Targeting KRAS for cancer therapy

In recent years, therapeutics targeted against KRAS proto-oncogene GTPase (KRAS)-mutant cancers have seen significant progress. Herein we outline the biology and epidemiology of KRAS alterations at the lineage and allele levels, reviewing the clinical evidence for KRAS^G12C inhibition from the discovery of the recessive switch pocket to sotorasib, adagrasib and other novel molecules, and extending to the non-KRAS^G12C era, including RAS (ON)- and KRAS^G12D-selective strategies and early efficacy signals. We summarize secondary mutations that lead to drug resistance, by-pass reconnection, adaptive circuits and reprogramming of lineage-cellular states. We propose a 'three-clock, two-window' framework, which includes half-life exposure, occupation retention and extracellular signal-regulated kinase (ERK) rebound calibration of dosing rhythm; a vascular normalization window and an immune/myeloid plasticity window to achieve longitudinal Src homology 2-containing protein tyrosine phosphatase 2/son of sevenless homologue 1 and transverse epidermal growth factor receptor, phosphoinositide 3-kinase-protein kinase-mammalian target of rapamycin synergy. At the same time, we construct and propose a closed loop of exposure, occupation, pathway inhibition, circulating tumour DNA (ctDNA) and imaging by utilizing ctDNA dynamics, phosphorylated ERK rebound and perfusion imaging, as well as myeloid lineage quantification, to improve durable inhibition and overall survival through time-aligned combined effects.