Rational Approaches for Combination Therapy Strategies Targeting the MAP Kinase Pathway in Solid Tumors

Molecular characterization of oncogenic mutations within genes in the MAPK and PI3K/AKT/mTOR pathways has led to the rational development of targeted therapies. Combining BRAF and MEK inhibitors to target two steps in the MAPK pathway (vertical inhibition) is now standard of care in advanced-stage melanoma harboring BRAF V600 mutation. Encouraging results have been seen in several tumor types with the same mutation, including BRAF V600-mutant non-small cell lung cancer. Yet similar results in other tumors, such as colorectal cancer, have not been observed, highlighting the unique nature of different tumors. Furthermore, considerable cross talk occurs between signaling pathways, and cancer cells usually harbor multiple aberrations and/or develop compensatory mechanisms that drive resistance. Therefore, it is logical to target multiple pathways simultaneously (horizontal inhibition) by combining selective inhibitors or engineering multitargeted agents. Yet horizontal inhibition has proven to be a significant challenge, primarily due to dose-limiting toxicities. This review focuses on ongoing or completed clinical trials with combination targeted therapies for solid tumors and highlights the successes and ongoing challenges. Novel strategies to overcome these obstacles include new delivery technologies, combinations with emerging agents, and treatment schedule optimization. Mol Cancer Ther; 17(1); 3-16. ©2017 AACR.