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Translational research in oncology10years

of progress and future prospects
James H. Doroshow and Shivaani Kummar
Abstract | International efforts to sequence the genomes of various human cancers have been broadly
deployed in drug discovery programmes. Diagnostic tests that predict the value of the molecularly targeted
anticancer agents used in such programmes are conceived and validated in parallel with new smallmolecule treatments and immunotherapies. This approach has been aided by better preclinical cancer
models; an enhanced appreciation of the complex interactions that exist between tumour cells and their
microenvironment; the elucidation of interactions between many of the genetic drivers of cancer, including
oncogenes and tumour suppressors; and recent insights into the genetic heterogeneity of human tumours
made possible by extraordinary improvements in DNA-sequencing techniques. These advances are being
employed in the first generation of genomic clinical trials that will examine the feasibility of matching a
broad range of systemic therapies to specific molecular tumour characteristics. More-extensive molecular
characterization of tumours and their supporting matrices are anticipated to become standard aspects of
oncological practice, permitting continuous molecular re-evaluations of human malignancies on a patient-bypatient and treatment-by-treatment basis. We review selected developments in translational cancer biology,
diagnostics, and therapeutics that have occurred over the past decade and offer our thoughts on future
prospects for the next few years.
Doroshow, J. H. & Kummar, S. Nat. Rev. Clin. Oncol. advance online publication 7 October 2014; doi:10.1038/nrclinonc.2014.158


Division of Cancer
Treatment and
Diagnosis (J.H.D., S.K.),
Therapeutics Branch of
the Center for Cancer
Research (J.H.D.),
Room 3A44,
National Cancer
Institute, NIH,
Bethesda, MD 20892,

The past decade has witnessed a remarkable acceler

ation in the pace of translational cancer medicine.13
The first issue of Nature Clinical Practice Oncology, the
forerunner of Nature Reviews Clinical Oncology, which
was published 10years ago, focused on the dramatic
clinical benefit of treatment with the EGFR inhibitor
gefitinib for patients with non-small-cell lung cancers
(NSCLCs) harbouring mutations in the EGFR gene.47
The demonstration that the mutational status of a solid
tumour could predict therapeutic efficacy for a specific
agent in a molecularly-defined subset of patients galva
nized oncology drug-development programmes around
a new biological paradigm, solidifying the shift toward
the elaboration of molecularly targeted therapeutics,
highlighted by the introduction of trastuzumab and
imatinib into the clinic. These findings ended the era of
nonspecific cytotoxin development.8,9
Advances in translational oncology over the past
10years have been characterized by the application of
ever-more-sophisticated molecular tools to larger popula
tions of patients with cancer or those who are at increased
risk of developing the disease (Figure1 (Timeline)). These
advances include the demonstration that risk of recur
rence for women with oestrogen receptor (ER)-positive
breast cancer and histologically uninvolved lymph
nodes receiving tamoxifen could be predicted based on

Correspondence to:

Competing interests
The authors declare no competing interests.

the expression levels of 21genes, determined using a

reverse-transcription-PCR (RTPCR) assay performed on
formalin-fixed tumour tissue (Oncotype DX, Genomic
Health Inc., Redwood City, CA). This test was one of the
first fully-validated predictive cancer biomarkers.10 The
application of molecular characterization technologies
(such as modern tumour tissue acquisition methods,
next-generation DNA sequencing, gene-expression analy
sis, DNA methylation profiling, proteomic evaluation,
and development of big data sets) to the understanding of
cancer biology in the clinic, exemplified by the work
of The Cancer Genome Atlas (TCGA) project 11 and the
International Cancer Genome Consortia,12 as well as
the application of large-scale human tumour cell line drug
screening,1315 has dramatically expanded appreciation of
the broad range of specific mutations and other molecular
abnormalities that could be examined as potential targets
for therapeutics development. In this way, molecularly
targeted therapies for additional subsets of patients with
adenocarcinoma of the lung (with rearrangements in the
anaplastic lymphoma kinase [ALK] gene) as well as a
major portion of the metastatic melanoma patient popu
lation (carrying V600E mutations in BRAF) were identi
fied; these therapies were then rapidly translated into
clinical trials demonstrating substantial therapeutic activ
ity for new drugs targeting specific molecular lesions.16,17
Improvements in DNA sequencing also provided the
basis for a much more sophisticated appreciation of
theevolution of human tumour heterogeneity.18



2014 Macmillan Publishers Limited. All rights reserved

Translational cancer biology

Key points

Around 10years ago, the possibility that all of the genes

in the exomes of a human cancer could be sequenced
with precision and at modest cost was considered an
aspirational goal; the fact that such DNA sequencing
procedures are now a routine part of translational onco
logy research speaks to the rapidly changing landscape
of cancer biology.2830 In concert with advances in DNA
sequencing, rapid advances in our understanding of the
biology of cancer have occurred since 2004, including
major efforts to improve both the model systems and the
scientific frameworks used to study human cancers and
cancer therapeutics.

The landscape of translational oncology has shifted dramatically over the

past 10years, characterized by the introduction of ever-more-sophisticated
molecular tools into the clinic
Translational cancer-biology studies have markedly improved preclinical models
applicable for therapeutics development, as well as our understanding of the
roles of inflammation and altered intermediary metabolism in carcinogenesis
Translational cancer diagnostics and therapeutics have been revolutionized by
the molecular characterization of human tumours, a process that now underlies
the development of molecularly-targeted, rather than broadly cytotoxic,
anticancer therapies
Improvements in molecular tumour-classification techniques will permit their
widespread application for patients at diagnosis, disease recurrence, and
during therapy, supporting continuous adaptation of therapeutic approaches
toevolving tumour characteristics

New molecular models of cancer

The availability of immunodeficient strains of mice,
30years ago, made it possible to grow established
human tumour cell lines as xenotransplants, facilitat
ing the testing of cancer therapeutic agents invivo
against a much wider range of tumour histologies than
had been possible previously with the use of syngeneic
mouse tumour models.31 However, although useful for
the demonstration of the potential therapeutic index of
a novel drug, years of experience with these models indi
cated that they did not faithfully predict histologically-
specific antitumour efficacy, particularly for molecularly
targeted drugs. This lack of prediction is perhaps a
result of the use of tumour cell lines (from which the
xenografts are often established) that had been propa
gated under the selective pressure of continuous two-
dimensional tissue culture for, in some cases, decades.31,32
For this reason, substantive investigational effort has
been focused on the development of new invivo and
invitro models for cancer discovery research. Using
these new models, as well as clinical specimens, a better
framework for understanding the roles of inflammation
and metabolism in carcinogenesis has also developed
over the past decade.

The rapidly expanding knowledge of human DNA

repair processes has been exploited to develop inhibi
tors of certain DNA repair proteins. For example, drugs
targeting poly(ADPribose) polymerase (PARP) have
shown clinical benefit in women with ovarian cancers
who carry germline mutations in the BRCA1 or BRCA2
genes.19,20 Enhanced understanding of the control of
tumour cell immunity, and technological advances in
the molecular engineering of immune cells, has recently
been translated into new immunotherapeutic treatment
programmes, including antibodies and cell vaccines, that
are beginning to transform cancer therapy.2123
Finally, tantalizing improvements over the past
10years in the development of both invitro and invivo
models of human cancer,24,25 including those produced
directly from a specific individuals tumour,26,27 suggest
that in the future we might be able to examine tumour
biology on a patient-by-patient basis. In this Review, we
evaluate selected developments in translational cancer
biology, diagnostics, and therapeutics that have occurred
over the past decade; such advances will be used as the
basis for suggesting specific prospects for future progress
in translational cancer medicine.
Lung cancer
EGFR mutations
and erlotinib


Sensitivity of BRCA
mutant tumours
to poly (ADP-ribose)
polymerase inhibitors


Oncotype Dx

TCGA begins

Large-scale cell line

screening identifies
ALK fusion inhibitor


Glioblastoma multiforme
genome completed
Molecularly targeted
melanoma therapy


inhibitors; genetically
engineered T cells


Intratumoral genomic heterogeneity


Development of individually
derived tumour models from
circulating tumour cells for
prospective drug testing


TCGA completed
>10,000 tumours

Large-scale screening for actionable mutations

in adult malignancies, and use of circulating tumour
DNA to assess cancer burden and therapeutic efficacy

Figure 1 | Timeline of 10-year translational research for oncology and prospects for the future. Over the past decade,
translational cancer research has undergone an extraordinary transformation, spanning the time from the first
demonstration of a single, functional driver mutation in a human solid tumour (NSCLC) with clear therapeutic
consequences (enhanced response to EGFR inhibitors) to the application of next-generation whole-exome sequencing for
therapeutic decision making in a growing population of cancer patients. Future prospects (shown in pink) include the
expected completion date for TCGA project and the rapid development of personal human tumour models that may begin
tobe used for testing of cancer therapeutic agents on an individualized basis. Abbreviations: ALK, anaplastic lymphoma
kinase; NSCLC, non-small-cell lung cancer; TCGA, The Cancer Genome Atlas.

2014 Macmillan Publishers Limited. All rights reserved


Treat with
most appropriate
targeted drugs


into syngeneic

c PDX and conditionally

reprogrammed cell lines

Create reprogrammed
cell lines

Pre-clinical clinical trials

Molecularly characterize,
treat/screen mice
bearing transplants and
cells with relevant drugs

into NSG mice


Figure 2 | Improving tumour models for cancer biology and drug development. a | GEMs of human cancer developed through
the organ-specific expression of driver mutations in immunocompetent mice, are used to evaluate the signal transduction
pathways associated with all stages of carcinogenesis as well as to examine the effects of molecularly targeted agents in
proof-of-mechanism studies. b | GDAs facilitate the use of larger numbers of animals carrying tumours that have been
biologically defined and derived for pre-clinical clinical trials in mice with intact immune systems. c | PDXs are developed
directly from implantation of surgical, biopsy, or circulating tumour cell specimens into immune-incompetent mice;
compared with older xenograft models derived from established human tumour cell lines, PDX tumours usually carry with
them some degree of human stroma during initial tumour passages invivo, facilitating a more accurate environment for
molecular characterization and drug testing. New invitro techniques to develop early passage conditionally reprogrammed
cell lines or tumour cell organoid cultures are also under active investigation as preclinical models that might more
accurately predict the efficacy of targeted therapeutic agents. We acknowledge the important role of TerryvanDyke,
National Cancer Institute, NIH, in the development of this figure. Abbreviations: GDA, GEM-derived allografts; GEM,
genetically-engineered mouse model; NGS, NOD scid gamma; PDX, patient-derived tumour xenograft model.

Model organisms
Among the most important developments in trans
lational cancer biology during the past 10years has
been the use of genetic approaches to produce moresophisticated models of human cancer.33,34 For example,
the elucidation of critical signalling pathways essen
tial for understanding the development of pancreatic
ductal adenocarcinoma has been facilitated greatly by
genetically-engineered mouse models(GEMs) of this
disease that recapitulate the carcinogenic process in mice
with an intact immune system.35 The genetic program
ming of organ-specific expression of driver mutations
not only underlies the development of premalignant
lesions and primary tumours in these mice, but allows
for proof-of-mechanism studies of targeted therapeu
tic agents active against the genetic lesions produced

in such animals (Figure2a). This exemplifies how the

exploration of human tumour biology in model systems
has been enhanced through the use of GEMs. Recent
efforts to improve the clinical use of GEMs, which
have been hindered by the prolonged timelines (often
912months) and expense required to generate the
models, have focused on the possibility that orthotopic
or subcutaneous transplantation of tumours initially
established in GEMs could facilitate their use for drug
screening (Figure2b). GEM allografts may enhance the
application of clinical trial design principles in preclini
cal clinical trials so that these models could more easily
be employed with adequate sample sizes, predefined
therapeutic hypotheses, and integrated pharmaco
dynamic and pharmacokinetic studies, facilitating
comparisons of drug efficacy in tumours from GEMs



2014 Macmillan Publishers Limited. All rights reserved

with human clinical trial results of the same agents and
combinations.34 Additional progress will expand the
diversity of GEM models to characterize more fully
the wide range of molecular aberrations observed in
clinical tumour specimens; there is also little question
that greater use of GEM technology could assist efforts
focusing on biomarker development for early stage
disease as well as the evolution of therapeutic resistance.
There has also been a dramatic resurgence of interest
in mouse tumour models generated directly from patient
surgical or biopsy samples, denoted as patient-derived
tumour xenografts (PDXs). 36 Although such model
systems had been investigated for decades, the availabil
ity of NOD/SCID and NOD/SCID/IL2Rnull (NSG) mice
over the past 10years, which enhances murine immunoincompetence by blocking natural killer cell maturation
and facilitates tumour engraftment, has led to a renais
sance in the use of this technique for generating tumour
models. Furthermore, for certain solid tumours, such
as colorectal, pancreatic, lung, and breast cancers, early
tumour passages (probably through the third or fourth
generation in most cases) retain a degree of human
stroma, facilitating studies of gene expression, drug effi
cacy, and tumour heterogeneity.36 In the case of endo
crine sensitive and resistant breast cancer, PDX models
have been used to demonstrate the stability of genomewide allele frequencies, and response to endocrine
therapy, between the initial human tumour specimens
and PDXs established from these tissues.37 Therefore,
the development of large panels of clinically-annotated
tumours could help evaluate the diversity of responses
expected in the clinical arena, or could be used for
molecularly-characterized preclinical trials to assess the
validity of target selection strategies in advance of clini
cal testing (Figure2c). These models avoid the problems
associated with invitro tumour cell selection; however,
the absence of an intact immune system negates their
value for testing immunotherapeutic strategies. Most
PDX models have been developed from surgical speci
mens rather than from biopsies of metastatic sites; thus,
these models might not be representative of the tumours
that occur in patients with recurrent malignancies who
require systemic therapy.38 Further development of PDX
models for both biological studies and drug selection
might have an important role in improving the precision
with which cancer treatments are selected in the future.
While there has been considerable focus on improv
ing invivo models of human cancer, recent studies have
suggested better ways to study human tumours invitro.
The immortalization of epithelial cells, including human
tumour cells, by inhibiting terminal differentiation
through the use of an inhibitor of Rho kinase and con
ditioned media, has excited investigational interest; if
widely applicable, this conditional reprogramming tech
nique might facilitate the long-term culture of tumour
cells that heretofore have been difficult to propagate, such
as tumours of the prostate (Figure2c).39,40 It is not known
whether tumour cells cultured in this fashion undergo
genetic adaptation to growth on plastic, which would
diminish their predictive potential. The development of

3D cultures of cancer organoidstumour cells that grow

in a collagen-rich matrix supported by essential growth
factors and that have phenotypic characteristics of cancer
stem cellsis the other major focus for the development
of invitro cancer models. Although these models lack
stroma and require very well-defined growth conditions,
organoids can be propagated indefinitely from indivi
dual patients, are amenable to drug screening, and can
retain essential molecular characteristics of the primary
disease (at least for colon cancer).41,42 There is great inter
est in the possibility that organoid cultures developed
for other malignancies (such as pancreatic and prostate
cancers) will provide important new invitro tools for
cancer biology and drug discovery.41,42
Inflammation and cancer
One of the most important translational research
relationships to understand is the interaction between
innate inflammatory responses, host defence, and
carcinogenesis; our understanding of this relationship,
including the role of the human microbiome in these pro
cesses, has expanded dramatically over the past decade.43
Adeeper appreciation of the molecular mechanisms
underlying chronic inflammation-related cancers (such
as those associated with inflammatory bowel disease,
chronic pancreatitis, and viral hepatitis) and the evidence
for the protective role of non-steroidal anti-inflammatory
agents in the prevention of multiple malignant histolo
gies, indicates that greater emphasis on the development
of new therapeutic modalities to prevent the adverse con
sequences of the unchecked cytokine release and reactive
oxygen production that accompany chronic inflamma
tory stress are urgently required. Such therapeutics might
interdict the proinflammatory microenvironment that is
conducive to DNA damage, cancer initiation, and pro
gression.4447 Recent evidence has demonstrated previ
ously unknown relationships between the inflammatory
environment, produced by commensal bacteria, and the
efficacy of both immune and cytotoxic anticancer thera
pies invivo, emphasizing the role of the tumour micro
environment in the control of therapeutic response.48 It
seems likely that in the near future a better understand
ing of how to control both proinflammatory and antiinflammatory responses will play a critical part in the
developmental therapeutics of cancer.
Cancer metabolism
Another remarkable change in translational cancer
biology over the past decade has been the recognition
that the metabolic reprogramming of tumour cells is inti
mately related to oncogene-induced proliferative signal
ling and the function of tumour suppressor genes.49,50
Thus, signal transduction pathways that are important for
malignant transformation (for example, those controlled
by Myc, p53, and mTOR) have a critical role in altering
the metabolic phenotypes of cancer cells, while at the
same time the products of altered tumour cell metabolism
(-ketoglutarate and reactive oxygen species [ROS]) affect
tumour cell signal transduction.51 To enhance cell pro
liferation, tumour cells adapt their metabolic machinery

2014 Macmillan Publishers Limited. All rights reserved

to use a variety of energy sources besides glucose (such
as glutamine) to increase the production of fatty acids
and other macromolecules needed for the production of
cell membranes as well as a diverse portfolio of anabolic
processes, in addition to ATP production. The metabolic
programmes of tumour cells are diverse, tissue context
dependent, highly influenced by the surrounding micro
environment as well as the tumour host, and hetero
geneous even within a single tumour.52 Recent evidence
suggests that metabolic reprogramming of tumour cells
might have a critical role in the epigenetic modification
of tumour cell DNA and histones.53 For these reasons,
substantial investigational effort is now being directed
toward the development of small-molecule inhibitors of
specific metabolic enzymes that contribute to tumour cell
proliferation (such as isocitrate dehydrogenase 1 [IDH1]
and IDH2) for low-grade gliomas and acute myelogenous
leukaemia, respectively.54,55

Characterization of tumours and host tissues

About the same time that imatinib was found to be an
effective treatment for chronic myelogenous leukaemia
and erlotinib for adenocarcinoma of the lung with EGFR
mutations, the sequencing of the human genome was
completed.56 The completion of this project propelled
the application of genomic sequencing technologies in
cancer biology (Figure1). Although much effort has
been focused on the presence of somatic mutations in
specific cancer histologies,57 the availability of powerful
sequencing techniques also led to a series of populationbased studies to discover germline mutations that could
confer cancer risk, so-called genome-wide association
studies.58 To date over 150 regions of the human genome,
often in noncoding domains, have been correlated with
two dozen human cancers. A major area of current
investigation is to understand how these genetic vari
ants predispose to cancer, and whether or how inter
actions occur between somatic and germline variants in
Human biospecimens
Molecular tumour characterization, whether it invol
ves DNA sequencing, evaluation of RNA expression,
proteomic or phosphoproteomic determinations, or
immunohistochemistry, requires the collection of high
quality biospecimens.60 The lack of accepted national
guidelines for specimen acquisition stimulated a multiyear process leading to the introduction of standards
for the collection and banking of both tumour and
normal tissues.61 Lack of standard biospecimen collec
tion, processing, and storage procedures hampered the
initiation of the TCGA project; difficulties were encoun
tered in obtaining tumour specimens that met quality
standards for sequencing in terms of the tumour cell
purity of the samples; the fixation method employed;
and available volumes of high-quality tumours across
The value of proof-of-mechanism pharmacodynamic
assays is frequently diminished because insufficient care is
taken to understand the stability of the analyte of interest

in the context of performing research tumour biopsies;

sample handling techniques that will stabilize biomarkers
after tissues are acquired are infrequently evaluated before
study initiation.6264 Unfortunately, regardless of the bio
marker, there is a need to improve the details of sample
acquisition that are fundamental to successful molecular
characterization of a tumour or normal tissue of interest.
Clinical characterization of tumours
The availability of massively parallel DNA sequencing
in the mid2000s allowed for an exponential increase in
the speed and amount of tumour DNA sequence that
could be obtained in a given period of time; this enhanced
efficiency led to plummeting costs for acquiring DNA
sequences and the development of better tools to analyse
sequence data.28 Systematic DNA sequencing substan
tiated the role of receptor tyrosine kinase mutations
in driving tumour cell signalling across many cancers
(PI3KCA in breast cancer and JAK2 in myeloprolifera
tive syndromes) and has been essential for stimulating
the development of new kinase inhibitors for the treat
ment of tumours that are dependent on such pathways.
The mutational patterns observedextremely high fre
quencies in lung cancer and melanoma, and relatively
low levels in untreated paediatric malignancieshave
also substantiated aetiological associations with the
extent and duration of mutagen exposure in the former
malignancies, and have suggested hypotheses for the
development of tumours in non-renewing tissue types
for the latter.65 Arecent analysis indicates that despite
the intensive investigation of >10,000 tumours by the
TCGA, additional novel driver mutations are likely to
be found at low frequency (<23%) through expanded
sequencing efforts, particularly for those diseases with
high mutational loads.57 The extent of the DNA altera
tions discovered in solid tumours, however, also sug
gests that it will be unlikely in the future to find specific
single mutations that have dramatic therapeutic implica
tions, such as that of BCRABL1 expression in chronic
It is likely that the broadest, most clinically-applicable
molecular characterizations will involve multidimen
sional analyses of genetic, epigenetic, and proteomic
descriptions of malignant disease.66,67 Epigenetic control
of gene expression and chromatin packaging provides
an alternate, yet stable, process to enhance the accu
mulation of oncogenic events. Silencing of tumour
suppressor gene function by promoter hypermeth
ylation, for example, can offer an alternative to muta
tional inactivation. This may be especially important
for the control of DNA repair genes, and can function
to increase mutation rates and genomic instability. For
this reason, TCGA studies have involved an evaluation
of both the mutational spectra of various cancers and
a detailed examination of the tumour epigenome; these
investigations have demonstrated the complementary
and non-overlapping effects of mutational and epigen
etic gene silencing. Finally, multidimensional studies that
combine mutational, epigenetic, and expression profil
ing with proteomic assessments of human cancers are



2014 Macmillan Publishers Limited. All rights reserved

beginning to demonstrate that in some instances gene
expression at the mRNA level may not provide a faithful
rendering of protein abundance in tumours,67 indicating
that integrated proteomic and genomic analyses are likely
to provide the most useful data for the development of
targeted therapeutics. Furthermore, the extent of the
data collected in these and ongoing studies of human
tumours will require collaborative efforts both in the
USA and internationally (such as the Global Alliance
for Genomics & Health) to share clinically annotated
genetic information in a way that optimizes harmonized
investigation of tumour genomics.68
Cancer genome sequencing efforts have demonstrated
the heterogeneity of the mutational spectra that exist in
primary and metastatic sites in the same patient.18,69,70
The clonal evolution of individual tumours that may or
may not retain specific driver mutations across multiple
sites of disease, or that might express resistance muta
tions in some but not other metastases, may compli
cate the application of therapies matched to specific
actionable mutations selected on the basis of sequence
data from a single biopsy.71,72 New technologies for the
molecular analysis of circulating tumour cells (CTCs)
and circulating tumour DNA offer the possibility of
repeating mutational profiles over time from small
samples of blood. 73,74 Thus, the confounding effects
of intratumoural heterogeneity might be minimized.
Furthermore, improvements in CTC collection metho
dologies have facilitated the use of these cells for repeated
pharmacodynamic, as well as mutational, analyses.75

Cancer diagnostics and therapeutics

There is perhaps no greater indication of the degree of

change in translational oncology over the past decade
than the shift in the drug discovery sphere from the
development of cytotoxic (and relatively nonspecific)
chemotherapeutic agents to the search for compounds
with better (if incompletely) defined/targeted mecha
nisms of action.76,77 Although cytotoxic chemotherapies
continue to play an important role in cancer therapy, in
the past 10years, over 40molecularly targeted agents
have been approved for the treatment of cancer by the
US FDA,78 whereas fewer than 10 new cytotoxic mol
ecules (including pemetrexed, eribulin, bendamustine,
and ixabepilone) were approved; and no cytotoxic
drugs have been approved since 2010 that are not
The other major change in cancer therapy over the
past decade has been the extraordinary speed with which
novel immunotherapeutics have demonstrated clinical
efficacy, not only in diseases known to respond to these
approaches (melanoma and renal cell cancer) but also
in diseases not traditionally responsive to immuno
therapy, such as NSCLC and squamous cancers of the
head andneck.21

Molecularly targeted therapy and diagnostics

The transition from cytotoxic to targeted therapeu
tics coincided with the application of the principles
of tumour biology described previously and with the

technological advances in molecular characterization

that occurred during the sequencing of the human
genome. Over the past decade, these technical improve
ments in molecular diagnostics, functional imaging,
and somatic genetics also stimulated reconsideration
of how preclinical studies and early phase cancer clini
cal trials should be conducted.3,79,80 The current model
for cancer drug development (Figure3) emphasizes
the use of annotated preclinical models to examine and
develop drug targets and translational research tools.
Once these tools have been validated using preclinical
human tumour models, they can then be employed for
molecular analysis of the effects of treatment in human
tumour biopsy specimens. When combined with clini
cal observations, the implications of specific phenotypic
and genotypic variants for either therapeutic response or
disease progression can be more fully appreciated.
Genomic prediction of therapeutic efficacy
The application of pretreatment genomic profiling for
human cancers began with the approval of trastuzumab
for breast cancer patients whose tumours overexpressed
the HER2 gene; both the drug and the companion
diagnostic to demonstrate HER2 overexpression were
approved by the US FDA in tandem in 1998.81 In 2004,
the efficacy of gefitinib for patients with adenocarci
nomas of the lung expressing specific EGFR mutations
set the stage for a remarkable set of genomic investiga
tions over the next decade that have transformed the
practice of oncology. Some of these transformative
studies include: the preclinical demonstration of syn
thetic lethality for inhibitors of PARP in tumours that
harbour mutations in BRCA1 and BRCA2;82 the applica
tion of prospective screening of lung cancer patients for
pre-specified biomarkers to adaptively-control assign
ment of targeted therapy (the BATTLE trial);83 the rapid
deconvolution of the mechanism of sensitivity to the
mTOR inhibitor everolimus in an isolated patient with
advanced bladder cancer through deep sequencing;30 and
one of the first demonstrations of genomic mutational
and phenotypic drift in patients with NSCLC that was
associated with therapeutic implications.84 Each of these
investigations provided support for expanding the use of
DNA sequencing to examine whether mutational profiles
in tumours could be used to suggest benefit from specific
targeted therapies.85,86
The current state-of-the-art is exemplified by clinical
programmes using gene panels with specified muta
tional variants and locked-down algorithms to match
mutation to therapy, and by the use of expert tumour
boards convened to recommend treatment regimens
based on sequencing results from a variety of platforms
in a multiplicity of diseases. For the most part, these
hypothesis-generating efforts are attempting to discover
novel therapeutic correlations.71 In some cases, as in
the recently-launched Lung-MAP study (sponsored by
a consortium including the National Cancer Institute
(NCI), the Southwest Oncology Group (SWOG) clinical
trials group, the Foundation for the NIH, and multiple
pharmaceutical companies),29 the approach is specific

2014 Macmillan Publishers Limited. All rights reserved

Non-clinical models for targets

Translational research with clinical models



Expression array

B-L5 B-L6 NL SW48



Analysis of tumour and

other tissues for
pathway activation or

Patients eligible for

early or late phase
clinical trials


Clinical observations
Clinical response

Patient assigned to trial

based on molecular
characterization of

Functional imaging



Patient monitoring:

Tumour and normal
tissue PD markers

Tumour-initiating cells


Figure 3 | Human tumour tissue-based experimental therapeutics for cancer. The evolving clinical trials paradigm for the
development of molecularly-targeted therapeutic agents focuses on careful use of pre-clinical cancer models to validate
assays that can be used with tissues obtained directly from patients for tumour characterization, proof-of-mechanism
pharmacodynamic studies, molecular monitoring of therapeutic response or the development of resistance, and correlation
with clinical observations based on imaging studies, pharmacokinetic evaluations, and assessments of toxicity.
Weacknowledge the important role of Percy Ivy, National Cancer Institute, NIH, in the development of this figure.
Abbreviations:CECs, circulating endothelial cells; CTCs, circulating tumour cells; FISH, fluorescence in situ hybridization;
IHC, immunohistochemistry; PD, pharmacodynamic; PK, pharmacokinetic.

for a single disease, in this case squamous cancers of the

lung (NCT02154490),87 and is powered to support filing
of new drug applications with the US FDA for one or
more targeted therapy arms, if any are positive. However,
most trials are being conducted to develop a more gen
eral understanding of the role of mutational profiling
in cancer therapy independent of disease histology;88
caveats about the variable implications of mutational
expression in differing disease contexts are inherent in
the conduct of these studies.89
Proof-of-mechanism pharmacodynamics
The importance of demonstrating proof-of-mechanism
in early phase trials of investigational agents has been
discussed extensively.90,91 Although the need seems clear,
particularly with respect to the desirability of clarifying
the dose range of a new drug that correlates both with
target engagement and antitumour efficacy, the develop
ment of robust pharmacodynamic assays has lagged
behind the development of genomic profiling.92 This
situation could be due to the challenges inherent in the
generation of multiple assays needed to interrogate an
enormous range of biochemical targets, often without
easily available high-quality reagents and calibrators,
using a wide range of technical platforms, with very low
quantities of tumour specimens.93 Despite these diffi
culties, it is hard to imagine defining the appropriate
schedules to use for targeted agent combinations without
first establishing the maximally tolerated doses capable
of producing the necessary degree of target inhibition to
support tumour cell killing by either agent alone. Insome

cases, failure to demonstrate proof-of-mechanism in

early phase trials has resulted directly in the failure of
costly phaseIII drug development programmes.94
When reproducible pharmacodynamic assays are
developed for their intended use,95,96 important insights
can be elaborated from treatment of small numbers of
patients that either confirm or reject prevailing mecha
nistic hypotheses for specific drug classes (for example,
inhibitors of PARP).97 Recent technological improve
ments in the automated quantitation of immunofluo
rescence assays performed on fixed tissues enable the
simultaneous evaluation of several pharmacodynamic
targets (Figure4).98 This technique allows invivo exami
nation of the effect of a therapeutic agent on multiple
aspects of a molecular pathway across time and in spatial
context. The visual representation (Figure4) and quanti
tation of such drug effects graphically demonstrate, in
this case, the cell-to-cell pharmacodynamic variabil
ity inherent in exposure to a DNA damaging agent.
There have also been important improvements in highthroughput proteomic approaches, such as the use of
reverse-phase protein arrays in pharmacodynamics.99
This technique has been applied to the development of
proteomic response signatures as well as understand
ing how protein abundance and post-translational
modifications change in tumours and bodily fluids as
a consequence of cancer therapy.100 It is likely that the
expansion of pharmacodynamic approaches to a variety
of critical signalling pathways will markedly enhance
our ability to correlate drug efficacy with molecular
mechanisms of drug action in patients.



2014 Macmillan Publishers Limited. All rights reserved











Figure 4 | Multiple biomarkers of DNA damage imaged simultaneously in tumour

biopsies following systemic cancer therapy. A five-channel quantitative
immunofluorescence assay was employed to analyse the response of DNA
damage/repair proteins in A375 human melanoma xenografts 4h after treatment
with either a vehicle control or 1.5mg/kg of the topoisomerase I inhibitor,
topotecan. Colour assignments for visualization of DNA damage/repair proteins
are: DAPI nuclear stain (purple); Rad51 (pink); phospho-Nbs1 (green); ERCC1
(cyan), and H2AX (red). a | The merged images of all the DNA damage/repair
proteins in xenografts from either vehicle-treated or topotecan-treated mice are
shown. b | The individual proteins are displayed. Quantitation of the mean percent
of cells positive for each marker, collected from 78 representative images, using
Definienssoftware, demonstrated an increase from <1% of cells positive for
phospho-Nbs1 or H2AX in tumours from vehicle-treated control mice to 12 or
20% tumour cells positive for these two markers, respectively, 4h following drug
treatment. Topotecan produced no significant changes in Rad51 orERCC1
expression in these tumours. We express our appreciation to RalphParchment
and Allison Marrero of Leidos, Inc. and NCI-Frederick for the development

Developing predictive biomarkers

Pharmacodynamic markers are of critical value for
understanding whether a presumed mechanism of drug
action can actually be observed in a patients tumour.
However, demonstration of target engagement does not
guarantee therapeutic activity. Unfortunately, beyond
the use of mutational predictors of therapeutic efficacy,
there have been relatively few predictive biomarkers that
have been successfully deployed in the clinic. Predictive
biomarkers must correlate with clinical outcome and
response to specific therapeutic interventions (unlike
prognostic biomarkers that provide only a more general,
population-based association with clinical benefit that
might not be related to a defined mechanism of drug
action).101 Widely-used predictive biomarkers include
demonstration of HER2 expression before treatment with
trastuzumab in patients with breast cancer, or the strong

association between the presence of mutant KRAS and

lack of efficacy of cetuximab for patients with colorec
tal cancer.102 The Oncotype DX and MammaPrint
(Agendia, Irvine, CA) assays have entered clinical prac
tice on the basis of 21gene or 70gene expression signa
tures, respectively, to predict breast cancer outcomes for
specific treatment strategies.10,103
Despite these successes, the past decade has witnessed
several high-profile attempts to use omics technologies
for the elaboration of predictive biomarkers that have not
made a functional transition to the oncology clinic.104
Examination of the criteria necessary for the develop
ment of such tests revealed several problems that have
slowed the field.105 These problems include inadequate
attention to: the details of specimen collection; the defi
nition of standard operating procedures or the require
ments for analytical validation of assays; the statistical
evaluation of the sources of assay variability; clinical trial
design issues; the clinical utility of the test, or how the
test will be used in context.106 Overcoming these issues
to facilitate the development of predictive tests capable
of guiding novel systemic therapies are of fundamental
importance for advancing the field of precision oncology.
Therapeutic resistance and therapy combinations
Major gains in the therapeutic activity of targeted
agents guided by the molecular characterization of
driver mutations must be tempered by the realization
that development of resistance to targeted single-agent
therapy is universal.107 The selective pressure of tar
geted therapy leads to the expression of pre-existing
mutations in receptor tyrosine kinases, the activation
of by-pass signalling pathways, and other resistance
mechanisms; 108 in light of recent demonstrations of
clinical tumour heterogeneity,71 the need to develop
combination approaches for molecularly targeted thera
peutics is clear.109 These approaches are challenged by
the scope and cost of conducting invitro studies (that
include large-scale, combination cell-line screening), the
translation of large numbers of potential combination
hits to relevant invivo models, and current deficiencies
in screening for the toxicities of molecularly targeted
agents used in combination.110 Nonetheless, systematic
combination screening efforts are currently being under
taken,111 and might help to guide future attempts to over
come known and unknown molecular mechanisms of
both acquired and intrinsic therapeutic resistance.

Immunologically-based therapy of cancer

Over the past decade, advances in our understanding
of the immune system have been rapidly translated into
novel cancer therapies; the success of immunologically-
based treatments has been established even for large
epithelial tumours that are resistant to cytotoxic
or molecularly targeted systemic approaches. 23,112
Immunot herapies under active development include
monoclonal antibodies against immune checkpoints,
adoptive cell transfer of Tcells expressing engineered
chimeric antigen receptors,113,114 and novel vaccines115

2014 Macmillan Publishers Limited. All rights reserved

Immune checkpoints are molecules on the surface
of cells that can send inhibitory stimuli to attenuate
immune responses.21 Ongoing or endogenous responses
to tumour antigens can be suppressed either by block
ing the clonal expansion of high avidity clones (cyto
toxic Tlymphocyte antigen 4 [CTLA4]) or inducing
inhibition or exhaustion of antitumour responses (pro
grammed death1 [PD1]programmed death ligand1
[PDL1] axis). Antibodies directed against these immune
checkpoints have recently been shown to result in Tcell
activation and antitumour responses.21 The antiCTLA4
antibody, ipilimumab, is a fully humanized immuno
globulin monoclonal antibody approved by the US FDA
for the treatment of metastatic melanoma, on the basis
of results from randomized phaseIII trials that showed
improved overall survival following treatment with ipili
mumab versus cytotoxic chemot herapy.117 Although
important antitumour effects have been observed, treat
ment with antiCTLA4 antibodies can result in severe
immune-mediated adverse reactions caused by Tcell
inflammatory infiltration of solid organs, including
enterocolitis, hepatitis, dermatitis, cranial neuropathy,
and endocrinopathy that usually occur during treatment,
but can infrequently occur weeks after stopping treat
ment.118 Whether and how toxicities associated with cir
cumventing immunological checkpoints in normal tissue
can be ameliorated is an area of active investigation.
PD1 is a transmembrane molecule on immune cells
that upon stimulation results in the inhibition of the
immune response mediated by these cells. PDL1 and
PDL2 are the two chief ligands for PD1; engagement
with these molecules allows PD1 to exert its inhibi
tory effects. PDL1 is expressed widely on a variety of
immune cells as well as non-immune cells, and PDL1
upregulation can occur in normal tissues in the setting
of inflammatory pressure. PDL2 is mainly expressed on
antigen-presenting cells and dendritic cells. Antibodies
against PD1 and PDL1 that negate immune inhibi
tion are therapeutically active against a variety of solid
tumours.22 The antiPD1 antibody nivolumab produced
an overall response rate of 31% (primarily in patients
with NSCLC, melanoma, and renal cancer) during a
phaseI trial.119 The antitumour activity of antiPD1
antibodies has been confirmed in these same tumour
types, as well as ovarian cancer.120 Drug-related adverse
events in trials with antiPD1 or antiPDL1 antibodies
have also included immunologically-mediated rash,
thyroiditis, pneumonitis, andhepatitis.119
Over the past decade, there has been renewed interest
in vaccine-based cancer prevention and treatment strat
egies. Better understanding of human papillomavirus
(HPV) biology in the early 1990s121,122 was translated into
the development of a highly effective vaccine against the
major types of HPV associated with cervical neoplasia
(HPV16/18); the remarkable success of first-generation
HPV vaccines in preventing infection will undoubtedly
lead to the prevention of several HPV-related cancers,
including those of the cervix and head and neck. 123
The success of vaccine-based strategies has also been
seen in the development of early therapeutic vaccines

for the treatment of advanced-stage prostate cancer.

SipuleucelT is the only vaccine currently approved by
the US FDA for the treatment of advanced-stage cancer;
it produced a 22% reduction in the risk of death (hazard
ratio, 0.78; 95% CI 0.610.98; P=0.03) and a 4.1month
improvement in median survival compared to placebo
in a double-blind multicentre phaseIII trial in patients
with chemotherapy naive, metastatic, castration-resistant
(hormone refractory) prostate cancer.115 Whole-cell irra
diated vaccines (GVAX) and a vaccinia-PSA-TRICOM
pox virus vaccine are also being evaluated in clinical
trials of patients with advanced-stage prostate cancer.124
There is also growing interest in targeting other known
immune checkpoints, such as the lymphocyte activation
gene 3 (LAG3),125 Tcell immunoglobulin and mucin
protein 3 (TIM3), inducible Tcell co-stimulator (ICOS),
killer Ig-like receptors (KIRs), CD40, OX40, CD137/
4-1BB, glucocorticoid-induced TNFR-related protein
(GITR), and CD27.126 The dramatic activity of chimeric
antigen receptor Tcell therapies for advanced haemato
logical malignancies is noteworthy, and suggests that
such treatment programmes will become more widely
available in the near future.113,127 Combinations of PD1
and CTLA4 antibodies128 have demonstrated remark
able activity in patients with melanoma, while many
other potential combinations remain to be evaluated.
Incorporating multimodality therapy with combinations
of small-molecule inhibitors and immune checkpoint
antibodies offers the prospect of extending the number
and duration of responses to a wide range of tumour
types.129 Efforts are also ongoing to identify predictive
markers of response and to define neoantigens that might
be targets for endogenous immune responses in patients
who will receive modern anticancerimmunotherapies.

Functional molecular imaging

Anatomic imaging modalities such as CT and MRI
form an integral part of staging and evaluation of
cancer patients. Functional imaging platforms, such
as PET and single photon emission computed tomo
graphy (SPECT), have also become an important part
of cancer care. Multimodality hybrid imaging technolo
gies, including PETCT, offer the advantage of providing
information about tumour physiology, while character
izing the anatomic features of a tumour, thus, refining
our ability to characterize drug effects.130 Diagnostic
PET imaging, using the radiolabelled glucose analogue
[18F]-fluorodeoxyglucose (FDG), can evaluate the meta
bolic status of cells; changes in FDG uptake in patients
with cancer inform staging, assessment of response to
therapy, and the documentation of disease recurrence.131
Dynamic contrast-enhanced MRI (DCE-MRI) and CT
(DCE-CT) imaging has been used to measure early
vascular responses to antiangiogenicagents.132
Over the past decade, our increasing ability to image
putative molecular drug targets and to demonstrate
drug-related target modulation has provided a noninvasive approach to documenting the presence of a
molecular target, as well as the heterogeneity of target
expression, and demonstrated target modulation



2014 Macmillan Publishers Limited. All rights reserved


PET-CT scan

SUV 8.6

SUV 1.5


Day 6

Figure 5 | Clinical demonstration of ER in metastatic breast cancer and blockade of

receptor occupancy by endoxifen. a,c | 18F-oestradiol PETCT scan of a patient with
breast cancer metastatic to the pelvis; metastatic site circled in red. Immediately
following the imaging procedure, the patient began therapy with endoxifen, the
active metabolite of the selective oestrogen receptor modulator, tamoxifen.
b,d|Images demonstrate that upon repeat PETCT scanning 6days later, uptake
of 18F-oestradiol had been substantively reduced; the SUV ofthe tumour decreased
from 8.6 to 1.5. We acknowledge the important roles of PaulaJacobs and
PeterChoyke, National Cancer Institute, NIH, in the development of this figure.
Abbreviations: ER, oestrogen receptor; SUV,standardized uptake value.

following administration of a therapeutic agent. Expan

ded use of molecular imaging approaches could provide
a non-invasive means of defining patient populations
likely to benefit from specific molecularly targeted thera
pies. Anumber of radiopharmaceuticals are currently
under development that possess sufficient specificity
and have the metabolic and clearance characteristics to
ensure optimal tumour-to-background detection ratios
for such targets as HER2 or VEGF.133,134
The extent of ER protein expression has therapeutic
and prognostic implications for patients with breast
cancer.135 Evaluation of ER expression is usually per
formed with immunohistochemical techniques on
tumour tissues obtained at biopsy or by surgical resec
tion. The selective oestrogen receptor modulator tamoxi
fen is approved by the FDA for the treatment of patients
with ERpositive metastatic breast cancer, as adjuvant
therapy for high-risk ER/progesterone receptor (PR)positive disease, and for chemoprevention in women at
high risk of developing breast cancer.136 The ability to
determine the degree of ER expression in primary and
metastatic tumours using whole-body imaging permits
documentation of target activity at all potential sites of
disease at the time tamoxifen treatment is initiated. An
investigational radiopharmaceutical agent, 16alpha[18F]fluoro17 beta-oestradiol (FES), is currently being evalu
ated in a clinical trial using PET to demonstrate the
presence of ER and its modulation by an active metabo
lite of tamoxifen (endoxifen; Figure5). A recent study in
patients with ERpositive advanced-stage breast cancer

correlatedinitial [ 18F]-FES uptake in tumours with

objective response to hormonaltherapy.137
In addition to suboptimal target engagement, low
intracellular concentrations of a therapeutic agent may
account for lack of clinical activity. The ability to radio
label a drug and image its uptake and clearance in the
tumour could provide valuable insight into drug metabo
lism, and help to develop an optimal dose and schedule
for its use. Early phase trials of a DNA methyltransfer
ase inhibitor, 5fluoro2'-deoxycytidine, administered
along with tetrahydrouridine (an inhibitor of cytidine/
deoxycytidine deaminase), are ongoing in patients with
advanced-stage solid tumours.138,139 Intracellular uptake
of the parent compound with activation to a charged
particle is essential for drug retention and antitumour
activity in tumour cells. A novel, radiolabelled PET probe
([18F]5-fluoro2'-deoxycytidine) has been developed
and is being evaluated in clinical trials to demonstrate
intracellular uptake and retention of the therapeutic drug
The compensatory feedback loops that contribute to
the development of drug resistance have expedited the
need to measure the status of multiple growth pathways
at baseline and in response to targeted small-molecule
and/or immunological therapies. While assays are being
developed to evaluate these pathways in tumours from
samples obtained using invasive techniques, the develop
ment of hybrid imaging technologies that can visualize
multiple targets and their modulation by therapeutic
agents over time could be essential to the design of treat
ment regimens that include combination or sequential
agent interventions.

Future prospects

The pace with which cancer gene sequencing has moved

from a technical tour de force to an FDA-approved
component of ongoing research initiatives is indicative
of the progress of translational oncology. Based on the
breadth of the changes in translational cancer biology
and therap eutics that have been described, it seems
likely that our approach to the molecular interrogation
of human cancers and oncology therapeutics is likely to
progress substantially in several areas that will enhance
further discovery. Investigational domains and technical
capabilities ripe for progress include: broader availability
of tumour tissues associated with clinical data; develop
ment of patient-specific tumour models; rapid under
standing of therapeutic resistance mechanisms coupled
with the development of small-molecule and immuno
therapeutic combinations to overcome ineffective treat
ment programmes; and the development of pathway
imaging andradiomics.
There are also important challenges that must be
overcome before we can make optimal use of the rapidly
improving tools of molecular oncology. These include a
host of complex issues ranging from the prioritization
of molecular targets for clinical interrogation, to the
choice of optimal designs for genomic clinical trials, to
questions of reimbursement for support of molecular
validation studies in the clinic.

2014 Macmillan Publishers Limited. All rights reserved

Clinically-annotated tumour/normal tissues
The standardization of tissue acquisition techniques,
from documentation of anoxic clamp times for surgi
cal specimens to the use of specific, uniform freezing
and fixation methodologies, is now an acknowledged
priority in pathology laboratories. The ease with
which human tumours can be perpetuated as PDXs,
with closely associated clinical histories, suggests that
many more human tumour specimens, including those
from patients enrolled on clinical trials, could become
more widely available to assist in studies of genomic
heterogeneity, the tumour microenvironment, and
cancer metabolismareas of investigation that would
benefit greatly from a proliferation of clinicallyannotated specimens that reflect the intact tumour
in its tissue context. As we understand how best to
collect human tumour specimens, we will also begin
to understand which specimens need to be obtained
under invasive (biopsy) or noninvasive (circulating
tumour cells/DNA) conditions to optimize individual

Prospects and challenges for immunotherapy

The rapid development of immunological checkpoint
inhibitors and molecularly-enhanced Tcell thera
pies suggests that the range of solid tumours amen
able to immunotherapeutic approaches will broaden
substantively over the next 5years. The capacity to
produce genetically-engineered, personalized cellular
or vaccine therapies could limit the availability of such
treatments, and thus further consideration regard
ing how to expand production capabilities in this
area is essential. It is also important to realize that our
understanding of the mechanisms of intrinsic resis
tance to immunological checkpoint inhibitors remains
limited and is largely unaffected by current molecular
(genomic) characterization efforts. It is likely, however,
that advances in multiplex molecular diagnostics that
are expanding our ability to interrogate critical onco
genic driver pathways in patient specimens will soon be
used to understand the complex interactions that occur
in the tumour and its microenvironment following

New therapeutic models

Current PDX models seem to offer advantages com
pared to murine xenograft models derived from cell
lines for drug development (Figure2). Expanded evalu
ation of these models raises the possibility of producing
individual models prospectively for individual patients,
particularly under circumstances in which relapse rates
following initial treatment are high.140 Currently, model
building has focused on tumours available from surgical
resection specimens. In the future, it would be advan
tageous to develop personal PDX models from circu
lating tumour cells, for instance, rather than requiring
repeat biopsies or surgical procedures. In this way, the
molecular evolution (and potentially the drug sensitiv
ity or resistance mechanisms) of an individuals disease
could be profiled in anticipation of the need for rapid
changes in therapeutic approach.27

Imaging molecular pathways in tumours

Molecular imaging approaches have matured such that
multiple examples of the ability to provide quantita
tive estimates of invivo membrane or nuclear recep
tor occupancy in human tumours currently exist.143,144
It is reasonable to expect that the capacity to image
a range of critical molecular pathways essential for
tumour cell homeostasis will increase over the next
510years. Examples of such pathways include early
attempts to measure reactive oxygen metabolites and
chemokine si gnalling in tumour cells and animal
Recent evidence also suggests that enhanced analyti
cal capabilities will soon be applied to current imaging
modalities, such as CT, to extract novel phenotypic fea
tures of tumours, including tumour texture, shape, and
image intensity from currently-available data. These
capabilities will allow quantitative image signatures
(radiomics) to be developed with clinical prognostic
significance across tumour types. Such image signatures
have been strongly associated with specific biological and
genetic features of tumours, particularly intratumoural
heterogeneity and proliferation (radiogenomics). 147
Using these new tools, it can be expected that molecular
tumour characterization will involve both invasive and
noninvasive (imaging) components used to develop a
comprehensive picture of both the anatomic architec
ture and the molecular infrastructure of human tumours
across all sites of disease.

New approaches to therapeutic resistance

Acquired resistance to molecularly targeted agents
occurs regularly in most patients receiving these
drugs, despite initial evidence of therapeutic efficacy.141
However, advances in molecular tumour character
ization now enable a much more active approach to
acquired resistance. Using sensitive molecular model
ling techniques to study genetic and structural altera
tions in tumour specimens (from repeat biopsies,
circulating tumour DNA, or circulating tumour cells)
obtained at the time resistance becomes manifest, it has
become much more common for drug developers to
rapidly identify second-generation and third-generation
molecules that circumvent acquired mechanisms of
resistance, and to quickly bring such drugs to the clinic,
over time spans unheard of a decade ago. This impor
tant trend has already changed the drug development
paradigm for tyrosine kinase inhibitors, and can be
expected to be more broadly used across anticancer drug
categories in the future.142

Clinical molecular characterization

Changes in molecular characterization over the past
decade have demanded concurrent, rapid adjustments
in the design of clinical trials to test the effect of match
ing genomic abnormalities to molecularly targeted
therapies.29 Initial efforts have focused on using available
early phase trials for patients based on best professional
judgement to employ drugs targeting molecular lesions



2014 Macmillan Publishers Limited. All rights reserved

that have been detected by sequencing of tumour DNA.
Over the coming decade, randomized trials (such as the
NCI MPACT and Lung-MAP studies), rather than nonrandomized (N of 1) efforts conducted without locked
down therapeutic algorithms, will address the usefulness
of broad panels of genomic predictors in a definitive
fashion. This is now becoming possible as regulatory
agencies in the US and Europe develop a greater degree
of comfort with the risks inherent in such trials and the
feasibility of using carefully validated multiplex genetic
testing to determine therapeutic choice. This approach,
which is just now being initiated for patients with
advanced-stage cancers, will likely become common
place in early stage disease, as the cost of genomic pro
filing continues to drop, especially when employed in
the context of rigorously-validated treatment algorithms.
The challenge of choosing which molecular targets to
investigate in the context of evolving genomic hetero
geneity will expand, rather than abate, until our ability to
interrogate large, aggregated data sets from mutationallyannotated clinical trials is dramatically improved. When
molecular characterization efforts from multiple tumour
sources in each patient are routine, it will be possible to
optimize combination approaches to driver pathways on
a patient-by-patient basis.


Dramatic changes have occurred in the field of trans

lational cancer medicine over the past decade. The


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