A Hard Road to a Cancer Drug

The long and winding story of the oncogene KRAS and its new drug, sotorasib.

After half a century of the "War on Cancer", new treatments are finally straggling into the clinic. It has been an extremely hard and frustrating road to study cancer, let alone treat it. We have learned amazing things, but mostly we have learned how convoluted a few billion years of evolution can make things. The regulatory landscape within our cells is undoubtedly the equal of any recalcitrant bureaucracy, full of redundant offices, multiple veto points, and stakeholders with obscure agendas. I recently watched a seminar in the field, which discussed one of the major genes mutated in cancer and what it has taken to develop a treatment against it. 

Cancer is caused by DNA mutations, and several different types need to occur in succession. There are driver mutations, which are the first step in the loss of normal cellular control. But additional mutations have to happen for such cells to progress through regulatory blocks, like escape from local environmental controls on cell type and cell division, past surveillance by the immune system, and past the reluctance of differentiated cells to migrate away from their resident organ. By the end, cancer cells typically have huge numbers of mutations, having incurred mutations in their DNA repair machinery in an adaptive effort to evade all these different controls.

While this means that many different targets exist that can treat some cancers, it also means that any single cancer requires a precisely tailored treatment, specific to its mutated genes. And that resistance is virtually inevitable given the highly mutable nature of these cells. 

One of the most common genes to be mutated to drive cancer (in roughly 20% of all cases) is KRAS, part of the RAS family of NRAS, KRAS, and HRAS. These were originally discovered through viruses that cause cancer in rats. These viruses (such as Kirsten rat sarcoma virus) had a copy of a rat gene in it, which it overpoduces and uses to overcome normal proliferation controls during infection. The viral gene was called an oncogene, and the original rat (or human) version was called a proto-oncogene, named KRAS. The RAS proteins occupy a central part of the signaling path that external events and stresses turn on to activate cell growth and proliferation, called the MAP kinase cascade. For instance, epidermal growth factor comes along in the blood, binds to a receptor on the outside of a cell, and turns on RAS, then MEK, MAPK, and finally transcription regulators that turn on genes in the nucleus, resulting in new proteins being expressed. "Turning on" means different things at each step in this cascade. The transcription regulators typically get phosphorylated by their upstream kinases like MAPK, which tag them for physical transport into the nucleus, where they can then activate genes. MAPK is turned on by being itself phosphorylated by MEK, and MEK is phosphorylated by RAF. RAF is turned on by binding to RAS, whose binding activity in turn is regulated by the state of a nucleotide (GTP) bound by RAS. When binding GTP, RAS is on, but if binding GDP, it is off.

A schematic of the RAS pathway, whereby extracellular growth signals are interpreted and amplified inside our cells, resulting in new gene expression as well as other more immediate effects. The cell surface receptor, activated by its ligand, activates associated SOS which activates RAS to the active (GTP) state. This leads to a kinase cascade through RAF, MEK, and MAPK and finally to gene regulators like MYC.

This whole system seems rather ornate, but it accomplishes one important thing, which is amplification. One turned-on RAF molecule or MEK molecule can turn on / phosphorylate many targets, so this cascade, though it appears linear in a diagram, is acutally a chain reaction of sorts, amplifying as it goes along. And what governs the state of RAS and its bound GTP? The state of the EGFR receptor, of course. When KRAS is activated, the resident GDP leaves, and GTP comes to take its place. RAS is a weak GTPase enzyme itself, slowly converting itself from the active back to the inactive state with GDP. 

Given all this, one would think that RAS, and KRAS in particular, might be "druggable", by sticking some well-designed molecule into the GTP/GDP binding pocket and freezing it in an inactive state. But the sad fact of the matter is that the affinity KRAS has to GTP is incredibly high- so high it is hard to measure, with a binding constant of about 20 pM. That is, half the KRAS-bound GTP comes off when the ambient concentration of GTP is infinitesimal, 0.02 nano molar. This means that nothing else is likely to be designed that can displace GTP or GDP from the KRAS protein, which means that in traditional terms, it is "undruggable". What is the biological logic of this? Well, it turns out that the RAS enzymes are managed by yet other proteins, which have the specific roles of prying GDP off (GTP exchange factor, or GEF) and of activating the GTP-ase activity of RAS to convert GTP to GDP (GTPase activating protein, or GAP). It is the GEF protein that is stimulated by the receptors like EGFR that induce RAS activity. 

So we have to be cleverer in finding ways to attack this protein. Incidentally, most of the oncogenic mutations of KRAS are at the twelfth residue, glycine, which occupies a key part of the GAP binding site. As glycine is the smallest amino acid, any other amino acid here is bulkier, and blocks GAP binding, which means that KRAS with any of these mutations can not be turned off. It just keeps on signaling and signaling, driving the cell to think it needs to grow all the time. This property of gain of function and the ability of any mutation to fit the bill is why this particular defect in KRAS is such a common cancer-driving mutation. It accounts for ~90% of pancreatic cancers, for instance. 

The seminar went on a long tangent, which occupied the field (of those looking for ways to inhibit KRAS with drugs) for roughly a decade. RAS proteins are not intrinsically membrane proteins, but they are covalently modified with a farnesyl fatty tail, which keeps them stuck in the cell's plasma membrane. Indeed, if this modification is prevented, RAS proteins don't work. So great- how to prevent that? Several groups developed inhibitors of the farnesyl transferase enzyme that carries out this modification. The inhibitors worked great, since the farnesyl transferase has a nice big pocket for its large substrate to bind, and doesn't bind it too tightly. But they didn't inhibit the RAS proteins, because there was a backup system- geranygeranyl transferase that steps into the breach as a backup, which can attach an even bigger fatty tail to RAS proteins. Arghhh!

While some are working on inhibiting both enzymes, the presenter, Kevan Shokat of UCSF, went in another direction. As a chemist, he figured that for the fraction of the KRAS mutants at position 12 that transform from glycine to cysteine, some very specific chemistry (that is, easy methods of cross-linking), can be brought to bear. Given the nature of the genetic code, the fraction of mutations that go from glycine to cysteine are small, there being eight amino acids that are within a one-base change of glycine, coded by GGT. So at best, this approach is going to have a modest impact. Nevertheless, there was little choice, so they forged ahead with a complicated chemical scheme to make a small molecule that could chemically crosslink to that cysteine, with selectivity determined by a modest shape fit to the surface of the KRAS protein near this GEF binding site. 

A structural model of KRAS, with its extremely tightly-bound substrate GDP in orange. The drug sotorasib is below in teal, bound in another pocket, with a tail extending upwards to the (mutant) cysteine 12, which is not differentiated by color, but sits over a magnesium ion (green) being coordinated by GDP. The main job of sotorasib is to interfere with the binding of the guanine exchange factor (GEF) which happens on the surface to its left, and would reset KRAS to an active state.

This approach worked surprisingly well, as the KRAS protein obligingly offfered a cryptic nook that the chemists took advantage of to make this hybrid compound, now called the drug sotorasib. This is an FDA-approved treatment for cancers which are specifically driven by this particular KRAS mutation of position 12 from glycine to cysteine. That research group is currently trying to extend their method to other mutant forms, with modest success. 

So let's take a step back. This new treatment requires, obviously, the patient's tumor to be sequenced to figure out its molecular nature. That is pretty standard these days. And then, only a small fraction of patients will get the good news that this drug may help them. Lung cancers are the principal candidates currently, (of which about 15% have this mutation), while only about 1-2% of other cancers have this mutation. This drug has some toxicity- while it is a magic bullet, its magic is far from perfect, (which is odd given the exquisite selectivity it has for the mutated form of KRAS, which should only exist in cancer tissues). And lastly, it gives, on average, under six months of reprieve from cancer progression, compared to four and a half months with a more generic drug. As mentioned above, tumors at this stage are riven with other mutations and evolve resistence to this treatment with appalling relentlessness.

While it is great to have developed a new class of drugs like this one against a very recalcitrant target, and done so on a highly rational basis driven by our growing molecular knowlege of cancer biology, this result seems like a bit of a let-down. And note also that this achievement required decades of publicly funded research, and doubtless a billion dollars or more of corporate investment to get to this point. Costs are about twenty five thousand dollars per patient, and overall sales are maybe two hundred million dollars per year, expected to increase steadily.

Does this all make sense? I am not sure, but perhaps the important part is that things can not get worse. The patent on this drug will eventually expire and its costs will come down. And the research community will keep looking for other, better ways to attack hard targets like KRAS, and will someday succeed.

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