amoeboid cancer cells.
(Rosel et al., 2008)
K2 – mesenchymal A3 - amoeboidTraction
[Pa]
0
250
500
MLCP
ROCK
MRCK
MLCK
ZIPKp
p-MLCMLC
PAK1
actomyosin
contractility
Cdc42
RhoCRhoA
Rac
5 µm
AMOEBOID INVASIVENESS IS INDEPENDENT
ON ECM DEGRADATION
nuclei
F-actin
FITC-dermis
0 -10 -20 -30 -40 µm
+ GM6001
+GM6001
(Tolde, unpublished results)
+ ++ +++ +++
AMOEBOID INVASIVENESS - METASTASIS
THE IMPORTANCE OF RHO/ROCK/MLC
PATHWAY
AMOEBOID INVASIVENESS - METASTASIS
THE IMPORTANCE OF RHO/ROCK/MLC
PATHWAY
EMT : Epithelio-mesenchymal transition
MESENCHYMAL
EMT
Snail, Twist
E-Cadherin
COLLECTIVE
MAT : Mesenchymal-ameboid transition
AMT : Ameboid-mesenchymal transition
MAT
AMT
Proteases
Integrins
Rho/ROCK
AMOEBOID
➢ AMT/MAT represents an escape mechanism for cancer cell from treatment e.g. with protease inhibitors
CANCER CELL INVASION PLASTICITY
MESENCHYMAL TO AMOEBOID TRANSITION
(Gandalovičová, unpublished results)
HT1080-iRhoA (G14V)
Mesenchymal – amoeboid transition
Amoeboid – mesenchymal transitionA375m2 (melanoma) treated with p38 kinase inhibitors (10 μM)
DMSO SB202190 BIRB796
M2 macrophages in dense (4,8
mg/ml) or sparse (1,65 mg/ml)
collagen
Mesenchymal HT1080 cells after induction of RhoAG14V
or treatment with 1 μM dasatinib
4,8 mg/ml
1,65 mg/ml
(Cell invasion in cancer lab, unpublished results)
Transcriptomic and proteomic analysis of amoeboid mode
of invasiveness
HT1080-iRhoAG14V+ doxycyklin vs. HT1080 +dasatinib
545 117 762 717 219 759
TRANSCRIPTOMICS
Elevated expression in amoeboid cells Decreased expression in amoeboid cells
RhoAG14VRhoAG14V dasatinib dasatinib
Gene set enrichment analysis (GSEA)
– search for similarities with published
data
Interferones alfa/gama
activated genes (25/26)
TNFalfa activated genes (8)
G2/M checkpoint (41)
E2F target genes (40)
Mitotic spindle (25)
The adaptation of cell to amoeboid phenotype is associated
with the activation of inflammatory (JAK/STAT, NFkB)
signaling pathways and supression of cell cycle(Cell invasion in cancer lab, unpublished results)
Transcriptomic and proteomic analysis of amoeboid mode
of invasiveness
Transcriptomic and proteomic analysis of amoeboid mode
of invasiveness
Gene set enrichment analysis (GSEA)IL24
IL1B
IL11
CXCL8
IL1A
LIF
TGFA
GDF15
S100A16
INHBA
EPHB2
FST
VEGFA
GDF7
CLCF1
SPARC
EFNB2
BMP2
BMP8B
BMP7
GDNF
TGFB1
HGF
PDGFA
JAG1
Genes with decreased expression after AMT:
KEGG Gene Sets
„Cytokine-cytokine receptor interaction“ (25 genů)
„Jak-STAT signaling pathway“ (14 genů)
„MAPK signaling pathway“ (17 genů)
„TGF-beta signaling pathway“ (9 genů)
Hallmark Gene Sets
„genes regulated by NF-κB in response to TNF“ (50 genů)
„genes defining epithelial-mesenchymal transition“ (44
genů)
„genes up-regulated by KRAS activation“ (36 genů)
„genes up-regulated in response to hypoxia“ (33 genů)
„genes up-regulated by STAT5 in response to IL2
stimulation“ (32 genes)
„genes defining inflammatory response“ (27 genů)
„TGF-beta signaling pathway“ (9 genů)
„genes up-regulated by IL6 via STAT3“ (8 genů)
AMT in A375m2
results in decreased
expression of many
secreted ligands
HT1080
A375m2HT1080
Co-cultivation of mesenchymal
HT1080 cells with A375m2 cells in
mixed spheroids triggers amoeboid
invasiveness in HT1080 cells
Increased expression in mesenchymal cells: 2084 genes
Decreased expression in mesenchymal cells: 1769 genesA375m2 after p38 kinase
inhibition
(Cell invasion in cancer lab, unpublished results)
(Gandalovičová et al., 2017)
MIGRASTATICS – NEW CATEGORY
OF ANTI-CANCER DRUGS
(Gandalovičová et al., 2017)
MIGRASTATICS – NEW CATEGORY
OF ANTI-CANCER DRUGS
MIGRASTATICS – NEW CATEGORY OF ANTI-
CANCER DRUGS
(Gandalovičová et al., 2017)
ANTIMETASTATIC TREATMENT– PROBLEMS
WITH CRITERIA OF EFFECTIVENESS
(Brábek et al., 2016)
FDA approves new treatment for a certain type of prostate
cancer using novel clinical trial endpoint
February 14, 2018
The U.S. FDA today approved Erleada (apalutamide) for the
treatment of patients with prostate cancer that has not spread,
but that continues to grow despite treatment with hormone
therapy. …This approval is the first to use the endpoint of
metastasis-free survival, measuring the length of time that
tumors did not spread to other parts of the body or that death
occurred after starting treatment,” said Richard Pazdur, M.D.,
director of the FDA’s Oncology Center of Excellence and acting
director of the Office of Hematology and Oncology Products in
the FDA’s Center for Drug Evaluation and Research.
"The FDA had now recognized that a prolonged delay in the
development of metastatic disease is an objective and
clinically relevant measure," Beaver and colleagues write.
THE CONCEPTUAL ADVANTAGES
OF MIGRASTATIC TREATMENT
cytotoxic challenge
Darwinian selection
of resistant clones
proliferative advantage
invasion/metastasis
no cytotoxic challenge
rare resistants without
proliferative advantage
NO invasion/metastasis
(Steeg, 2016)
INCORPORATION OF PRECLINICAL METASTASIS
MODELS INTO DRUG DEVELOPMENT
CONCLUSION:
PLAN B FOR CANCER MOONSHOT INITIATIVE
Plan A Precision medicine (”driver genes” etc.)
Plan B Therapy directed to ”3 Ms”
cancer microenvironment, motility (MIGRASTATICS) and metabolism
(Brábek, Rosel, Fernandes, New England Journal of Medicine, 2017)
WHAT´S NEXT
➢ Based on our work, we plan on exploring the determinants
of metastasis and tractable targets for pharma
intervention, e.g. migrastatics.
➢ Collaboration with medicinal chemists is crucial and we need
to explore both synthetic compounds and natural products.
➢ Accordingly, we plan on making suggestions for the revision
of regulations on new cancer drugs. Primarily, rationalizing
and justifying criteria for the evaluation of sustainable
efficacy.
“The basis for the allele-oriented SMT has recently been
questioned, and the relevance of embryonic fields to cancer
has been re-established. Alterations in paracrine factor
signaling in both the target and producer cells have been
seen to initiate cancer formation, and embryonic
processes such as epithelial-mesenchymal
transformation are now seen as critical in metastasis. It is
without question, though, that developmental biology helped
establish oncology and has continued to help mold it. The
rightful sovereign returns.”
(Joyce and Pollard, 2009)
TUMOR HISTOLOGY
STROMAL ENVIRONMENT INTERACTIONS
(Mueller a Fusenig, 2004)
(Vander Heiden, et al., 2009)
STROMAL ENVIRONMENT INTERACTIONS
(Olumi, et al., 1999)
Cancer-associated Fibroblasts (CAFs)
TUMOR MICROENVIRONMENT
CANCER CELL INVASIVENESS
THE ROLE OF CAFs
(Wolf et al., 2007)
Ctrl Ctrl - GFP Ctrl HFP3 HFP3+A2058 Mel Fib MelFib+A2058
+IL8 Antibody
CANCER CELL INVASIVENESS
THE ROLE OF CAFs
(Jobe et al., 2017)
PODĚKOVÁNÍ
DANIEL RÖSEL
ONDŘEJ TOLDE
VLADIMÍR ČERMÁK
ANETA GANDALOVIČOVÁ
LADISLAV MERTA
DANIELA PAŇKOVÁ
KAREL SMETANA Jr.
PAVEL MARTÁSEK
VLADIMÍR KRÁL
PAVEL VESELÝ
JAN KOSLA
MICHAL DVOŘÁK
JIŘÍ PLACHÝ
BEN FABRY
VICTORIA SANZ-MORENO
Biotechnology and Biomedicine Center
of the Academy of Sciences
and Charles University in Vestec
THANK YOU FOR ATTENTION!
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