Interconnected axes of phenotypic plasticity drive coordinated cellular behaviour and worse clinical outcomes in breast cancer

Phenotypic plasticity plays a key role in cancer progression and metastasis, enabling cancer cells to adapt and evolve, but precisely how distinct axes governing phenotypic plasticity interact to shape tumour progression and patient outcomes remains unclear. We investigated five major interconnected axes of plasticity in ER-positive (ER+) breast cancer: Metabolic Reprogramming, Epithelial-to-Mesenchymal Plasticity (EMP), Luminal-Basal (Lineage) Switching, Stemness, and Drug-resistance using network dynamics simulations, integrative bulk and single-cell transcriptomic analyses and patient survival analyses. We show that these axes are not independent but drive one another, forming two mutually inhibiting teams of nodes enabling specified cellular behaviour. One team (favouring high glycolysis, stem-like, basal-like, mesenchymal/hybrid and tamoxifen-resistant phenotype) was found to be associated with aggressive progression and worse survival. On the other hand, the opposing team (favouring high oxidative phosphorylation, non-stem-like, luminal-like, epithelial and tamoxifen-sensitive phenotype) correlated with better outcomes. Importantly, altering one axis of plasticity often drove coordinated responses along other axes and vice versa. Our findings establish phenotypic plasticity in cancer as a coordinated, multi-axis dynamical process, thus suggesting novel strategies to disrupt systems-level reprogramming enabling metastasis and therapeutic resistance.