Despite aggressive treatment for localized cancer, prostate cancer (PC) remains a leading cause of cancer-related death for American men due to a subset of patients progressing to lethal and incurable metastatic castrate-resistant prostate cancer (CRPC). Organ-confined PC is treated by surgery or radiation with or without androgen deprivation therapy (ADT), while options for locally advanced and disseminated PC include radiation combined with ADT, or systemic treatments including chemotherapy. Progression to CRPC results from failure of ADT, which targets the androgen receptor (AR) signaling axis and inhibits AR-driven proliferation and survival pathways. The exact mechanisms underlying the transition from androgen-dependent PC to CRPC remain incompletely understood. Reactivation of AR has been shown to occur in CRPC despite depletion of circulating androgens by ADT. At the same time, the presence of AR-negative cell populations in CRPC has also been identified. While AR signaling has been proposed as the primary driver of CRPC, AR-independent signaling pathways may represent additional mechanisms underlying CRPC progression. Identification of new therapeutic strategies to target both AR-positive and AR-negative PC cell populations and, thereby, AR-driven as well as non-AR-driven PC cell growth and survival mechanisms would provide a two-pronged approach to eliminate CRPC cells with potential for synthetic lethality. In this review, we provide an overview of AR-dependent and AR-independent molecular mechanisms which drive CRPC, with special emphasis on the role of the Jak2-Stat5a/b signaling pathway in promoting castrate-resistant growth of PC through both AR-dependent and AR-independent mechanisms.

5051 Background: The FOLH1 gene encodes prostate-specific membrane antigen (PSMA), a transmembrane glycoprotein that is expressed in PC cells. PSMA is a target for diagnostic imaging and treatment in PC. We utilized a database of molecularly profiled PC tumors to evaluate correlates of high FOLH1 mRNA expression. Methods: NextGen sequencing of DNA (592-gene/whole exome) and RNA (whole transcriptome) was performed on PC specimens (n=7,558) through Caris Life Sciences. FOLH1-High/Low expression was defined as above/below median RNA transcripts per million (TPM). Androgen receptor (AR), neuroendocrine (NEPC), MAPK, and T-cell inflamed RNA signature scores were calculated. Tumor cell PD-L1+ expression (≥2+, ≥5%; SP142) was assessed by IHC. Overall survival (OS) and time on treatment (TOT) were calculated from time of diagnosis or therapy start. Results: Specimens were derived from the prostate gland (n=4495, 59.5%), lymph nodes (n=858, 11.4%), bone (n=568, 7.5%), liver (n=359, 4.7%), urinary tract (n=340, 4.5%), lung (n=116, 1.5%), and other metastatic sites (n=822, 10.9%). Relative to the prostate (390.9 TPM), FOLH1 mRNA expression varied by metastatic site, with highest expression in lymph nodes (518.2 TPM, p<0.001) and lowest expression in lung (209.7 TPM, p<0.001) and liver metastases (143.1 TPM, p<0.001). Higher FOLH1 expression significantly correlated with presence of AR-V7 variants (18% vs 15%) and ASXL1 (6% vs 3.9%) alterations, and fewer alterations in FOX1A (7.9% vs 10.6%), APC (4% vs 10.3%), PIK3CA(3.1% vs 6.4%), CTNNB1 (3.1% vs 4.8%), and PIK3R1 (0.7% vs 2%). High FOLH1 expression positively associated with AR signaling score, MAPK activation, and T-cell inflammation, and negatively correlated with NEPC signaling (all p<0.001). Tumors with high FOLH1 expression were more frequently PD-L1+ (3.9% vs 2.2%, p<0.01). Among primary tumors, OS was similar between FOLH1 high and low groups; however, among metastatic tumors, OS was improved in patients (pts) with high FOLH1 expression compared to low expression (96.3 vs 87.9 months, HR 0.82 95% CI 0.73-0.92). There was no difference in TOT among pts receiving ARSIs, taxanes, or PARPi. Among 149 pts that received 177Lu-PSMA-617, there was a trend towards improved TOT in FOLH1-high (n=78) versus -low (n=71) tumors (HR 0.76, 95%CI 0.55-1.05). Conclusions: This is the largest combined genomic, transcriptomic and survival outcomes analysis of PSMA ( FOLH1) expression in PC. In PC, greater FOLH1 mRNA expression was associated with higher AR signaling scores and AR-V7 expression, and fewer mutations in the Wnt and PI3K pathways. FOLH1-high pts showed greater T cell inflammation and PD-L1 expression, and lower NEPC signaling. High FOLH1 expression was associated with greater OS among patients with metastatic tumors, with a trend towards improved outcomes to 177Lu-PSMA-617. Such pts may benefit from distinct therapeutic strategies.

The second-generation antiandrogen, enzalutamide, is approved for castrate-resistant prostate cancer (CRPC) and targets androgen receptor (AR) activity in CRPC. Despite initial clinical activity, acquired resistance to enzalutamide arises rapidly and most patients develop terminal disease. Previous work has established Stat5 as a potent inducer of prostate cancer growth. Here, we investigated the significance of Jak2-Stat5 signaling in resistance of prostate cancer to enzalutamide. The levels of Jak2 and Stat5 mRNA, proteins and activation were evaluated in prostate cancer cells, xenograft tumors, and clinical prostate cancers before and after enzalutamide therapy. Jak2 and Stat5 were suppressed by genetic knockdown using lentiviral shRNA or pharmacologic inhibitors. Responsiveness of primary and enzalutamide-resistant prostate cancer to pharmacologic inhibitors of Jak2-Stat5 signaling was assessed in vivo in mice bearing prostate cancer xenograft tumors. Patient-derived prostate cancers were tested for responsiveness to Stat5 blockade as second-line treatment after enzalutamide ex vivo in tumor explant cultures. Enzalutamide-liganded AR induces sustained Jak2-Stat5 phosphorylation in prostate cancer leading to the formation of a positive feed-forward loop, where activated Stat5, in turn, induces Jak2 mRNA and protein levels contributing to further Jak2 activation. Mechanistically, enzalutamide-liganded AR induced Jak2 phosphorylation through a process involving Jak2-specific phosphatases. Stat5 promoted prostate cancer growth during enzalutamide treatment. Jak2-Stat5 inhibition induced death of prostate cancer cells and patient-derived prostate cancers surviving enzalutamide treatment and blocked enzalutamide-resistant tumor growth in mice. This work introduces a novel concept of a pivotal role of hyperactivated Jak2-Stat5 signaling in enzalutamide-resistant prostate cancer, which is readily targetable by Jak2 inhibitors in clinical development.

Androgen deprivation therapy (ADT) for metastatic and high-risk prostate cancer (PC) inhibits growth pathways driven by the androgen receptor (AR). Over time, ADT leads to the emergence of lethal castrate-resistant PC (CRPC), which is consistently caused by an acquired ability of tumors to re-activate AR. This has led to the development of second-generation anti-androgens that more effectively antagonize AR, such as enzalutamide (ENZ). However, the resistance of CRPC to ENZ develops rapidly. Studies utilizing preclinical models of PC have established that inhibition of the Jak2-Stat5 signaling leads to extensive PC cell apoptosis and decreased tumor growth. In large clinical cohorts, Jak2-Stat5 activity predicts PC progression and recurrence. Recently, Jak2-Stat5 signaling was demonstrated to induce ENZ-resistant PC growth in preclinical PC models, further emphasizing the importance of Jak2-Stat5 for therapeutic targeting for advanced PC. The discovery of the Jak2V617F somatic mutation in myeloproliferative disorders triggered the rapid development of Jak1/2-specific inhibitors for a variety of myeloproliferative and auto-immune disorders as well as hematological malignancies. Here, we review Jak2 inhibitors targeting the mutated Jak2V617F vs. wild type (WT)-Jak2 that are currently in the development pipeline. Among these 35 compounds with documented Jak2 inhibitory activity, those with potency against WT-Jak2 hold strong potential for advanced PC therapy.