Drug-induced resistance evolution necessitates less aggressive treatment

Increasing body of experimental evidence suggests that anticancer and antimicrobial therapies may themselves promote the acquisition of drug resistance by increasing mutability. The successful control of evolving populations requires that such biological costs of control are identified, quantified and included to the evolutionarily informed treatment protocol. Here we identify, characterise and exploit a trade-off between decreasing the target population size and generating a surplus of treatment-induced rescue mutations. We show that the probability of cure is maximized at an intermediate dosage, below the drug concentration yielding maximal population decay, suggesting that treatment outcomes may in some cases be substantially improved by less aggressive treatment strategies. We also provide a general analytical relationship that implicitly links growth rate, pharmacodynamics and dose-dependent mutation rate to an optimal control law. Our results highlight the important, but often neglected, role of fundamental eco-evolutionary costs of control. These costs can often lead to situations, where decreasing the cumulative drug dosage may be preferable even when the objective of the treatment is elimination, and not containment. Taken together, our results thus add to the ongoing criticism of the standard practice of administering aggressive, high-dose therapies and motivate further experimental and clinical investigation of the mutagenicity and other hidden collateral costs of therapies.Author summary: Evolution of drug resistance to anticancer and antimicrobial therapies is widespread among cancer and pathogen cell populations. Classical theory posits strictly that genetic and phenotypic variation is generated in evolving populations independently of the selection pressure. However, recent experimental findings among antimicrobial agents, traditional cytotoxic chemotherapies and targeted cancer therapies suggest that treatment not only imposes selection but can also affect the rate of adaptation by increasing mutability. Here we analyse a model with drug-induced increase in mutation rate and explore its consequences for treatment optimisation. We argue that the true biological cost of treatment is not limited to the harmful side-effects, but instead realises even more profoundly by fundamentally changing the underlying eco-evolutionary dynamics within the microenvironment. Using the concept of evolutionary rescue, we formulate the treatment as an optimal control problem and solve the optimal elimination strategy, which minimises the probability of evolutionary rescue. We show that aggressive elimination strategies, which aim at eradication as fast as possible and which represent the current standard of care, can be detrimental even with modest drug-induced increases (fold change ≤10) to the baseline mutation rate.