Targeted Cancer Therapies
What are targeted cancer therapies?
Targeted cancer therapies are drugs or other substances that block the growth and spread of cancer by interfering with specific molecules ("molecular targets") that are involved in the growth,progression, and spread of cancer. Targeted cancer therapies are sometimes called "molecularly targeted drugs," "molecularly targeted therapies," "precision medicines," or similar names.
Targeted therapies differ from standard chemotherapy in several ways:
- Targeted therapies act on specific molecular targets that are associated with cancer, whereas most standard chemotherapies act on all rapidly dividing normal and cancerous cells.
- Targeted therapies are deliberately chosen or designed to interact with their target, whereas many standard chemotherapies were identified because they kill cells.
- Targeted therapies are often cytostatic (that is, they block tumor cell proliferation), whereas standard chemotherapy agents are cytotoxic (that is, they kill tumor cells).
Many targeted cancer therapies have been approved by the Food and Drug Administration (FDA) to treat specific types of cancer (see Questions 8 and 9). Others are being studied inclinical trials (research studies with people), and many more are in preclinical testing (research studies with animals).
How are targets for targeted cancer therapies identified?
The development of targeted therapies requires the identification of good targets—that is, targets that play a key role in cancer cell growth and survival. (It is for this reason that targeted therapies are sometimes referred to as the product of "rational" drug design.)
One approach to identify potential targets is to compare the amounts of individual proteins in cancer cells with those in normal cells. Proteins that are present in cancer cells but not normal cells or that are more abundant in cancer cells would be potential targets, especially if they are known to be involved in cell growth or survival. An example of such a differentially expressed target is the human epidermal growth factor receptor 2 protein (HER-2). HER-2 is expressed at high levels on the surface of some cancer cells. Several targeted therapies are directed against HER-2, including trastuzumab (Herceptin®), which is approved to treat certain breast and stomach cancers that overexpress HER-2.
Another approach to identify potential targets is to determine whether cancer cells produce mutant (altered) proteins that drive cancer progression. For example, the cell growth signaling protein BRAF is present in an altered form (known as BRAF V600E) in many melanomas.Vemurafenib (Zelboraf®) targets this mutant form of the BRAF protein and is approved to treat patients with inoperable or metastatic melanoma that contains this altered BRAF protein.
Researchers also look for abnormalities in chromosomes that are present in cancer cells but not in normal cells. Sometimes these chromosome abnormalities result in the creation of a fusion gene (a gene that incorporates parts of two different genes) whose product, called a fusion protein, may drive cancer development. Such fusion proteins are potential targets for targeted cancer therapies. For example, imatinib mesylate (Gleevec®) targets the BCR-ABL fusion protein, which is made from pieces of two genes that get joined together in some leukemia cells and promotes the growth of leukemic cells.
How are targeted therapies developed?
Once a candidate target has been identified, the next step is to develop a therapy that affects the target in a way that interferes with its ability to promote cancer cell growth or survival. For example, a targeted therapy could reduce the activity of the target or prevent it from binding to areceptor that it normally activates, among other possible mechanisms.
Most targeted therapies are either small molecules or monoclonal antibodies. Small-molecule compounds are typically developed for targets that are located inside the cell because such agents are able to enter cells relatively easily. Monoclonal antibodies are relatively large and generally cannot enter cells, so they are used only for targets that are outside cells or on the cell surface.
Candidate small molecules are usually identified in what are known as "high-throughput screens," in which the effects of thousands of test compounds on a specific target protein are examined. Compounds that affect the target (sometimes called "lead compounds") are then chemically modified to produce numerous closely related versions of the lead compound. These related compounds are then tested to determine which are most effective and have the fewest effects on nontarget molecules.
Monoclonal antibodies are developed by injecting animals (usually mice) with purified target proteins, causing the animals to make many different types of antibodies against the target. These antibodies are then tested to find the ones that bind best to the target without binding to nontarget proteins.
Before monoclonal antibodies are used in humans, they are "humanized" by replacing as much of the mouse antibody molecule as possible with corresponding portions of human antibodies. Humanizing is necessary to prevent the human immune system from recognizing the monoclonal antibody as "foreign" and destroying it before it has a chance to bind to its target protein. Humanization is not an issue for small-molecule compounds because they are not typically recognized by the body as foreign.
What types of targeted therapies are available?
Many different targeted therapies have been approved for use in cancer treatment. These therapies include hormone therapies, signal transduction inhibitors, gene expression modulator,apoptosis inducer, angiogenesis inhibitor, immunotherapies, and toxin delivery molecules.
- Hormone therapies slow or stop the growth of hormone-sensitive tumors, which require certain hormones to grow. Hormone therapies act by preventing the body from producing the hormones or by interfering with the action of the hormones. Hormone therapies have been approved for both breast cancer and prostate cancer.
- Signal transduction inhibitors block the activities of molecules that participate in signal transduction, the process by which a cell responds to signals from its environment. During this process, once a cell has received a specific signal, the signal is relayed within the cell through a series of biochemical reactions that ultimately produce the appropriate response(s). In some cancers, the malignant cells are stimulated to divide continuously without being prompted to do so by external growth factors. Signal transduction inhibitors interfere with this inappropriate signaling.
- Gene expression modulators modify the function of proteins that play a role in controlling gene expression.
- Apoptosis inducers cause cancer cells to undergo a process of controlled cell death called apoptosis. Apoptosis is one method the body uses to get rid of unneeded or abnormal cells, but cancer cells have strategies to avoid apoptosis. Apoptosis inducers can get around these strategies to cause the death of cancer cells.
- Angiogenesis inhibitors block the growth of new blood vessels to tumors (a process called tumor angiogenesis). A blood supply is necessary for tumors to grow beyond a certain size because blood provides the oxygen and nutrients that tumors need for continued growth. Treatments that interfere with angiogenesis may block tumor growth. Some targeted therapies that inhibit angiogenesis interfere with the action of vascular endothelial growth factor (VEGF), a substance that stimulates new blood vessel formation. Other angiogenesis inhibitors target other molecules that stimulate new blood vessel growth.
- Immunotherapies trigger the immune system to destroy cancer cells. Some immunotherapies are monoclonal antibodies that recognize specific molecules on the surface of cancer cells. Binding of the monoclonal antibody to the target molecule results in the immune destruction of cells that express that target molecule. Other monoclonal antibodies bind to certain immune cells to help these cells better kill cancer cells.
- Monoclonal antibodies that deliver toxic molecules can cause the death of cancer cells specifically. Once the antibody has bound to its target cell, the toxic molecule that is linked to the antibody—such as a radioactive substance or a poisonous chemical—is taken up by the cell, ultimately killing that cell. The toxin will not affect cells that lack the target for the antibody—i.e., the vast majority of cells in the body.
How is it determined whether a patient is a candidate for targeted therapy?
For some types of cancer, most patients with that cancer will have an appropriate target for a particular targeted therapy and, thus, will be candidates to be treated with that therapy. CML is an example: most patients have the BCR-ABL fusion gene. For other cancer types, however, a patient’s tumor tissue must be tested to determine whether or not an appropriate target is present. The use of a targeted therapy may be restricted to patients whose tumor has a specificgene mutation that codes for the target; patients who do not have the mutation would not be candidates because the therapy would have nothing to target.
Sometimes, a patient is a candidate for a targeted therapy only if he or she meets specific criteria (for example, their cancer did not respond to other therapies, has spread, or isinoperable). These criteria are set by the FDA when it approves a specific targeted therapy.
What are the limitations of targeted cancer therapies?
Targeted therapies do have some limitations. One is that cancer cells can become resistant to them. Resistance can occur in two ways: the target itself changes through mutation so that thetargeted therapy no longer interacts well with it, and/or the tumor finds a new pathway to achieve tumor growth that does not depend on the target.
For this reason, targeted therapies may work best in combination. For example, a recent study found that using two therapies that target different parts of the cell signaling pathway that isaltered in melanoma by the BRAF V600E mutation slowed the development of resistance anddisease progression to a greater extent than using just one targeted therapy (1).
Another approach is to use a targeted therapy in combination with one or more traditionalchemotherapy drugs. For example, the targeted therapy trastuzumab (Herceptin®) has been used in combination with docetaxel, a traditional chemotherapy drug, to treat women with metastatic breast cancer that overexpresses the protein HER2/neu.
Another limitation of targeted therapy at present is that drugs for some identified targets are difficult to develop because of the target’s structure and/or the way its function is regulated in the cell. One example is Ras, a signaling protein that is mutated in as many as one-quarter of all cancers (and in the majority of certain cancer types, such as pancreatic cancer). To date, it has not been possible to develop inhibitors of Ras signaling with existing drug development technologies. However, promising new approaches are offering hope that this limitation can soon be overcome.
What are the side effects of targeted cancer therapies?
Scientists had expected that targeted cancer therapies would be less toxic than traditionalchemotherapy drugs because cancer cells are more dependent on the targets than are normal cells. However, targeted cancer therapies can have substantial side effects.
The most common side effects seen with targeted therapies are diarrhea and liver problems, such as hepatitis and elevated liver enzymes. Other side effects seen with targeted therapies include:
- Skin problems (acneiform rash, dry skin, nail changes, hair depigmentation)
- Problems with blood clotting and wound healing
- High blood pressure
- Gastrointestinal perforation (a rare side effect of some targeted therapies)
The few targeted therapies that are approved for use in children can have different side effects in children than in adults, including immunosuppression and impaired sperm production (4).
What targeted therapies have been approved for specific types of cancer?
The FDA has approved targeted therapies for the treatment of some patients with the following types of cancer (some targeted therapies have been approved to treat more than one type of cancer):
Adenocarcinoma of the stomach or gastroesophageal junction: Trastuzumab (Herceptin®)
Basal cell carcinoma: Vismodegib (Erivedge™)
Brain cancer: Bevacizumab (Avastin®), Everolimus (Afinitor®)
Breast cancer: Everolimus (Afinitor®), tamoxifen, toremifene (Fareston®), Trastuzumab (Herceptin®), fulvestrant (Faslodex®), anastrozole (Arimidex®), exemestane (Aromasin®),lapatinib (Tykerb®), letrozole (Femara®), pertuzumab (Perjeta™), ado-trastuzumab emtansine (Kadcyla™)
Colorectal cancer: Cetuximab (Erbitux®), Panitumumab (Vectibix®), Bevacizumab (Avastin®),Ziv-aflibercept (Zaltrap®), Regorafenib (Stivarga®)
Dermatofibrosarcoma protuberans: Imatinib mesylate (Gleevec®)
Head and neck cancer: Cetuximab (Erbitux®)
Gastrointestinal stromal tumor: Imatinib mesylate (Gleevec®), Sunitinib (Sutent®),Regorafenib (Stivarga®)
Giant cell tumor of the bone: Denosumab (Xgeva®)
Kaposi sarcoma: Alitretinoin (Panretin®)
Kidney cancer: Bevacizumab (Avastin®), Sorafenib (Nexavar®), Sunitinib (Sutent®), Pazopanib (Votrient®), Temsirolimus (Torisel®), Everolimus (Afinitor®), Axitinib (Inlyta®)
Leukemia: Tretinoin (Vesanoid®), Imatinib mesylate (Gleevec®), Dasatinib (Sprycel®), Nilotinib (Tasigna®), Bosutinib (Bosulif®), Rituximab (Rituxan®), Alemtuzumab (Campath®), Ofatumumab (Arzerra®), Obinutuzumab (Gazyva™)
Liver cancer: Sorafenib (Nexavar®)
Lymphoma: Tositumomab and 131I-tositumomab (Bexxar®), Ibritumomab tiuxetan (Zevalin®),Denileukin diftitox (Ontak®), Brentuximab vedotin (Adcetris®), Rituximab (Rituxan®), Vorinostat (Zolinza®), Romidepsin (Istodax®), Bexarotene (Targretin®), Bortezomib (Velcade®),Pralatrexate (Folotyn®), Lenaliomide (Revlimid®), Ibrutinib (Imbruvica™), Siltuximab (Sylvant™)
Melanoma: Ipilimumab (Yervoy®), Vemurafenib (Zelboraf®), Trametinib (Mekinist®), Dabrafenib (Tafinlar®)
Multiple myeloma: Bortezomib (Velcade®), Carfilzomib (Kyprolis®), Lenaliomide (Revlimid®),Pomalidomide (Pomalyst®)
Myelodysplastic/myeloproliferative disorders: Imatinib mesylate (Gleevec®)
Non-small cell lung cancer: Bevacizumab (Avastin®), Crizotinib (Xalkori®), Erlotinib (Tarceva®), Gefitinib (Iressa®), Afatinib dimaleate (Gilotrif®), Ceritinib (LDK378/Zykadia)
Pancreatic cancer: Erlotinib (Tarceva®), Everolimus (Afinitor®), Sunitinib (Sutent®)
Prostate cancer: Cabazitaxel (Jevtana®), Enzalutamide (Xtandi®), Abiraterone acetate (Zytiga®), Radium 223 chloride (Xofigo®)
Soft tissue sarcoma: Pazopanib (Votrient®)
Stomach cancer: Ramucirumab (Cyramza™)
Systemic mastocytosis: Imatinib mesylate (Gleevec®)
Thyroid cancer: Cabozantinib (Cometriq™), Vandetanib (Caprelsa®), Sorafenib (Nexavar®)
Where can I find information about clinical trials of targeted therapies?
Both FDA-approved and experimental targeted therapies for specific types of cancer are being studied in clinical trials. The names of the targeted therapy types listed below are links to lists of ongoing clinical trials that are testing those types of targeted therapies in cancer patients. These trial descriptions can also be accessed directly by searching NCI’s list of cancer clinical trials. NCI’s list of cancer clinical trials includes all NCI-funded clinical trials as well as studies conducted by investigators at hospitals and medical centers throughout the United States and around the world. For information about other ways to search the list, see "Help Using the NCI Clinical Trials Search Form."
Signal transduction inhibitors
Gene expression modulators
Monoclonal antibody conjugates
- Flaherty KT, Infante JR, Daud A, et al. Combined BRAF and MEK inhibition in melanoma with BRAF V600 mutations. New England Journal of Medicine 2012; 367(18):1694-1703.[PubMed Abstract]
- Petrelli F, Borgonovo K, Cabiddu M, Lonati V, Barni S. Relationship between skin rash and outcome in non-small-cell lung cancer patients treated with anti-EGFR tyrosine kinase inhibitors: A literature-based meta-analysis of 24 trials. Lung Cancer 2012; 78(1):8-15.[PubMed Abstract]
- Cai J, Ma H, Huang F, et al. Correlation of bevacizumab-induced hypertension and outcomes of metastatic colorectal cancer patients treated with bevacizumab: a systematic review and meta-analysis. World Journal of Surgical Oncology 2013; 11:306.[PubMed Abstract]
- Gore L, DeGregori J, Porter CC. Targeting developmental pathways in children with cancer: what price success? Lancet Oncology 2013; 4(2):e70-78.[PubMed Abstract]