CCR 20th Anniversary Commentary

20th Anniversary Commentary

CCR 20th Anniversary Commentary: RAS as a

Biomarker for EGFR-Targeted Therapy for
Colorectal Cancer—From Concept to Practice
E. Ramsay Camp1,2,3 and Lee M. Ellis4,5

Clinical data support the use of EGFR mAbs in patients with
metastatic colorectal cancer (mCRC) with wild-type RAS status.
This notion, hypothesized in the review article by Camp, Ellis, and
colleagues in the January 1, 2005, issue of Clinical Cancer Research,
serves as an example of the successful application of basic science
principles to clinical practice. The exclusion of patients with
mCRC with Ras-mutated tumors from therapy with EGFR mAbs
has led to improved outcomes while sparing patients unnecessary
and potentially harmful therapy. Clin Cancer Res; 21(16); 3578–80.

2015 AACR.
See related article by Camp et al., Clin Cancer Res 2005;11(1):
January 1, 2005;397–405

Introduction therapies. At this time, EGFR mutations in lung cancer were being
identified as markers of sensitivity to EGFR tyrosine kinase recep-
The therapeutic potential of mAbs targeting the EGFR was
tor inhibitors (2). Our laboratory had been interested in growth
established by promising preclinical studies and subsequent
factor receptors and downstream intracellular signaling, with a
early-phase clinical trials in patients with metastatic colorectal
focus on Src in collaboration with G. Gallick at The University of
cancer (mCRC; ref. 1). Ultimately, in 2004, the FDA approved the
Texas MD Anderson Cancer Center (Houston, TX). In reviewing
human–mouse chimeric EGFR mAb, cetuximab, for use in che-
the literature and applying our own knowledge of cell signaling,
motherapy-refractory patients with mCRC. Similarly, panitumu-
the general topics of this review in Clinical Cancer Research (CCR)
mab, a fully human EGFR mAb, was FDA approved for similar
focused on the following as resistance factors to EGFR-targeted
indications in 2006, and ultimately both drugs were subsequently
therapies: (i) the presence of redundant tyrosine kinase receptors;
approved in the first-line setting in combination with chemother-
(ii) increased angiogenic signaling; (iii) existence of specific EGFR
apy. However, the earliest clinical trials investigating EGFR mAbs
mutations; and (iv) constitutive activation of downstream med-
in mCRC demonstrated that these agents only provided modest
iators (3). This last proposed mechanism of resistance was not
benefit when used in combination with chemotherapy. Around
based on actual data, but a simple hypothesis: If an important
this time, a concerted effort to identify predictive markers
intracellular pathway is constitutively activated by a mutation,
for EGFR-targeted therapies was undertaken simultaneous to
then blocking signaling at the cell surface would be ineffective.
advances in genomic sequencing.
In our original schematic drawing describing this hypothesis,
As principal investigator of a laboratory, the senior author
we listed several activated downstream intermediates as potential
of this article (L.M. Ellis) learned early on in his career that the
resistance pathways. One, in particular, has demonstrated clinical
best way to educate a trainee on a topic was to have this individual
utility in selecting patients with mCRC for EGFR mAb therapy.
write a review article. This strategy exposes trainees to the entire
The therapeutic relevance of downstream RAS mutations on EGFR
field of the topic of interest, requiring a critical evaluation of the
mAb efficacy in patients with mCRC highlights the importance of
literature, and identifying knowledge gaps. In 2004, the first
understanding the molecular basis of malignant disease to
author of this article (E.R. Camp) entered the laboratory and was
improve personalized medicine. We recognize that this concept
given the task of writing a review on resistance to EGFR-targeted
is the basis of many preclinical and clinical studies, but at the time
of writing this review, there were no publications that had dis-
1
Department of Surgery, Medical University of South Carolina, Charles- cussed or hypothesized that mutated RAS or other constitutively
ton, South Carolina. 2Hollings Cancer Center, Medical University of activated signaling intermediates could serve as markers of resis-
South Carolina, Charleston, South Carolina. 3Ralph H. Johnson VA tance (or even detriment) in patients with mCRC. However, at
Medical Center, Charleston, South Carolina. 4Department of Surgical
Oncology, The University of Texas MD Anderson Cancer Center, that time, several studies were examining the role of mutated RAS
Houston, Texas. 5Department of Molecular and Cellular Oncology, The as a resistance marker for EGFR tyrosine kinase inhibitors in lung
University of Texas MD Anderson Cancer Center, Houston, Texas. cancer (4, 5); other investigators had hypothesized that RAS could
Corresponding Author: Lee M. Ellis, Department of Surgical Oncology, Unit be a resistance marker for EGFR-targeted therapies, and this work
1484, PO Box 301402, The University of Texas MD Anderson Cancer Center, 1515 occurred simultaneous to, or shortly after, our publication. Soon
Holcombe Boulevard, Houston, TX 77230. Phone: 713-792-6926; Fax: 713-792- after the publication of our review in January 2005, several studies
4689; E-mail: lellis@mdanderson.org
were examining the role of KRAS in EGFR mAb resistance, sug-
doi: 10.1158/1078-0432.CCR-14-2900 gesting that others had this idea and had already begun studies.

2015 American Association for Cancer Research. However, we have not identified any publication prior to ours in

3578 Clin Cancer Res; 21(16) August 15, 2015

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CCR addressing this topic. Of course, since then we have learned
that additional RAS mutations may render patients resistant to
EGFR mAb therapy (6).
Constitutive RAS Pathway Activation and
Its Impact on EGFR mAb Therapy
In 2006, a retrospective study of 30 patients with mCRC treated
with cetuximab (mostly combined with chemotherapy) was the
first clinical study to correlate KRAS mutational status with
resistance to EGFR mAb therapy (7). In this small study, patients
with tumors harboring a KRAS mutation showed a 0% response
rate. Overall survival (OS) in cetuximab-treated patients was
significantly shorter in those with KRAS mutations in comparison
with patients with wild-type (WT) KRAS (6.9 vs. 16.3 months; P ¼
0.016). A subsequent investigation confirmed the clinical signif-
icance of KRAS mutations as predictive markers for cetuximab or
panitumumab therapy for patients with mCRC (8). Furthermore,
this study was the first to demonstrate a causal relationship
between activating KRAS mutation (Gly12Val) and decreased in
vitro response to cetuximab therapy in human colon cancer cell
lines.
A landmark retrospective analysis of a prospective randomized
trial in 392 chemotherapy-refractory patients with mCRC com-
paring cetuximab treatment with best supportive care (BSC)
solidified the significance of KRAS mutational status in clinical
practice (9). OS in patients with WT KRAS tumors was signifi-
cantly longer in those treated with cetuximab than in those who
received BSC (9.5 vs. 4.8 months; P < 0.001). In contrast, patients
with mutated KRAS tumors experienced an equivalent OS
between cetuximab therapy and BSC. A larger concern was that
results from the randomized phase II OPUS trial comparing first-
line FOLFOX4 with or without cetuximab in patients with mCRC
suggested that the addition of an EGFR mAb might actually have a
detrimental effect on outcomes in mCRC patients with mutated
KRAS tumors (10) and other studies have confirmed these find-
ings (6). These initial translational investigations laid the foun-
dation for personalized molecular medicine in mCRC by dem-
onstrating the predictive capability of KRAS mutational status for
improving patient selection and outcomes for EGFR mAb therapy.
In response to the growing evidence supporting the predictive
implications of KRAS status for EGFR mAb therapy, the FDA
restricted the use of cetuximab and panitumumab to patients with
WT KRAS mCRC in 2009.
The Clinical Implication of Expanded RAS
Status on Cetuximab Therapy
The initial studies investigating the role of KRAS mutation
status on the efficacy of cetuximab in patients with mCRC focused
on the most prevalent KRAS mutations involving codons 12 and
13 in exon 2, which are present in approximately 40% of patients
with mCRC. Even though multiple studies confirmed that exon 2
mutated KRAS rendered patients with mCRC resistant to EGFR
mAb therapy, EGFR mAbs were found to be effective in some, but
not all, patients with KRAS WT tumors; this suggested that
alternative molecular abnormalities might be influencing thera-
peutic response. Extending this line of investigation further, an
expanded or "all-RAS" mutation analysis including all KRAS and
NRAS mutations has been proposed for identifying patients with
mCRC who would benefit from EGFR mAb therapy. The first
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RAS as a Biomarker for EGFR-Targeted Therapy
study to identify the negative predictive value of driver mutations,
including NRAS, reported on a large retrospective cohort of
chemotherapy-refractory patients with mCRC who were subse-
quently treated with irinotecan plus cetuximab (11). In this study,
assessment of data from patients with tumors harboring driver
mutations beyond KRAS identified even more patients unlikely to
respond to EGFR mAbs, thus improving response rates in those
patients with tumors without these mutations. Subsequently, a
retrospective analysis of 1,060 patient tumor samples from the
randomized PRIME trial in patients with mCRC treated with first-
line FOLFOX4 with or without panitumumab highlighted the
significance of an expanded RAS assessment to predict response
for EGFR mAb-containing regimens (6). In this trial, 52% of the
analyzed tumors were identified as RAS mutated, including any
KRAS or NRAS mutations in exon 2, 3, or 4. Of the original 641
patients categorized as having exon 2 WT KRAS tumors, an
additional 108 (17%) had an alternative RAS mutation. Patients
with tumors expressing any RAS mutation who received panitu-
mumab with FOLFOX4 experienced a significantly decreased
progression-free survival (PFS) as well as OS compared with
patients with WT RAS tumors. The survival outcomes were similar
between exon 2 KRAS mutations and tumors with alternative RAS
mutations, suggesting that any RAS mutation equally negates the
therapeutic benefit achieved with EGFR mAbs. However, the
numbers of patients with these less frequent RAS mutations limit
the ability to firmly state that they are indeed markers of resistance.
Similar to the findings from the OPUS trial, patients with any RAS
mutation actually experienced a significantly decreased PFS and
OS with the addition of panitumumab to FOLFOX4, reinforcing
the concern that EGFR mAbs may actually be detrimental in this
setting. Similarly, a recent meta-analysis of nine randomized,
controlled trials with EGFR mAbs for mCRC patients evaluating
RAS mutational status further solidified the predictive impact of
an expanded RAS mutational profile on PFS as well as OS (12). In
general, expanded RAS analysis may increase the percentage of
patients ineligible for EGFR mAb therapy by approximately 15%
compared with KRAS exon 2 mutations alone. Based on the
potential detrimental impact of any RAS mutation in patients
receiving EGFR mAb therapy, the FDA endorsed an extended RAS
assessment for EGFR mAb therapy in 2013 and, subsequently, the
National Comprehensive Cancer Network (NCCN) published
clinical guidelines recommending prospective expanded RAS
mutational assessment for all mCRC patients considered candi-
dates for EGFR mAb therapy.
The failure of efficacy with EGFR mAbs in a statistically signi-
ficant number of patients with WT KRAS tumors fueled further
investigations evaluating alternative downstream mediators of
EGFR. The first report to extend the molecular analysis beyond
RAS in patients with mCRC investigated the role of mutated
BRAFv600e as a marker of cetuximab resistance in WT KRAS tumors
(13). BRAF is a downstream mediator in the RAS pathway, but, of
course, can be constitutively activated as it is mutated in approx-
imately 5% to 10% of colorectal cancers. In this study, patients
with tumors expressing the BRAFv600e mutation experienced a
shorter PFS and OS in response to cetuximab compared with WT
BRAF tumors. Although initial reports suggested that BRAF might
be a predictive marker for EGFR mAbs, subsequent studies have
not uniformly confirmed this association. For example, in the
retrospective analysis of the PRIME trial, patients with tumors
expressing the BRAFv600e mutation showed an equally poor PFS
and OS in response to FOLFOX4 alone compared with the
Clin Cancer Res; 21(16) August 15, 2015 3579
 CCR 20th Anniversary Commentary
addition of panitumumab (6). In contrast, the randomized PIC-
COLO trial investigating the role of irinotecan plus panitumumab
in fluorouracil-refractory patients with mCRC demonstrated a
significantly worse OS if patients' tumors harbored a BRAF muta-
tion. Despite the inconsistent results regarding BRAF as an EGFR
mAb predictive marker, BRAF mutational status appears to have
strong negative prognostic significance, as highlighted by results
from several trials. Compared with patients with WT RAS/BRAF
tumors, BRAFv600e mutations conferred an approximately 50%
reduced PFS and OS in both arms of the trial. Given the aggressive
biology associated with BRAFv600e mutation, the actual impact on
the therapeutic efficacy of EGFR mAbs may be difficult to deter-
mine. Similar to BRAF, PIK3CA mutations and loss of PTEN have
shown an inconsistent impact on the therapeutic efficacy of EGFR
mAbs. Currently, testing for BRAF and PIK3CA/PTEN is not
recommended for EGFR mAb mCRC patient selection, although
these mutations/alterations may be beneficial in determining
prognosis and eligibility for clinical trials.
The improved objective response with the addition of EGFR
mAbs observed in "all-RAS" WT tumors highlights the potential of
molecularly driven personalized cancer therapy. The role for
prospective RAS mutational analysis for cetuximab selection has
been explored in recent cooperative group clinical trials that
analyzed a comprehensive ("all-RAS") molecular profile to assess
the benefit of using cetuximab in combination with FOLFIRI or
mFOLFOX6 (14). The CALGB/SWOG 80405 trial evaluated
response to cetuximab-containing regimens in 526 "all-RAS" WT
colorectal cancer patients. In the "all-RAS" WT cohort, patients
receiving cetuximab plus chemotherapy achieved an improved
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median PFS and OS of 11.4 and 32 months, respectively, com-
pared with historical controls.
Taken together, the evidence is growing that mutations in RAS
can predict for resistance to EGFR mAbs in patients with mCRC.
NCCN clinical guidelines, the FDA, and the European Medicines
Agency mandate restricted use of EGFR mAbs for patients with
RAS WT mCRC. The foundation of this clinical practice change can
be traced back to the fundamentals learned from preclinical
studies of signaling pathways. This dramatic change in clinical
practice highlights the continued need for adequate funding for
translational research to improve oncologic outcomes for our
patients.
Disclosure of Potential Conflicts of Interest
L.M. Ellis is a consultant/advisory board member for Celgene, Eli Lilly, and
Genentech/Roche. No potential conflicts of interest were disclosed by the other
author.
Authors' Contributions
Conception and design: E.R. Camp, L.M. Ellis
Writing, review, and/or revision of the manuscript: E.R. Camp, L.M. Ellis
Grant Support
E.R. Camp was supported by NIH grant K08CA142904. L.M. Ellis was
supported by NIH grant R01CA157880, Department of Defense grant
CA100879, and the William C. Liedtke Jr Chair in Cancer Research.
Received February 6, 2015; revised February 27, 2015; accepted February 28,
2015; published online August 14, 2015.
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Clinical Cancer Research
CCR 20th Anniversary Commentary: RAS as a Biomarker for
EGFR-Targeted Therapy for Colorectal Cancer−−From Concept to
Practice
E. Ramsay Camp and Lee M. Ellis

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