Exploiting selective BCL-2 family inhibitors to dissect cell survival dependencies and define improved strategies for cancer therapy

Selective inhibition of BCL-XL synergizes with docetaxel to inhibit the growth of solid tumors but does not inhibit granulopoiesis. A more refined antitumor strategy The BCL-2 family is a group of related proteins that regulate apoptosis in a variety of ways. The success of anticancer treatments often hinges on the ability to induce cancer cell death by apoptosis. As a result, there has been a great deal of interest in developing drugs that can inhibit the antiapoptotic members of the BCL-2 pathway. Unfortunately, some of these drugs are also associated with dose-limiting hematologic toxicities, such as neutropenia. Now, Leverson et al. have used a toolkit of BCL-2 family inhibitors with different specificities to show that specifically inhibiting BCL-XL (one member of this protein family) is effective for killing tumors, but without the common side effects seen with less selective drugs. The BCL-2/BCL-XL/BCL-W inhibitor ABT-263 (navitoclax) has shown promising clinical activity in lymphoid malignancies such as chronic lymphocytic leukemia. However, its efficacy in these settings is limited by thrombocytopenia caused by BCL-XL inhibition. This prompted the generation of the BCL-2–selective inhibitor venetoclax (ABT-199/GDC-0199), which demonstrates robust activity in these cancers but spares platelets. Navitoclax has also been shown to enhance the efficacy of docetaxel in preclinical models of solid tumors, but clinical use of this combination has been limited by neutropenia. We used venetoclax and the BCL-XL–selective inhibitors A-1155463 and A-1331852 to assess the relative contributions of inhibiting BCL-2 or BCL-XL to the efficacy and toxicity of the navitoclax-docetaxel combination. Selective BCL-2 inhibition suppressed granulopoiesis in vitro and in vivo, potentially accounting for the exacerbated neutropenia observed when navitoclax was combined with docetaxel clinically. By contrast, selectively inhibiting BCL-XL did not suppress granulopoiesis but was highly efficacious in combination with docetaxel when tested against a range of solid tumors. Therefore, BCL-XL–selective inhibitors have the potential to enhance the efficacy of docetaxel in solid tumors and avoid the exacerbation of neutropenia observed with navitoclax. These studies demonstrate the translational utility of this toolkit of selective BCL-2 family inhibitors and highlight their potential as improved cancer therapeutics.