The role of memory in non-genetic inheritance and its impact on cancer treatment resistance

Intra-tumour heterogeneity is a leading cause of treatment failure and disease progression in cancer. While genetic mutations have long been accepted as a primary mechanism of generating this heterogeneity, the role of phenotypic plasticity is becoming increasingly apparent as a driver of intra-tumour heterogeneity. Consequently, understanding the role of this plasticity in treatment resistance and failure is a key component of improving cancer therapy. We develop a mathematical model of stochastic phenotype switching that tracks the evolution of drug-sensitive and drug-tolerant subpopulations to clarify the role of phenotype switching on population growth rates and tumour persistence. By including cytotoxic therapy in the model, we show that, depending on the strategy of the drug-tolerant subpopulation, stochastic phenotype switching can lead to either transient or permanent drug resistance. We study the role of phenotypic heterogeneity in a drug-resistant, genetically homogeneous population of non-small cell lung cancer cells to derive a rational treatment schedule that drives population extinction and avoids competitive release of the drug-tolerant sub-population. This model-informed therapeutic schedule results in increased treatment efficacy when compared against periodic therapy, and, most importantly, sustained tumour decay without the development of resistance.Author summary: We propose a simple mathematical model to understand the role of phenotypic plasticity and non-genetic inheritance in driving therapy resistance in cancer. We identify the role of non-genetic inheritance on treatment resistance and use a variety of analytical and numerical techniques to understand the impact of phenotypic plasticity on population fitness and dynamics. We further use our model to study the role of phenotypic heterogeneity in therapeutic resistance in a genetically identical non-small cell lung cancer population. Finally, we combine analytical perspectives and techniques from the theory of structured populations, renewal equations, and infinite dimensional dynamical systems to derive a model-informed therapeutic strategy that both drives tumour eradication and avoids competitive release of a drug-tolerant subpopulation. These results exemplify the potential of using mathematical techniques to identify therapeutic strategies to guide the evolution of a heterogeneous tumour.