Abstract 1750: Combination of ZEN-3694 with CDK4/6 inhibitors reverses resistance in ER-positive breast cancer

CDK4/6 inhibitors have been shown to significantly prolong progression-free survival in patients with advanced hormone receptor (HR)-positive, HER2-negative breast cancer. In spite of the great successes with the currents lines of therapies, the patients still acquire resistance over time and, the development of additional novel therapeutic strategies is needed. The bromodomain and extra-terminal domain (BET) proteins are key epigenetic regulators that interact with acetylated lysine (AcLys) residues of histones or transcription factors, leading to the regulation of gene transcription. BET proteins have also been shown to be directly involved in the transcription of the estrogen receptor (ER) mRNA as well as cell cycle and therefore, BET inhibitors can potentially offer new strategies in the treatment of CDK4/6i- resistant and endocrine resistant ER+ breast cancer. ZEN-3694 is an orally bioavailable small molecule inhibitor of BET proteins currently being evaluated in Phase 1/2 clinical trials in metastatic castration-resistant prostate cancer (NCT02711956) and triple negative breast cancer (NCT03901469). We have shown previously that ZEN-3694 inhibits proliferation and induces apoptosis in ER+ cell lines. To assess the effects of ZEN-3694 in the combination with CDK4/6 inhibitors as a potential therapy in a CDK4/6i resistant population, we have developed a panel of ER+ cell lines resistant to palbociclib or abemaciclib by continuous stepwise exposure to increasing concentrations of CDK4/6 inhibitors. These cell lines have demonstrated cross-resistance to all three CDK4/6 inhibitors. Here, we describe that the combination treatment of ZEN-3694 with CDK4/6 inhibitors potently inhibits proliferation and induces apoptosis in all CDK4/6i resistant cell lines. The resistance to both palbociclib and abemaciclib was associated with the strong upregulation of CDK6 and CCND1protein levels in MCF7 which is consistent with their clinical mechanism of resistance. ZEN-3694 showed efficacy in all CDK4/6i-resistant models leading to downregulation of ER and CDK6 protein levels. Furthermore, our RNAseq data revealed several potential pathways involved in CDK4/6i resistance, including upregulation of cell cycle pathway and decrease of interferon signaling and demonstrated that the mechanisms of resistance to abemaciclib and palbociclib are similar but not identical. Additionally, we elucidated the mechanism of action of ZEN-3694 and in combinations with CDK4/6 inhibitors alleviating these resistance mechanisms. The pathway analysis demonstrated that the combination of ZEN-3694 with CDK4/6 inhibitors led to the strong downregulation of multiple pathways including cell cycle regulation, signaling by Rho family GTPases, STAT3, IL6 and other pathways. We conclude that ZEN-3694 has therapeutic potential in a combination with CDK4/6 inhibitors in ER+ breast cancer patients that developed resistance to endocrine therapies and/or CDK4/6 inhibitors. Citation Format: Olesya A. Kharenko, Reena G. Patel, Cyrus Calosing, Edward H. van der Horst. Combination of ZEN-3694 with CDK4/6 inhibitors reverses resistance in ER-positive breast cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1750.