Cancer Drug Resistance

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Cancer Drug Resistance
Published on January 2009

Report Summary

Drug resistance is the single most important cause of cancer treatment failure and carries a massive burden to patients, healthcare
providers, drug developers and society. It is estimated that Multidrug Resistance (MDR) plays a major role in up to 50% of cancer
cases. Today, most drug therapies involve multiple agents, as it is almost universally the case that single drugs (or single-target
drugs) will encounter resistance.

This report gives a comprehensive review of resistance-associated changes and mechanisms for approved cancer drugs (60 drug
classes) and Phase III candidates, as well as an examination of how developers are tackling drug resistance using novel agents and
new drug combinations. This report looks at every general class of cancer drug in the pipeline or launched (around 400, representing
2000+ agents) and has identified all new drug classes from Preclinical through to Phase III, that will provide new strategies to tackle
resistance.

This new report includes i) A Global Resistance Map: a presentation and review of resistance mechanisms or resistance-associated
changes at the gene, protein or functional level reported for currently approved cancer drugs, covering 60 general cancer drug
classes and 190 agents ii) Drug Pipeline: a presentation of the entire anticancer drug development pipeline (2000+ agents from
approx. 400 general drug classes), from preclinical to launched, including mechanisms of action of individual drugs iii) New Drug
Mechanisms: new cancer agents in the development pipeline (i.e. drug mechanisms not previously developed in any previous drug
development phase), representing 157, 56, 84 and 37 new drug classes at preclinical, phase I, phase II and phase III, respectively iv)
Strategies to Combat Cancer Drug Resistance: including targeting, bypassing or exploiting resistance mechanisms, current and new
drug combinations and novel drugs offering new ways to target drug resistance. v) Resistance Biomarkers: a presentation of current
findings at the gene and/or protein level for all currently launched anticancer drugs, that offer potential resistance biomarkers for drug
discovery, diagnostics and therapy decisions.

Cancer Drug Resistance: Anticancer drugs fail to kill cancer cells for a number of reasons. These include kinetic factors, where drugs
fail to reach tumours, are poorly absorbed or metabolically deactivated. Drug resistance mechanisms are either innate, where they
are intrinsic to the cancer or acquired, which occurs due to adaptive changes in response to therapy and due to the selection of
survival phenotypes. Today, new drug combinations are central to the strategy to combat resistance and this report estimates (from
trials in the US & UK) that 40-50% of current cancer drug trials involve multiple drug combinations. These include combinations of
established small molecule drugs with others, with new agents or with immunotherapeutic molecules. Targeting Resistance
Mechanisms: Advancing knowledge at the gene and protein level in cancer cells is enabling scientists to better understand
interconnected pathways involved cell cycle control, cell signaling and cell death and this is enabling viability-critical targets or target
combinations to be more readily identified. In developing new combination drug therapies, a key goal is to identify targets that
together represent an Achilles Heel to the cell. For example, scientists have reported that BRCA1 or BRCA2 mutant cells, which show
defective DNA maintenance, are very sensitive to inhibitors of another genome maintenance pathway. These studies showed that
inhibitors of the enzyme PARP (Poly(ADP-Ribose) polymerase) are able to kill cells that are defective in BRCA1 or BRCA2 at very
low concentrations, compared to normal cancer cells. This illustrates the potential of targeting co-supportive or co-dependent
pathways. Resistance data (at the gene and protein level), cited in this report, provides a comprehensive and detailed update of
scientists' findings on cancer drug resistance, to assist efforts to better understand and target the associated mechanisms.

Further Information: This report also reviews all current phase III anticancer drugs, focusing on novel drug classes that are creating

Cancer Drug Resistance Page 1/8


interest in their potential to combat drug resistance. This includes immunotherapeutic drugs (500+ agents in development or
launched), second-generation targeted therapies (i.e. multi-target drugs; 15+ prominent candidates in development) and other drug
classes such as the NF- B inhibitors (30+candidates in development), heat shock protein inhibitors (40+ candidates in development),
HDAC inhibitors and many others. This report also includes an in-depth discussion with Michael M. Gottesman M.D. (Head, Molecular
Cell Genetics, Multidrug Resistance Unit, Centre for Cancer Research, US National Cancer Institute) and cites more than 260
References.

Table of Content

ReportIndex Page

Chapter 1 Cancer Drug Resistance 10
This chapter gives a brief introduction to cancer drug resistance and identifies areas covered
later in the report.
1.1 Introduction 11
1.2 Resistance Mechanisms 12
1.3 Innate Resistance 12
1.4 Acquired Resistance 12
1.5 Cancer Stem Cells 13
1.6 Resistance Biomarkers 14
Chapter 1 References

Chapter 2 Cancer Resistance and the Current Drug pipeline 15
This chapter presents a comprehensive review of resistance mechanisms and/or resistance-associated changes at the gene or
protein levels in cancer cells. These have been identified in a number of cancers and all classes of currently approved anticancer
drugs have been included as part of this review. In total, this represents around 60 different anticancer drug classes (based on their
general pharmacological mechanisms of action) and includes approximately 190 individual cancer drugs. This chapter also presents
the current cancer drug pipeline (preclinical through to phase III) by agent, pharmacological mechanism and development phase and
identifies new drug types (i.e. based on new general pharmacological mechanisms) being developed to target cancer in new and
more effective ways.
2.1 Cancer Drugs 16
2.2 Pharmacological Mechanisms 16
2.3 New Pharmacological Mechanisms 17
2.4 Launched Anti-Cancer Drugs 18
2.4.1 Adenosine Deaminase Inhibitors 18
2.4.2 Androgen antagonists 18
2.4.3 Angiogenesis inhibitors 21
2.4.4 Antimetabolite & Antifolates 21
2.4.5 Aromatase inhibitors 22
2.4.6 Bcl2 antagonists 23
2.4.7 Bcr-Abl inhibitors 23
2.4.8 Beta tubulin antagonists 23
2.4.9 B-raf kinase inhibitors 24
2.4.10 Cancer cell lysis 24
2.4.11 CD20 Antagonists 24



2.4.12 Cyclin G1 inhibitors 25
2.4.13 Cysteine Protease Stimulants 25
2.4.14 DNA antagonists 25
2.4.15 DNA synthesis inhibitors 29
2.4.16 DNA topoisomerase ATP hydrolysing inhibitors 30
2.4.17 DNA topoisomerase inhibitors 31
2.4.18 Endothelial growth factor antagonists 31
2.4.19 Endothelial growth factor receptor kinase inhibitors 31
2.4.20 Epidermal growth factor receptor 2 antagonists 32
2.4.21 Epidermal Growth Factor Receptor Antagonists 32
2.4.22 ErbB-1 tyrosine kinase inhibitors 32
2.4.23 ErbB-2 tyrosine kinase inhibitors 33
2.4.24 Estrogen antagonists 33
2.4.25 Farnesyltransferase Inhibitors 33
2.4.26 Histone Deacetylase Inhibitors 34
2.4.27 Hypoxanthine Phosphoribosyltransferase Inhibitors 34
2.4.28 Immunostimulants 34
2.4.29 Interferons 35
2.4.30 Interferon Alpha 2 Agonists 35
2.4.31 Interferon Alpha 2A Agonists 35
2.4.32 Interferon Alpha 2b Agonists 35
2.4.33 The Interleukins 36
2.4.34 LHRH agonists 36
2.4.35 LHRH Antagonists 36
2.4.36 Lymphocyte Inhibitors 36
2.4.37 Membrane integrity antagonists 36
2.4.38 Microtubule disruptions 36
2.4.39 Microtubule Inhibitors 37
2.4.40 Microtubule stimulants 37
2.4.41 mTOR kinase inhibitors 37
2.4.42 p53 Stimulants 37
2.4.43 Proteasome Inhibitors 37
2.4.44 Radical Formation Agonists 37
2.4.45 Retinoic acid alpha receptor agonists 38
2.4.46 Retinoic Acid Receptor Agonists 38
2.4.47 Retinoid X alpha receptor agonists 38
2.4.48 Retinoid X Receptor Agonists 38
2.4.49 Ribonuclease Stimulants 38
2.4.50 RNA directed RNA Polymerase Stimulants 38
2.4.51 RNA Synthesis Inhibitors 38
2.4.52 Thymidylate Synthase Inhibitors 39
2.4.53 Tubulin Antagonists 40
2.4.54 Tumour Necrosis Factor Alpha Agonists 40
2.4.55 Drugs with Unidentified Pharmacological Activity 40

Chapter 3 Drug Resistance and Cancer Stem Cells 65
Chapter 3 presents a review of Cancer Stem cells (CSCs), a subset of cancer cells in tumours that have been strongly implicated in
cancer drug resistance. This chapter also includes proposed resistance mechanisms associated with CSCs, drug discovery strategies



for the targeting of these cells, the current CSC-targeting drug development pipeline and the potential of these cells in cancer
diagnostics.
3.2 What are Cancer Stem Cells' 66
3.3 Different Cancers 67
3.4 Drug Resistance 67
3.5 Drug Discovery 68
3.5.1 EGFR/HER2 tyrosine kinase inhibitors 68
3.5.2 Proposed Migration of CSCs 69
3.5.3 The Stem Cell Niche 69
3.5.4 Metabotropic Receptors 70
3.5.5 Telomerase 70
3.5.6 Notch 70
3.5.7 Hedgehog and Wnt 71
3.5.8 Bmi-1 Gene 72
3.5.9 CSC-Targeting Viruses 73
3.5.10 Metastasis and Invasion 73
3.5.11 MicroRNAs
3.6 Clinical Development 74
3.7 Diagnostics 75
3.7.1 Circulating Tumour Cells 75
3.7.2 The Invasiveness Gene Signature 76
3.7.3 Hedgehog Activity 76
3.7.4 Microarrays 77
3.7.5 Sox2 77
3.7.6 Other 77

Chapter 4 Cancer Resistance Biomarkers 83
Chapter 4 presents the findings on drug resistance-associated changes or resistance mechanisms described Chapter 2, as potential
resistance biomarkers. Cell markers reported to characterise CSCs and to differentiate them from non-tumourigenic cancer cells, are
also presented.
4.1 Cancer Resistance Biomarkers 84
4.2 Cancer Stem Cells Markers 84

Chapter 5 Strategies to Combat Cancer Drug Resistance 99
Chapter 5 presents current developments and strategies designed to combat resistance to anticancer agents and includes pipeline
drugs, novel drugs, drug combinations, multiple-targeting drugs, direct targeting and avoidance of resistance mechanisms, CSCs and
other areas. This chapter includes a review of all phase III anticancer candidates.
5.1 Background 100
5.2 Novel Drugs 102
5.2.1 Drug Pipeline 102
5.2.2 Immunotherapy 110
5.2.3 Cancer Stem Cells 111
5.3 New Drug Combinations 114
5.4 Targeting Resistance Mechanisms 115
5.4.1 Transport Proteins 115



5.4.2 Current Anticancer Drugs 117
5.5 Avoiding Drug Resistance 117
5.5 Predictive Methods 117

Chapter 6 Discussion 129
Chapter 6 presents a discussion on the information and data presented in Chapters 1-5 of this report, focussing in particular on the
practical steps being taken to combat resistance to cancer drugs.
6.1 Overview 130
6.2 Resistance Map 131
6.3 Drug Pipeline 132
6.5 Resistance Biomarkers 137
6.6 Strategies to Combat Resistance 139
6.7 Opportunities 142
6.8 Speculative Comments 143

Tables Page
Table 2.1 (a-o) Launched anti-cancer drugs, showing compound, pharmacology 41-55
and drug resistance mechanisms
Table 3.1 Development pipeline of csc-targeting candidate drug molecules 74
Table 4.1 (a-e) Cancer resistance biomarkers by cancer, associated drug and 85-89
drug pharmacological class
Table 4.2 (a-b) Cancer stem cell markers (potential resistance biomarkers) 90-91
5.1 Immunotherapies in development (preclinical to phase III) 112
5.2 Development pipeline of csc-targeting candidate drug molecules 113
Table 5.3 (a-b) Substrates and inhibitors of ABC binding cassette transporters. 118-119
Cells could be selected in increasing concentrations of a cytotoxic drug, which
could result in the increased expression of a specific ABC transporter (see green boxes representing drug'gene pairs in which an ABC
transporter was found to be overexpressed in cell lines selected for resistance to the respective drug). Resistant cells overexpressing
a single ABC transporter often show characteristic cross-resistance to other, structurally unrelated, drugs (red boxes). The ability of
ABC transporters to alter cell survival, drug transport and/or drug accumulation can be inhibited or altered by various modulators
(yellow boxes). White boxes denote unexplored or absent drug'gene relationships (Source (Adapted From): Targeting Multidrug
Resistance in Cancer, Gergely Szakacs, Jill K Patterson, Joseph A Ludwig, Catherine Booth-Genthe and Michael M Gottesman
Nature Reviews (Drug Discovery), 200, Vol 5, 219-234)
Table 5.4 (a-b) Characteristics and results of completed and Phase III clinical 120-121
trials with ABC transporter inhibitors (Source (Adapted From): Targeting Multidrug Resistance in Cancer, Gergely Szakacs, Jill K
Patterson, Joseph A Ludwig, Catherine Booth-Genthe and Michael M Gottesman Nature Reviews (Drug Discovery), 200, Vol 5,
219-234)
Table 5.3 (a-c) Cellular and molecular mechanisms found to be associated with 122-124
drug resistance of approved cancer drugs
Table 6.1 Examples of combinations of anticancer drugs used in the treatment 131
of several common cancer
Table 6.2 (a-d) Resistance mechanisms reported for anticancer drugs. Drug 133-136
class (i.e. pharmacological mechanisms) and an example of a drug in each class,
are indicated.

Figures Page



Figure 2.1a Cancer drugs (according to cancer type) in the drug 17
development pipeline (pre-clinical to Phase III) or fully launched
Figure 2.1b Cancer drugs (according to cancer type) in the drug 18
Report Contents and Sample Pages Cancer Drug Resistance, 2008
development pipeline (pre-clinical to Phase III) or fully launched.
Figure 2.2 Cancer drugs in the global drug development pipeline 19
(pre-clinical to Phase III) or Registered/fully launched.
Figure 2.3 Cancer drugs by the number of different pharmacological 20
mechanisms in each phase considered individually.
Figure 2.4 Cancer drugs by the number of New pharmacological 21
mechanisms in each phase.
Figure 5.1 Strategies for Combating Cancer Drug Resistance. 101
Figure 5.2 Cancer drugs by the number of new pharmacological 102
mechanisms in each drug development phase
Figure 5.3 Immunotherapies in development 111
(Preclinical to Phase III) or launched

Appendices Page
Appendix 1 (a-e) Pipeline candidate anticancer drugs and launched anticancer drugs and their associated pharmacological
mechanisms (2000+ molecules) 145-217
Appendix 2 Pipeline anticancer drugs (preclinical'Phase III) with new pharmacological mechanisms of action (330+ molecules)
218-229



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