Oncogenic genomic alterations in non-small cell lung cancer (NSCLC) are excellent therapeutic targets. Compelling clinical examples include somatic mutations in the epidermal growth factor receptor (EGFR) and in anaplastic lymphoma kinase (ALK) rearrangements. In both instances, treatment with specific kinase inhibitors, erlotinib (EGFR) and crizotinib (ALK), results in improved outcomes compared to systemic chemotherapy for patients with advanced EGFR mutant or ALK rearranged NSCLC, and are the standard of care first line therapies. However, the therapeutic benefit is limited (8 to 12 months): currently no patient is cured and all patients wll ultimately develop acquired drug resistance. Drug resistance to kinase inhibitors occurs by two types of mechanisms: i) secondary mutations in the kinase target or ii) activation of a bypass signaling pathway. In both cases, downstream signaling pathways become reactivated despite the presence of the kinase inhibitor. In EGFR mutant NSCLC, EGFR T790M secondary mutation is the most common mechanism, detected in 50-60% of cancers from EGFR mutant patients that develop clinical resistance to erlotinib. Bypass mechanisms include activation of MET (through MET amplification or by HGF) and AXL signaling. To date, clinical therapies for EGFR mutant erlotinib resistant NSCLC patients have been ineffective. These observations are likely due to i) lack of effective therapeutic agents against EGFR T790M, ii) incomplete understanding of the heterogeneity of drug resistance in patients, and iii) inability to develop strategies to inhibit multiple drug resistane mechanisms simultaneously. We have previously shown that we can overcome resistance conferred by EGFR T790M mutations in preclinical models with irreversible EGFR inhibitors. However, current clinical irreversible quinazoline EGFR inhibitors, including afatinib and dacomitinib, although effective in some preclinical models harboring EGFR T790M, are not effective in EGFR T790M NSCLC patients. One possible explanation for these observations may lie in the fact that afatinib and dacomitinib are very good inhibitor of wild type (WT) EGFR. As such, inhibition of WT EGFR results in "on-target" toxicity, skin rash, which prevents clinical administration of doses high enough to inhibit EGFR T790M. In order to overcome this limitation, we have developed two pre-clinical strategies: i.) intermittet "pulsatile" administration of dacomitinib to transiently but effectively inhibit EGFR T79M and ii.) identification of the first in class mutant selective EGFR inhibitor, WZ4002. Both strategies are currently being evaluated in clinical trials. Here we propose critical studies that will inform the clinical development of these and future treatment strategies by comprehensively studying heterogeneity of drug resistance mechanisms, developing novel combination strategies with WZ4002 informed by drug resistance mechanisms, and developing clinical trial-based biomarkers for improved evaluation of the evolution and treatment of drug resistance.

Public Health Relevance

The development of drug resistance limits the long term success of epidermal growth factor receptor (EGFR) inhibitors in EGFR mutant lung cancer patients. By studying the genomic landscape of drug resistant cancers and plasma derived DNA from lung cancer patients coupled with the development of therapeutic strategies which can be clinically implemented in the near term, the studies in this proposal aim to improve the outcome of EGFR mutant lung cancer patients.

National Institute of Health (NIH)
National Cancer Institute (NCI)
Research Project (R01)
Project #
Application #
Study Section
Clinical Oncology Study Section (CONC)
Program Officer
Timmer, William C
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Dana-Farber Cancer Institute
United States
Zip Code
Paweletz, Cloud P; Sacher, Adrian G; Raymond, Chris K et al. (2016) Bias-Corrected Targeted Next-Generation Sequencing for Rapid, Multiplexed Detection of Actionable Alterations in Cell-Free DNA from Advanced Lung Cancer Patients. Clin Cancer Res 22:915-22
Jia, Yong; Yun, Cai-Hong; Park, Eunyoung et al. (2016) Overcoming EGFR(T790M) and EGFR(C797S) resistance with mutant-selective allosteric inhibitors. Nature 534:129-32
Sacher, Adrian G; Paweletz, Cloud; Dahlberg, Suzanne E et al. (2016) Prospective Validation of Rapid Plasma Genotyping for the Detection of EGFR and KRAS Mutations in Advanced Lung Cancer. JAMA Oncol 2:1014-22
Oxnard, Geoffrey R; Thress, Kenneth S; Alden, Ryan S et al. (2016) Association Between Plasma Genotyping and Outcomes of Treatment With Osimertinib (AZD9291) in Advanced Non-Small-Cell Lung Cancer. J Clin Oncol 34:3375-82
Bahcall, Magda; Sim, Taebo; Paweletz, Cloud P et al. (2016) Acquired METD1228V Mutation and Resistance to MET Inhibition in Lung Cancer. Cancer Discov 6:1334-1341
Chong, Curtis R; Bahcall, Magda; Capelletti, Marzia et al. (2016) Identification of existing drugs that effectively target NTRK1- and ROS1-rearrangements in lung cancer. Clin Cancer Res :
Kawabata, Shigeru; Hollander, M Christine; Munasinghe, Jeeva P et al. (2015) Epidermal growth factor receptor as a novel molecular target for aggressive papillary tumors in the middle ear and temporal bone. Oncotarget 6:11357-68
Thress, Kenneth S; Paweletz, Cloud P; Felip, Enriqueta et al. (2015) Acquired EGFR C797S mutation mediates resistance to AZD9291 in non-small cell lung cancer harboring EGFR T790M. Nat Med 21:560-2
Ercan, Dalia; Choi, Hwan Geun; Yun, Cai-Hong et al. (2015) EGFR Mutations and Resistance to Irreversible Pyrimidine-Based EGFR Inhibitors. Clin Cancer Res 21:3913-23
Calles, Antonio; Kwiatkowski, Nicholas; Cammarata, Bernard K et al. (2015) Tivantinib (ARQ 197) efficacy is independent of MET inhibition in non-small-cell lung cancer cell lines. Mol Oncol 9:260-9

Showing the most recent 10 out of 45 publications