A longitudinal analysis of radiosensitizer development in cancer therapy

It has been 75 years since the concept of a radiosensitizer was introduced as an adjuvant drug intended to enhance radiotherapy. Starting shortly after this time, we provide a brief history of how oxygen availability and hypoxia in solid tumors came to dominate the definition of a radiosensitizer and the clinical effort to deliver oxygen to patients to sensitize their tumors to radiation. Next, we review the clinical use of three classes of drugs developed based on oxygen/hypoxia criteria for radiosensitizers, as well as a fourth class that meets the original definition of a radiosensitizer as an enhancer of ionizing radiation therapy. We also present recent preclinical evaluations of potential future radiosensitizers, including our work on RK-33, a non-toxic small-molecule inhibitor of the RNA helicase DDX3. A brief presentation of advances in monitoring hypoxia and tumor blood flow is presented. Additionally, we discuss the dynamic heterogeneity of solid tumors, which has significantly contributed to many shortcomings reported in clinical trials using hypoxia-targeting radiosensitizers. From this perspective, identifying radiosensitizers targeting multifunctional regulators, such as DDX3, may help overcome tumor heterogeneity and lead to safe, effective, and enhanced radiotherapy.