Every which way? On predicting tumor evolution using cancer progression models

Successful prediction of the likely paths of tumor progression is valuable for diagnostic, prognostic, and treatment purposes. Cancer progression models (CPMs) use cross-sectional samples to identify restrictions in the order of accumulation of driver mutations and thus CPMs encode the paths of tumor progression. Here we analyze the performance of four CPMs to examine whether they can be used to predict the true distribution of paths of tumor progression and to estimate evolutionary unpredictability. Employing simulations we show that if fitness landscapes are single peaked (have a single fitness maximum) there is good agreement between true and predicted distributions of paths of tumor progression when sample sizes are large, but performance is poor with the currently common much smaller sample sizes. Under multi-peaked fitness landscapes (i.e., those with multiple fitness maxima), performance is poor and improves only slightly with sample size. In all cases, detection regime (when tumors are sampled) is a key determinant of performance. Estimates of evolutionary unpredictability from the best performing CPM, among the four examined, tend to overestimate the true unpredictability and the bias is affected by detection regime; CPMs could be useful for estimating upper bounds to the true evolutionary unpredictability. Analysis of twenty-two cancer data sets shows low evolutionary unpredictability for several of the data sets. But most of the predictions of paths of tumor progression are very unreliable, and unreliability increases with the number of features analyzed. Our results indicate that CPMs could be valuable tools for predicting cancer progression but that, currently, obtaining useful predictions of paths of tumor progression from CPMs is dubious, and emphasize the need for methodological work that can account for the probably multi-peaked fitness landscapes in cancer.Author summary: Knowing the likely paths of tumor progression is instrumental for cancer precision medicine as it would allow us to identify genetic targets that block disease progression and to improve therapeutic decisions. Direct information about paths of tumor progression is scarce, but cancer progression models (CPMs), which use as input cross-sectional data on genetic alterations, can be used to predict these paths. CPMs, however, make assumptions about fitness landscapes (genotype-fitness maps) that might not be met in cancer. We examine if four CPMs can be used to predict successfully the distribution of tumor progression paths; we find that some CPMs work well when sample sizes are large and fitness landscapes have a single fitness maximum, but in fitness landscapes with multiple fitness maxima prediction is poor. However, the best performing CPM in our study could be used to estimate evolutionary unpredictability. When we apply the best performing CPM in our study to twenty-two cancer data sets we find that predictions are generally unreliable but that some cancer data sets show low unpredictability. Our results highlight that CPMs could be valuable tools for predicting disease progression, but emphasize the need for methodological work to account for multi-peaked fitness landscapes.