Sensitization strategies in lung cancer.

The commonly used treatment avenues employed by cancer physicians include surgery, radiotherapy (RT) and chemotherapy in addition to rapid developmental and confirmatory studies on the efficacy of targeted therapies. However, the success rate in these commonly used treatments remains relatively low due to associated side effects, such as normal cell targeting/toxicity and resistance. In addition, investigators are continuing their efforts to enhance the efficacy of RT and chemotherapy to prevent associated side effects and improve the survival rate of the affected patient in order to increase patient survival. In the present study, we have reviewed the sensitization approaches used to improve chemotherapy and RT sensitivity in tumors.

Introduction

Cancer is a complex disease demanding improvisation in the therapeutic avenues for improved efficacy and survival rate (1). The main reason for the increasing incidence of cancer is the aging of the worldwide population. The most documented as well as confirmed causative agents for cancer included smoking, overweight, viral infections and lifestyle habits including lack of physical activity (2). According to global cancer statistics, it is estimated that approximately 14.1 million new cancer cases and 8.2 million mortalities occurred in 2012 worldwide (3).

Lung cancer is the main cause of cancer associated with mortality among men, and is superior to the incidence of breast cancer in women (4). For lung cancer, the primary and main risk factor is the use of tobacco. For more advanced stages of disease or inoperable tumors, radiotherapy (RT) with or without chemotherapy (i.e., mainly using cisplatin, carboplatin, paclitaxel, pemetrexed) remains the main treatment option, although for EGFR-mutated cases and cases with EML4-ALK translocation-targeted agents are approved for treatment (5). In non-resectable, locally advanced lung cancer as well as in cases with metastatic disease (approximately 50% of all diagnosed lung cancer cases), chemotherapy remains the only available treatment option (6). Thus, ways to improve the chemotherapeutic response of SCLC are required, especially for the therapy of refractory cases where the second-line treatment options are limited.

Previous findings have identified molecular alterations within human cells that lead to malignant transformation, termed as cancer hallmarks (7). Additionally, information and concepts regarding the origin of cancer are also documented in the literature, but little progress has been made in exploiting etiology and the mechanisms of disease (8). Most of the anticancer therapies which constitute the main treatment options, including chemotherapy, were in fact developed decades ago, when the development of therapeutics was not yet supported and driven by detailed knowledge of the genetic, molecular and biochemical, and cellular mechanisms of cancer pathogenesis (9). More recent cancer therapy approaches, such as small-molecular-weight drugs or monoclonal antibodies targeting aberrant growth factor receptors and RNA interference or gene therapeutics involving the utilization of viral vectors, have been developed with the aim to target cancer pathogenesis, but only few percent of these new solutions have been transferred from the lab to the clinic (10,11).

Although studies have focused on developing new targeted therapies, conventional ways of treating cancer play a key role in the clinic. Thus, surgery remains the main treatment of choice, whenever possible, as it has the highest chance for complete cure. If surgery is not an option, chemotherapy and/or RT are considered. Ionizing radiation and most conventional chemotherapeutic agents cause DNA damage and have a more severe effect on rapidly proliferating cells. Nevertheless, neither of these treatment modalities is able to distinguish between tumor and normal cells, resulting in significant normal tissue toxicity. Therefore, the development of new strategies, which can be more accurate in treatment delivery or dose delivery in case of RT, and which selectively can sensitize tumor cells to enhance the efficacy of chemotherapy or RT, is imperative and is the main subject theme of the present study.

DNA damage response (DDR)

Every day each cell of the human body is exposed to tens of thousands of DNA lesions. Such an amount of DNA damage, their recognition and repair processes influence cell processes by inhibition of the progression of the cell cycle, replication or transcription. When DNA damage is not correctly repaired or left unrepaired, it leads to the establishment of mutations in the DNA sequence of the cell or may even cause more serious genomic aberrations, such as deletions, translocations and aneuploidy, resulting in genomic instability, which is dangerous for the cell and the whole organism and may also increase risk of cancer (12). Some DNA damage appears as a consequence of physiological processes, e.g., DNA replication, hydrolytic or non-enzymatic reactions or reactive oxygen species formation by oxidative respiration, products of lipid peroxidation or by macrophages or neutrophils during infections and inflammation (13). DNA damage may also be a result of environmental agents, such as physical factors, including ultraviolet (UV) light, ionizing radiation generated during radioactive compound decay or in therapeutic settings of tumors, but also after exposure to chemical factors, i.e., cancer-causing DNA-damaging chemicals, such as those found in cigarette smoke or aflatoxins in contaminated food (14). Both endogenous processes and exogenous factors, which attack DNA, lead to the formation of diverse DNA damage, such as base modifications or loss, DNA interstrand crosslinks or DNA single- or double-strand breaks (DNA SSBs and DSBs). This diverse DNA damage can lead to alteration in the DNA sequence and, thus, DNA rearrangements and/or loss of genetic information and may therefore cause genomic instability (15). The cell response to DNA damage includes inhibition of the cell cycle, which allows for repair of the damage, or leads to the induction of cell death if the damage cannot be correctly repaired. Of note, inappropriate DNA repair may cause cell transformation, which in the whole organism can result in tumor formation, premature aging or inherited defects (13).

In order to counteract this DNA damage and maintain genomic integrity, cells develop several defense mechanisms known as the DNA damage response (DDR), and which consist of multiple signaling networks (16). These networks involve the detection of DNA lesions and signal transducers with the help of sensors. These signal transducers in turn transmit information of the presence of DNA damage, and downstream effector molecules, which mediate cell cycle arrest, localized chromatin remodeling, and the promotion of DNA repair (17–21). Thus, if the DNA damage is correctly repaired, DDR signaling is inactivated, the cell cycle restarts and the cell survives. When DNA lesions are not correctly repaired or cannot be eradicated, persistent DDR signaling causes cell inactivation by either death (apoptosis) or by senescence, a form of permanent cell cycle blockade, both of which have antitumor potential (22,23).

DDR signaling in cancer and as a target for cancer therapy

DDR as a barrier against cancer. During DDR, cells make decision to repair inflicted DNA damage or to descend to death. Thus, DDR is considered as the first barrier against the malignant process (24). Loss of genetic stability, which is a hallmark of tumorigenesis (25), is driven by DNA damage and errors that are incorporated during DNA repair (26). In addition, tumors often harbor genetic/epigenetic defects that, consequently impair factors in DDR signaling pathways, i.e., p53, ATM, Chk2, γH2AX, causing further activation of proto-oncogenes and inhibition of tumor suppressor genes, respectively (27). Studies on DDR have revealed plenty of links between oncogenesis and inherited changes in the genome. Additionally, cells defective in DDR/DNA repair mechanisms generally present increased sensitivity towards DNA damaging agents and this leads to a high probability of cancer.

The role of DDR in the protection against cancer development is also supported by the reported genetic defects in some DDR components and the increased cancer incidence in individuals carrying these aberrations. One example is defects in the NER components in Xeroderma pigmentosum (XP) syndrome. The XP syndrome is associated with impaired capacity to repair point mutations such as those inflicted by UV and, accordingly, individuals with XP deficiency have a 1,000-fold higher probability of incidence of UV-induced skin cancer and increased neurodegeneration and premature aging (28). Other inherited human syndromes linked to DDR, which are rare diseases, are chromosome aberrations in ATM in Ataxia telangiectasia (AT), in MRE11 in AT-like disorder, or in NBS1 in Nijmegen breakage syndrome (NBS). Patients with these syndromes have a higher predisposition to cancer (especially lymphomas), immunodeficiency, radiation hypersensitivity, and often also neurological complications and premature ageing (29–31). Syndromes connected with defects in HR repair include hereditary breast/ovarian cancers caused by defects in BRCA1 and BRCA2 (32), but also cancer prone chromosomal instabilities, i.e., the Werner, Bloom and Rothmund Thomson syndromes, with involved RecQ-like helicases (33). Mouse models with deficiency in HR and NHEJ give severe mutant phenotypes, indicating the importance of the two DNA DSB repair mechanisms (34).

DDR signaling as a target for cancer therapy. Overexpression or loss of specific factors in DNA repair machinery, result in altered functions of HR and NHEJ repair pathways in tumors (35). Deregulations in DNA repair promote genomic instability and malignancy but tumor cells survive with the help of their acquired potentials to survive DNA damage inflicted by chemotherapy and RT (36). Therefore, inhibition of DDR and/or DNA repair pathways has become an attractive strategy to overcome resistance to DNA damaging therapy and small DNA repair inhibitors have been developed to be used as a single-agent therapy or, more often, in tandem with DNA damaging treatments (37–39).

Abrogation of cell cycle checkpoints

Inactivation of the tumor suppressor p53 (40), by chromosomal aberration (deletion), inactivating mutation or overexpression of p53-negative regulator, MDM2, results in impaired G1 checkpoint control of tumors. Accordingly, tumor cells with inactivation of p53 function depend on S and G2 phase checkpoints to repair DNA damage and survive (41). Based on these observations, one of the strategies to overcome altered function of DDR in tumors is an abrogation of the remaining, intact checkpoints leading to enhanced tumor cell death (42). Thus, results from preclinical studies have shown that abrogation of the S and G2 checkpoints with small molecule inhibitors, specific enzymes, and RNA interference towards Chk1 (43), may impair the DNA repair response to DNA damaging chemotherapy in a tumor selective way (44), which also have formed the basis for clinical trials with Chk1/2 inhibitors (45).

PARP inhibitors (PARPi). The pharmacological inhibition of the DNA repair pathways may significantly increase the cell death-inducing capacity of DNA damaging agents. Combinations of cytotoxic agents with DNA repair inhibitors are under preclinical investigations or have already been introduced to the clinic as ongoing clinical trials. However, some aspects including normal tissue reaction to inhibition of DNA repair, and selectivity of the potential drugs against carcinogenesis including DNA repair pathways are involved in tumor cell response to therapy, but also tumor DNA repair pathway redundancy when exposed to certain chemotherapeutic drugs (46).

One of the more advanced DNA repair inhibiting strategies is to attack PARP-1, a component of base-excision repair of apurinic sites (47,48). Additionally, PARPi in combination with temozolomide, platinum chemotherapy (cisplatin, carboplatin) are now in clinical trials, but concerns are raised because of toxicity of the combined treatment regimen towards normal cells (49). PARPi have also been tested as a monotherapy. The rationale for this use of PARPi, is based on synthetic lethality, a concept proposed by Helleday et al (39), to be a genetic phenomenon in which the combination of two otherwise non-lethal mutations lead to a non-viable cell. Man-made destructive phenotypes are indicative of an interaction between the products of the two mutant genes within the cell. This concept was introduced when PAPRi were used in patients with inherited breast and ovarian cancers that lacked wild-type and carried mutated BRCA1 and/or BRCA2 genes, resulting in impaired HR repair and increased sensitivity to PARP inhibition (50). The obtained preclinical results have given support for clinical trials with PARPi as monotherapy in breast and ovarian cancer patients carrying BRCA1 or BRCA2 mutations. However, not all patients with BRCA mutations respond to this new, targeted therapy and resistance to such treatment is also reported (47). Of note, deficiency in other HR repair proteins than BRCA, presents enhanced sensitivity to PARPi, suggesting a broad spectrum of their utility, alone or even in combination with other inhibitors (51,52).

ATM and DNA-PK inhibitors. Inhibition of one of the main kinases of the phosphatidylinositol 3-kinase-related protein kinase family, ATM, which play a crucial role in the repair of DNA DSBs, have also been tested. The rationale is that inhibition of ATM may result in lack of proper detection of the DNA DSB inflicted by the chemotherapy and, hence, they may accumulate to a level leading the tumor cells towards cell death. Attempts have thus generated small molecules, which in preclinical settings have been shown to inhibit ATM kinase activity, e.g., KU55933 (AstraZeneca, Cambridge, UK) (Fig. 1). DNA-PK also plays a critical role in NHEJ-mediated repair and has been the focus for small molecule inhibitor development (53). A number of candidates have been generated, among them NU7441 and NU7026 (Fig. 1). These agents have shown some effect as monotherapy (54,55). However, they have also been demonstrated to sensitize tumor cells to DNA DSB-inducing treatments, i.e., ionizing radiation and etoposide, a topoisomerase II inhibitor, proving the concept of DNA-PK inhibition in tumor treatment (56,57). Notably, induced hyper-activation of DNA-PK causes a chemosensitizing effect in tumor cells (58). Thus, perturbations of DNA-PK kinase activity, i.e., hypo- or hyper-activation/phosphorylation, may also increase sensitivity of tumor to standard DNA damaging treatment.

Figure 1.

DNA repair inhibition strategies.

Epigenetics as a new tool to target DDR signaling

Recently, a novel, promising approach was introduced to cancer therapy and there are successful examples that targeting of alterations in epigenetic signaling in tumor cells may be used as therapy, as shown by the introduction of HDAC inhibitors (HDACi) in hematological malignancies (59). Epigenetic alterations have been shown to be involved in DDR signaling, e.g., the (NAD+)-dependent histone deacetylase, SIRT1, was reported to impair repair via the NHEJ pathway (60), SIRT6 was found to stabilize DNA-PK associated with chromatin and in this way influence DNA DSB repair (61). Additionally, HDAC1 and HDAC2 were reported to promote DSB repair (62). Previous studies also demonstrated that HDACi applied in tandem with DNA damaging agents caused increased cytotoxicity as a consequence of increased DNA damage and/or impaired DNA repair capacity (63). One such example is decitabine (2′-deoxy-5-azacytidine), a DNA demethylating agent, which was combined in tests with platinum-based drugs (i.e., cisplatin or carboplatin) to reverse drug resistance in ovarian cancer patients in clinical trials (64).

Conclusion

DDR signaling targeting therefore holds good potential in enhancing sensitization in different therapeutic avenues against cancer.