Metronomic therapy prevents emergence of drug resistance by maintaining the dynamic of intratumor heterogeneity.

Despite recent advances in deciphering cancer drug resistance mechanisms, relapse is a widely observed phenomenon in advanced cancers, mainly due to intratumor clonal heterogeneity. How tumor clones progress and impact each other remains elusive. By better understanding clone dynamics, we could reveal valuable biological insights and unveil vulnerabilities that could be therapeutically exploited. In this study, we developed 2D and 3D non-small cell lung cancer co-culture systems and defined a phenomenological mathematical model. Our results demonstrated a dominant role of the drug-sensitive clones over the drug-resistant ones under untreated conditions. Model predictions and their experimental in vitro and in vivo validations indicated that metronomic schedule leads to a better regulation of tumor cell heterogeneity over time than maximum-tolerated dose schedule, while achieving control of global tumor progression. We finally showed that drug-sensitive clones exert a suppressive effect on the proliferation of the drug-resistant ones through a paracrine mechanism way, which is linked to metabolic cell clone activity. Altogether, these computational and experimental approaches allow assessment of drug schedules controlling drug-sensitive and -resistant clone balance and highlight the potential of targeting cell metabolism to manage intratumor heterogeneity. SignificanceCombined computational and experimental models reveal how drug-sensitive tumor cells exert their dominance over drug-resistant cells and how it impacts optimal chemotherapy scheduling.