While the frequency of alterations of the RB gene is substantial for many human cancer types including as lung, esophageal, and liver, alterations in up-steam regulatory components of pRb such as CDK4 and CDK6 have been the main targets for potential therapeutics to treat cancers with dysregulation in the RB pathway. This focus has resulted in the recent development and FDA clinical approval of three small molecule CDK4/6 inhibitors (Palbociclib (IBRANCE, Pfizer Inc. 2015), Ribociclib (KISQUALI, Novartis. 2017), & Abemaciclib (VERZENIO, Eli Lilly. 2017)) for the treatment of specific breast cancer subtypes. However, recent clinical studies finding limited efficacy, high toxicity, and acquired resistance of these inhibitors suggests the need to further elucidate mechanisms that influence CDK4/6 activity as well as explore other potential targets downstream in the pRb pathway to reactivate pRb's tumor suppressive functions. Treatment of cancers by CDK4/6 inhibitors depends on the presence of pRb within the cell for therapeutic effect, limiting their usage only to cancers where RB is not mutated and pRb protein levels are not significantly depleted.
Direct pRb reactivation in humans has not been achieved. However, in murine models, novel genetic methods have allowed for in vivo pRb reactivation experiments. pRb loss induced in mice with oncogenic KRAS-driven tumors of lung adenocarcinoma negates the requirement of MAPK signal amplification for progression to carcinoma and promotes loss of lineage commitment as well as accelerate the acquisition of metastatic competency. Reactivation of pRb in these mice rescues the tumors towards a less metastatic state, but does not completely stop tumor growth due to a proposed rewiring of MAPK pathway signaling, which suppresses pRb through a CDK-dependent mechanism.