TREATMENT REGIMEN FOR CANCERS THAT ARE INSENSITIVE TO BCL-2 INHIBITORS USING THE MCL-1 INHIBITOR ALVOCIDIB

STATEMENT REGARDING SEQUENCE LISTING

The Sequence Listing associated with this application is provided in text format in lieu of a paper copy, and is hereby incorporated by reference into the specification. The name of the text file containing the Sequence Listing is 910208_431WO_SEQUENCE_LISTING.txt. The text file is 1.24KB, was created on September 1 1, 2018, and is being submitted electronically via EFS-Web.

BACKGROUND

Technical Field

The present invention relates, in general, to methods for treating BCL-2 inhibitor insensitive subjects using MCL-1 inhibitors and compositions related thereto.

Description of the Related Art

The B-cell lymphoma 2 (BCL-2) inhibitor Venetoclax (ABT-199, Venclexta) was approved by the FDA in 2016 for the treatment of chronic lymphocytic leukemia (CLL) for patients with chromosome 17p deletion and at least one prior treatment. Venetoclax functions by disrupting the interaction between the pro-survival BCL-2 protein and anti-survival, pro- apoptotic proteins such as BCL-2 interacting mediator of cell death (BIM) and BCL-2 associated death promoter (BAD). Venetoclax has demonstrated a high overall response rate in Phase I and Phase II clinical trials as a monotherapy in CLL (70-79%; Zhu, H., Almasan, A. Drug Des Devel Ther 2017, 11, 685-94).

Despite the success of Venetoclax in CLL, approximately 20-30% of patients show no response, a low number of patients demonstrate complete remission (8-20%), and nearly 50% of patients show disease progression after 18 months (Huber, H., et al. Oncotargets and Therapy, 2017, 10, 645-56).

Additional pro-survival proteins B-cell lymphoma-extra-large (BCL-xL) and myeloid cell leukemia 1 (MCL-1) also inhibit cell death by suppressing BFM and BAD, and represent possible resistance mechanisms to Venetoclax (Choudhary, G.S. et al. Cell Death and Disease Jan 2015, 6 (1), el 593 and Oppermann, S. et al., Blood 2016 128 (7) 934-47). The first generation BCL-2 inhibitor, navitoclax (ABT-263), that inhibits BCL-2 and BCL-xL, was toxic due to thrombocytopenia and demonstrated a key role of BCL-xL in platelet survival along with other reports (Zhang, H. et al. Cell Death and Differentiation, 2007 14, 943-51; Debrincat, M.A. et al., Cell Death & Disease 2015, 6, 1721).

Accordingly, a current therapeutic need exists to provide treatment for patients resistant to treatment using BCL-2 inhibitors and those who do not show a complete response and/or disease progression after treatment. The present invention fulfills these needs and offers other related advantages.

BRIEF SUMMARY

Embodiments of the present invention are generally directed to methods for treating cancer, for example, a BCL-2 inhibitor-resistant cancer. Some embodiments provide a method for treating a cancer in a subject in need thereof, the method comprising administering an effective amount of a treatment regimen comprising alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, the cancer being BCL-2 inhibitor resistant, the subject being non-responsive or resistant to a prior treatment with a BCL-2 inhibitor, thereby treating the cancer in the subject.

One embodiment provides a method for treating a cancer in a subject in need thereof, the method comprising, determining that the cancer is BCL-2 inhibitor resistant and administering an effective amount of a treatment regimen comprising alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, to the subject, thereby treating the cancer.

One other embodiment provides a method for treating a cancer in a subject in need thereof, the method comprising identifying the subject as likely to respond to treatment with alvocidib or a prodrug thereof, if the cancer is BCL-2 inhibitor resistant and the subject is non-responsive or resistant to a prior treatment with a BCL-2 inhibitor and administering a treatment regimen comprising an effective amount of alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, to the subject.

Still another embodiment affords a method for treating a cancer in a subject in need thereof, the method comprising:

administering a treatment regimen comprising alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, to the subject, the cancer being BCL-2 inhibitor resistant as determined by an in vitro method comprising:

obtaining a cancer cell from the subject; and

i) quantifying expression of BCL-2 and MCL-1 in the cancer cell, wherein an increase in MCL-1 expression relative to BCL-2 expression indicates the subject has a BCL-2 inhibitor resistant cancer;

ii) determining dependency on BCL-2 in the cancer cell, wherein a low BCL-2 dependency indicates the subject has a BCL-2 inhibitor resistant cancer; or

iii) determining dependency on MCL-1 in the cancer cell, wherein a high MCL-1 dependency indicates the subject has a BCL-2 inhibitor resistant cancer.

Accordingly, these and other embodiments provide utility for treating cancer (e.g., leukemia) patients resistant and/or non-responsive to BCL-2 inhibitors. These and other aspects will be apparent upon reference to the following detailed description and attached figures.

BRIEF DESCRIPTION OF THE DRAWINGS

In the figures, identical reference numbers identify similar elements. The sizes and relative positions of elements in the figures are not necessarily drawn to scale and some of these elements are enlarged and positioned to improve figure legibility. Further, the particular shapes of the elements as drawn are not intended to convey any information regarding the actual shape of the particular elements, and have been solely selected for ease of recognition in the figures.

Fig. 1 shows a dose-dependent reduction in MCL-1 protein expression in MV-4-11 cells treated with alvocidib. Fig. 2 illustrates a dose dependent decrease in MCL-1 expression in MV- 4-11 cells treated with alvocidib, palbociclib and dinaciclib.

Fig. 3 illustrates in vivo tumor growth in alvocidib treated OCI-AML3 tumor cells compared to treatment with Venetoclax/ABT-199.

Fig. 4 demonstrates an in vitro decrease in MCL-1 protein expression for OCI-AML3 cells treated with alvocidib.

Fig. 5 shows in vitro inhibition of cell viability in alvocidib treated HEL cells compared to treatment with Venetoclax.

Fig. 6 shows in vitro inhibition of cell viability in alvocidib treated OPM2 cells compared to treatment with Venetoclax.

DETAILED DESCRIPTION

In the following description, certain specific details are set forth in order to provide a thorough understanding of various embodiments of the invention. However, one skilled in the art will understand that the invention may be practiced without these details.

Unless the context requires otherwise, throughout the present specification and claims, the word "comprise" and variations thereof, such as, "comprises" and "comprising" are to be construed in an open, inclusive sense, that is, as "including, but not limited to".

Reference throughout this specification to "one embodiment" or "an embodiment" means that a particular feature, structure or characteristic described in connection with the embodiment is included in at least one embodiment of the present invention. Thus, the appearances of the phrases "in one embodiment" or "in an embodiment" in various places throughout this specification are not necessarily all referring to the same embodiment. Furthermore, the particular features, structures, or characteristics may be combined in any suitable manner in one or more embodiments.

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as is commonly understood by one of skill in the art to which this invention belongs. As used in the specification and claims, the singular form "a", "an" and "the" include plural references unless the context clearly dictates otherwise. Alvocidib (also known as Flavopiridol) refers to a compound having the following structure:

Pharmaceutically acceptable salts of alvocidib are included in within the definition of alvocidib in certain embodiments.

'Prodrug" is meant to indicate a compound that is converted under physiological conditions or by solvolysis to alvocidib. In some aspects, a prodrug is inactive when administered to a subject, but is converted in vivo to alvocidib, for example, by hydrolysis. The prodrug compound often offers advantages of solubility, tissue compatibility or delayed release in a mammalian organism (see, e.g., Bundgard, H., Design of Prodrugs (1985), pp. 7-9, 21-24 (Elsevier, Amsterdam). A discussion of prodrugs is provided in Higuchi, T., et al., "Pro-drugs as Novel Delivery Systems," A.C.S. Symposium Series, Vol. 14, and in Bioreversible Carriers in Drug Design, ed. Edward B. Roche, American Pharmaceutical Association and Pergamon Press, 1987, both of which are incorporated in full by reference herein. Prodrugs of alvocidib are typically prepared by modifying functional groups present in alvocidib in such a way that the modifications are cleaved in vivo to alvocidib. Exemplary prodrugs of alvocidib include compounds wherein a hydroxy group is masked with a functional group such that when the compound is administered to a mammalian subject, the functional group cleaves to form the free hydroxy compound (i.e., alvocidib). Specific examples of prodrugs include phosphate prodrugs of alvocidib as disclosed herein. Pharmaceutically acceptable salts of prodrugs are included within the scope of certain embodiments.

The term "effective amount" or "therapeutically effective amount" refers to that amount of a compound in a composition described herein that is sufficient to effect the intended application including but not limited to disease treatment, as defined below. The therapeutically effective amount may vary depending upon the intended treatment application {in vivo), or the subject and disease condition being treated, e.g., the weight and age of the subject, the severity of the disease condition, the manner of administration and the like, which can readily be determined by one of ordinary skill in the art. The term also applies to a dose that will induce a particular response in target cells, e.g., reduction of platelet adhesion and/or cell migration. The specific dose will vary depending on the particular compound of the compositions chosen, the dosing regimen to be followed, whether it is administered in combination with other compounds, timing of administration, the tissue to which it is administered, and the physical delivery system in which it is carried.

As used herein, "treatment" or "treating" refers to an approach for obtaining beneficial or desired results with respect to a disease, disorder or medical condition including but not limited to a therapeutic benefit and/or a prophylactic benefit. By therapeutic benefit is meant eradication or amelioration of the underlying disorder being treated. Also, a therapeutic benefit is achieved with the eradication or amelioration of one or more of the physiological symptoms associated with the underlying disorder such that an improvement is observed in the subject, notwithstanding that the subject may still be afflicted with the underlying disorder. In certain embodiments, for prophylactic benefit, the compositions are administered to a subject at risk of developing a particular disease, or to a subject reporting one or more of the physiological symptoms of a disease, even though a diagnosis of this disease may not have been made.

A "therapeutic effect," as that term is used herein, encompasses a therapeutic benefit and/or a prophylactic benefit as described above. A prophylactic effect includes delaying or eliminating the appearance of a disease or condition, delaying or eliminating the onset of symptoms of a disease or condition, slowing, halting, or reversing the progression of a disease or condition, or any combination thereof.

The term "co-administration," "administered in combination with," and their grammatical equivalents, as used herein, encompass administration of two or more agents to an animal, including humans, so that both agents and/or their metabolites are present in the subject at the same time. Co-administration includes simultaneous administration in separate compositions, administration at different times in separate compositions, or administration in a composition in which both agents are present.

"Pharmaceutically acceptable salt" includes both acid and base addition salts.

"Pharmaceutically acceptable acid addition salt" refers to those salts which retain the biological effectiveness and properties of the free bases, which are not biologically or otherwise undesirable, and which are formed with inorganic acids such as, but are not limited to, hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid, phosphoric acid and the like, and organic acids such as, but not limited to, acetic acid, 2,2-dichloroacetic acid, adipic acid, alginic acid, ascorbic acid, aspartic acid, benzenesulfonic acid, benzoic acid, 4-acetamidobenzoic acid, camphoric acid, camphor- 10-sulfonic acid, capric acid, caproic acid, caprylic acid, carbonic acid, cinnamic acid, citric acid, cyclamic acid, dodecylsulfuric acid, ethane- 1,2-disulfonic acid, ethanesulfonic acid, 2-hydroxyethanesulfonic acid, formic acid, fumaric acid, galactaric acid, gentisic acid, glucoheptonic acid, gluconic acid, glucuronic acid, glutamic acid, glutaric acid, 2-oxo-glutaric acid, glycerophosphoric acid, glycolic acid, hippuric acid, isobutyric acid, lactic acid, lactobionic acid, lauric acid, maleic acid, malic acid, malonic acid, mandelic acid, methanesulfonic acid, mucic acid, naphthalene-l,5-disulfonic acid, naphthalene-2-sulfonic acid, l-hydroxy-2-naphthoic acid, nicotinic acid, oleic acid, orotic acid, oxalic acid, palmitic acid, pamoic acid, propionic acid, pyroglutamic acid, pyruvic acid, salicylic acid, 4-aminosalicylic acid, sebacic acid, stearic acid, succinic acid, tartaric acid, thiocyanic acid, ^-toluenesulfonic acid, trifluoroacetic acid, undecylenic acid, and the like.

"Pharmaceutically acceptable base addition salt" refers to those salts which retain the biological effectiveness and properties of the free acids, which are not biologically or otherwise undesirable. These salts are prepared from addition of an inorganic base or an organic base to the free acid. Salts derived from inorganic bases include, but are not limited to, the sodium, potassium, lithium, ammonium, calcium, magnesium, iron, zinc, copper, manganese, aluminum salts and the like. Preferred inorganic salts are the ammonium, sodium, potassium, calcium, and magnesium salts. Salts derived from organic bases include, but are not limited to, salts of primary, secondary, and tertiary amines, substituted amines including naturally occurring substituted amines, cyclic amines and basic ion exchange resins, such as ammonia, isopropylamine, trimethylamine, diethylamine, triethylamine, tripropylamine, diethanolamine, ethanolamine, deanol, 2-dimethylaminoethanol, 2-diethylaminoethanol, dicyclohexylamine, lysine, arginine, histidine, caffeine, procaine, hydrabamine, choline, betaine, benethamine, benzathine, ethyl enedi amine, glucosamine, methylglucamine, theobromine, triethanolamine, tromethamine, purines, piperazine, piperidine, N-ethylpiperidine, polyamine resins and the like. Particularly preferred organic bases are isopropylamine, diethylamine, ethanolamine, trimethylamine, dicyclohexylamine, choline and caffeine.

In some embodiments, pharmaceutically acceptable salts include quaternary ammonium salts such as quaternary amine alkyl halide salts (e.g., methyl bromide).

The terms "antagonist" and "inhibitor" are used interchangeably, and they refer to a compound having the ability to inhibit a biological function of a target protein, whether by inhibiting the activity or expression of the protein, such as MCL-1. Accordingly, the terms "antagonist" and "inhibitors" are defined in the context of the biological role of the target protein. A preferred biological activity inhibited by an antagonist is associated with the development, growth, or spread of a tumor.

The term "agonist" as used herein refers to a compound having the ability to initiate or enhance a biological function of a target protein, whether by inhibiting the activity or expression of the target protein. Accordingly, the term "agonist" is defined in the context of the biological role of the target polypeptide. While preferred agonists herein specifically interact with (e.g., bind to) the target, compounds that initiate or enhance a biological activity of the target polypeptide by interacting with other members of the signal transduction pathway of which the target polypeptide is a member are also specifically included within this definition.

As used herein, "agent" or "biologically active agent" refers to a biological, pharmaceutical, or chemical compound or other moiety. Non-limiting examples include a simple or complex organic or inorganic molecule, a peptide, a protein, an oligonucleotide, an antibody, an antibody derivative, antibody fragment, a vitamin derivative, a carbohydrate, a toxin, or a chemotherapeutic compound. Various compounds can be synthesized, for example, small molecules and oligomers (e.g., oligopeptides and oligonucleotides), and synthetic organic compounds based on various core structures. In addition, various natural sources can provide compounds for screening, such as plant or animal extracts, and the like.

An "anti-cancer agent", "anti-tumor agent" or "chemotherapeutic agent" refers to any agent useful in the treatment of a neoplastic condition. One class of anticancer agents comprises chemotherapeutic agents. "Chemotherapy" means the administration of one or more chemotherapeutic drugs and/or other agents to a cancer patient by various methods, including intravenous, oral, intramuscular, intraperitoneal, intravesical, subcutaneous, transdermal, buccal, or inhalation or in the form of a suppository.

The term "cell proliferation" refers to a phenomenon by which the cell number has changed as a result of division. This term also encompasses cell growth by which the cell morphology has changed (e.g., increased in size) consistent with a proliferative signal.

The term "selective inhibition" or "selectively inhibit" refers to a biologically active agent refers to the agent's ability to preferentially reduce the target signaling activity as compared to off-target signaling activity, via direct or indirect interaction with the target.

"Subject" refers to an animal, such as a mammal, for example a human. The methods described herein can be useful in both human therapeutics and veterinary applications. In some embodiments, the subject is a mammal, and in some embodiments, the subject is human.

"Mammal" includes humans and both domestic animals such as laboratory animals and household pets (e.g., cats, dogs, swine, cattle, sheep, goats, horses, rabbits), and non-domestic animals such as wildlife and the like.

"Radiation therapy" means exposing a subject, using routine methods and compositions known to the practitioner, to radiation emitters such as alpha-particle emitting radionuclides (e.g., actinium and thorium radionuclides), low linear energy transfer (LET) radiation emitters (i.e., beta emitters), conversion electron emitters (e.g., strontium-89 and samarium- 153 -ED TMP, or high-energy radiation, including without limitation x-rays, gamma rays, and neutrons.

The term "in vivo" refers to an event that takes place in a subject's body.

A "pharmaceutical composition" refers to a formulation of a compound and a medium generally accepted in the art for the delivery of the biologically active compound to mammals, e.g., humans. Such a medium includes all pharmaceutically acceptable carriers, diluents or excipients therefor.

"Pharmaceutically acceptable carrier, diluent or excipient" includes without limitation any adjuvant, carrier, excipient, glidant, sweetening agent, diluent, preservative, dye/colorant, flavor enhancer, surfactant, wetting agent, dispersing agent, suspending agent, stabilizer, isotonic agent, solvent, or emulsifier which has been approved by the United States Food and Drug Administration as being acceptable for use in humans or domestic animals.

Methods for Treatment

The current approved therapeutic regimen for treating patients with CLL with chromosome 17p deletion (i.e., Venetoclax/ABT-199) shows a favorable overall response and initial disease free progression; however only a small subset of patients show a complete response and at least 50% of patients show disease progression after 18 months. Thus, the present disclosure is based, at least in part, on the fact that CDK9/MCL-1 inhibitors provide a useful treatment option for cancer patients (e.g., with CLL) that show resistance to BCL-2 inhibitors.

Accordingly, embodiments of the present invention are useful to treat leukemia patients resistant and/or non-responsive to BCL-2 inhibitors. In addition, certain embodiments may be used with or without a companion diagnostic assay, such as a BH3 profiling assay, that determines if patients will respond to CDK9/MCL-1 inhibitors.

One embodiment provides a method for treating a BCL-2 inhibitor- resistant cancer in a subject in need thereof, the method comprising administering an effective amount of a treatment regimen comprising alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, to a subject being non-responsive or resistant to a prior treatment with a BCL-2 inhibitor, thereby treating the cancer in the subject.

In embodiments, the treatment regimen comprises a prodrug of alvocidib, such as those described in US2016/0340376, which is incorporated by reference herein in its entirety. In embodiments, the prodrug of alvocidib is a phosphate prodrug of alvocidib. In some embodiments the phosphate prodrug of alvocidib has the following structure (I):

(I)

or a stereoisomer, tautomer or pharmaceutically acceptable salt thereof, wherein:

one of R ¹ , R ² and R ³ is -P(=0)(OH) ₂ , and the other two of R ¹ , R ² and R ³ are each H.

In certain embodiments, the phosphate prodrug of alvocidib has the following structure:

Another embodiment provides a method for treating a cancer in a subject in need thereof, the method comprising, determining that the cancer is BCL-2 inhibitor resistant and administering an effective amount of a treatment regimen comprising alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, to the subject, thereby treating the cancer. In specific embodiments, the cancer is resistant to a prior treatment with a BCL-2 inhibitor. A related embodiment provides a method for treating a cancer in a subject in need thereof, the method comprising identifying the subject as likely to respond to treatment with alvocidib or a prodrug thereof if the cancer is BCL-2 inhibitor resistant and the subject is non-responsive or resistant to a prior treatment with a BCL-2 inhibitor and administering a treatment regimen comprising an effective amount of alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, to the subject.

One embodiment affords a method for treating a cancer in a subject in need thereof, the method comprising, administering a treatment regimen comprising alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, to the subject, the cancer being BCL-2 inhibitor resistant as determined by an in vitro method comprising

obtaining a cancer cell from the subject; and

i) quantifying expression of BCL-2 and MCL-1 in the cancer cell, wherein an increase in MCL-1 expression relative to BCL-2 expression indicates the subject has a BCL-2 inhibitor resistant cancer;

ii) determining dependency on BCL-2 in the cancer cell, wherein a low BCL-2 dependency indicates the subject has a BCL-2 inhibitor resistant cancer; or

iii) determining dependency on MCL-1 in the cancer cell, wherein a high MCL-1 dependency indicates the subject has a BCL-2 inhibitor resistant cancer.

In certain embodiments, the subject has received a prior treatment with a BCL-2 inhibitor, such as Venetoclax.

MCL-1 and BCL-2 dependency can be determined based on methods known in the art, such as BH3 profiling as described in U.S. Patent Nos. 7,868,133; 8,221,966; and 8,168,755 and US Patent Publication Nos. 2011/0130309, 2016/0303101, and 2018/0172673, the contents of all of which are hereby incorporated by reference in their entireties.

In some embodiments, MCL-1 dependency is determined by contacting a subject's cancer cell with any one or more of the profiling peptides, such as those described in US Patent Publication No. 2018/0172673, which is incorporated by reference in its entirety. In some embodiments, the profiling peptide comprises the sequence of YGRKKRRQRRRGGGRPEIWMTQGLRRLGDEINAYYAR (SEQ ID NO: l) or RPEIWMTQGLRRLGDEINAYYARGGGYGRKKRRQRRR (SEQ ID NO:2). In some embodiments, the profiling peptide consists of the sequence of SEQ ID NO: l or SEQ ID NO:2. In other embodiments, the profiling peptide is at least a portion ofNOXA.

Such peptides may be used to produce a sensitivity profile for a cancer cell or a plurality of cancer cells. In some embodiments, the cancer cell or plurality of cancer cells is isolated from a tumor. In certain embodiments, the cancer cell or plurality of cancer cells is derived from the biopsy of a non-solid tumor. In embodiments, the cancer cell or plurality of cancer cells is obtained from peripheral blood from the subject. In other embodiments the cancer cell or plurality of cancer cells is obtained from bone marrow of the subject.

In embodiments, the cancer cells are from a solid cancer. In some embodiments, the cancer cell or plurality of cancer cells is derived from a solid tumor. In some embodiments, the cancer cell or plurality of cancer cells is a circulating tumor cell. In embodiments, the cancer cells are from a non-solid cancer. In various embodiments, the cancer cells are from a pre-metastatic cancer. In various embodiments, the cancer cells are from a metastatic cancer.

In a specific embodiment, the cancer cell or plurality of cancer cells is a multiple myeloma cell that is enriched by selection from a biopsy sample with an anti- CD138 antibody bound to a solid matrix or bead. In a specific embodiment, the cancer cell or plurality of cancer cells is an AML cell that is enriched by binding to a CD45- directed antibody. In a specific embodiment, the cancer cell or plurality of cancer cells is from a chronic lymphogenous leukemia or diffuse large B-cell lymphoma that is enriched by non-B cell depletion.

In various embodiments, the plurality of cancer cells is from a sample that has been frozen. In such embodiments, the sample may be warmed using a quick thaw process. The sample may then be added to culture medium and incubated. In other embodiments, the plurality of cancer cells is from a sample that has not been frozen, i.e., that has been freshly collected. In such embodiments, the sample is added to culture medium and incubated after being isolated.

In embodiments, the cancer cell, the plurality of cancer cells, or a portion thereof, is contacted with one or more profiling peptides disclosed herein and a percent polarization is determined. In embodiments, the cancer cell, the plurality of cancer cells, or a portion thereof, is contacted with one or more profiling peptides disclosed herein and a change in mitochondrial integrity of the cell(s) is detected. In various embodiments, more than one profiling peptide may be used at once. In such embodiments, a panel of profiling peptides (e.g., 2, 3, 4, 5, 10, etc. profiling peptides) may be screened on a single subject specimen.

In some embodiments, the cancer cell, the plurality of cancer cells, or a portion thereof, is contacted with a composition comprising a profiling peptide. In such embodiments, the composition may comprise a profiling peptide in a concentration ranging from about 1.5 μΜ to about 2.5 μΜ. In embodiments, the composition comprises a profiling peptide in a concentration ranging from about 1.75 μΜ to about 2.25 μΜ. In embodiments, the composition comprises a profiling peptide in a concentration of about 2.0 μΜ.

In embodiments, the plurality of cancer cells, or a portion thereof, is contacted with one or more profiling peptides for about 15 minutes to about 45 minutes. In some embodiments, the plurality of cancer cells, or a portion thereof, is contacted with one or more profiling peptides for about 20 minutes to about 40 minutes. In some embodiments, the plurality of cancer cells, or a portion thereof, is contacted with one or more profiling peptides for about 30 minutes.

A percent polarization can be related to a change in mitochondrial integrity in the cell or plurality of cells. A change in mitochondrial integrity can be detected in any suitable manner, such as, for example, a change in mitochondrial membrane potential, chromatin condensation, loss of viability, Cytochrome C translocation from the mitochondrial intermembrane space to the cytosol, swelling of the mitochondria, mitochondrial fission, morphological changes (e.g., cell shrinkage, membrane blebbing, etc.), phosphatidyl serine externalization (e.g., as measured by annexin V staining) or the increase in reactive oxygen intermediates. As is understood by one of skill in the art, various methods of detection for each of the indications of a change in mitochondrial integrity may be employed.

In embodiments, the change in mitochondrial integrity will be a decrease in mitochondrial integrity. In some embodiments, the decrease in mitochondrial integrity is measured by a decrease in mitochondrial membrane potential. The decrease in mitochondrial potential may be determined using any suitable method known in the art. In some embodiments, the decrease in mitochondrial integrity is measured by Cytochrome C leakage. In some embodiments, the decrease will be a statistically significant, clinically significant, or biologically significant decrease. In some embodiments, the decrease is a 2%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%), 60%), 70%), 80%), or 90% difference in a measurement of mitochondrial integrity, as described herein, as compared to a control.

A change in mitochondrial membrane potential may be measured using any suitable detecting agent. The detecting agent can be any suitable agent, such as a fluorescent dye, a non-fluorescent dye that can be converted to a fluorescent dye, an antibody, and the like. Fluorescent dyes include, for example, 5,5',6,6'-Tetrachloro- l, l ',3,3'-tetraethyl-imidacarbocyanine iodide (JC-1), propidium iodide (PI), l, l ',3,3,3',3'-hexamethylindodicarbo-cyanine iodide (DilCl), and 3,3'- Dihexyloxacarbocyanine Iodide (DiOC ₆ ). In various embodiments, the fluorescent dye is a potentiometric dye. Suitable potentiometric dyes include, for example, DilCl, JC-1, and rhodamine 123. In embodiments, the potentiometric dye included is JC-1 or rhodamine 123. In other embodiments, the dye is dihydrorhodamine 123, a non- fluorescent dye that can be converted via oxidation to rhodamine 123, a fluorescent dye.

In embodiments, the plurality of cancer cells, or a portion thereof, is contacted with a dye in a concentration ranging from about 0.5 nM to about 1.5 nM. In embodiments, the plurality of cancer cells, or a portion thereof, is contacted with a dye in a concentration ranging from about 0.75 nM to about 1.25 nM. In embodiments, the plurality of cancer cells, or a portion thereof, is contacted with a dye in a concentration of about 1.0 μΜ. In embodiments, the plurality of cancer cells, or a portion thereof, is contacted with a dye for about 60 minutes to about 120 minutes. In embodiments, the plurality of cancer cells, or a portion thereof, is contacted with a dye for about 75 minutes to about 105 minutes. In embodiments, the plurality of cancer cells, or a portion thereof, is contacted with a dye for about 80 minutes to about 100 minutes. In embodiments, the plurality of cancer cells, or a portion thereof, is contacted with a dye for about 90 minutes.

In another example, Cytochrome C translocation can be measured using immunofluorescence staining. In a further example, an increase in reactive oxygen intermediates can be measured flow cytometric analysis after staining with carboxy- dichlorofluorescin diacetate.

In various embodiments, the plurality of cancer cells is divided into two or more portions (e.g., three portions) for the purposes of profiling. In embodiments, one portion is treated with a negative control and one portion is contacted with one or more profiling peptides or a composition comprising one or more profiling peptides disclosed herein. Any suitable negative control may be used. Examples of negative controls include water and water soluble organic solvents, such as DMSO, ethanol, and methanol. In some embodiments, the negative control is water.

Accordingly, methods of the present disclosure comprise contacting a first portion of a plurality of cancer cells with a profiling peptide; contacting a second portion of the plurality of cancer cells with a negative control; and determining a percent polarization of the first portion and the second portion of the plurality of cancer cells.

In some embodiments, one portion of the plurality of cancer cells is contacted with a positive control. In embodiments, one portion is treated with a negative control, one portion is contacted with a positive control, and one portion is contacted with one or more profiling peptides or a composition comprising one or more profiling peptides disclosed herein. In such embodiments, methods of the disclosure further comprise contacting a third portion of the plurality of cancer cells with a positive control. Any suitable positive control may be used. Examples of positive controls include Carbonyl cyanide-4-(trifluoromethoxy)phenylhydrazone (FCCP), Carbonyl cyanide m-chlorophenyl hydrazone (CCCP), N5,N6-bis(2-fluorophenyl)- [l,2,5]oxadiazolo[3,4-b]pyrazine-5,6-diamine (BAM-15), and the like. In particular embodiments, the positive control used is CCCP.

In embodiments, the plurality of cancer cells, or a portion thereof, is contacted with a positive control in a concentration ranging from about 25 μΜ to about 250 μΜ. In embodiments, the plurality of cancer cells, or a portion thereof, is contacted with a positive control in a concentration ranging from about 25 μΜ to about 200 μΜ. In embodiments, the plurality of cancer cells, or a portion thereof, is contacted with a positive control in a concentration ranging from about 50 μΜ to about 150 μΜ. In embodiments, the plurality of cancer cells, or a portion thereof, is contacted with a positive control in a concentration of about 100 μΜ.

In embodiments, at least a portion of the plurality of cancer cells is contacted with a blocking buffer that blocks receptors on the cells that bind to the Fragment crystallizable (FC) region of antibodies (i.e., FC receptors). In embodiments, the plurality of cancer cells is contacted with the blocking buffer before being separated into portions. In embodiments, the blocking buffer is incubated with the plurality of cancer cells at room temperature.

In some embodiments, a plurality of cancer cells is contacted with one or more labels. In embodiments, the plurality of cancer cells is contacted with a label before being separated into portions. In some embodiments that use flow cytometry, the labels are fluorophores attached to antibodies or a chemical entity with affinity for a cell membrane feature or other cellular structure. In other embodiments that use flow cytometry, the labels are quantum dots attached to antibodies or a chemical entity with affinity for a cell membrane feature or other cellular structure. In any of these embodiments, the antibodies or chemical entities may recognize any suitable cell surface marker, such as CD3, CD13, CD20, CD33, CD34, or CD45. In various embodiments, a combination of labels is used.

In embodiments, the label comprises at least one monoclonal antibody. In some embodiments, the at least one monoclonal antibody comprises an anti-CD45 antibody, an anti-CD3 antibody, an anti-CD20 antibody, an anti-CD 13 antibody, an anti-CD33 antibody, an anti-CD34 antibody, an anti-CD117 antibody, anti-HLA-DR antibody, or a combination thereof. In specific embodiments, the at least one monoclonal antibody comprises an anti-CD45 antibody, an anti-CD3 antibody, an anti- CD20 antibody, an anti-CD13 antibody, an anti-CD33 antibody, an anti-CD34 antibody, or a combination thereof.

In some embodiments, an additive with a high affinity for calcium channels is added to the plurality of cancer cells, or a portion thereof. In some such embodiments, the additive is a diterpenoid. In particular embodiments, the additive is ryanodine. In embodiments, the additive is added in a concentration that is sufficient to significantly reduce or prevent nonspecific dye uptake. In some embodiments, the additive is added in a concentration of at least about 20 μΜ. In some embodiments, the additive is added in a concentration of at least about 30 μΜ. In embodiments, the diterpenoid is added in a concentration ranging from about 10 μΜ to about 50 μΜ. In embodiments, the diterpenoid is added in a concentration ranging from about 20 μΜ to about 40 μΜ. In embodiments, the diterpenoid is added in a concentration of about 30 μΜ.

In some embodiments, an ATP synthase inhibitor is added to the plurality of cancer cells, or a portion thereof. In some such embodiments, the ATP synthase inhibitor is an Oligomycin. In particular embodiments, the Oligomycin is Oligomycin A. In some embodiments, the ATP synthase inhibitor is added in a concentration of at least 0.25 um. In some embodiments, the ATP synthase inhibitor is added in a concentration of at least about 0.5 um. In some embodiments, the ATP synthase inhibitor is added in a concentration of no more than about 1.0 um. In embodiments, the ATP synthase inhibitor is added in a concentration ranging from about 0.25 μΜ to about 0.75 μΜ. In embodiments, the ATP synthase inhibitor is added in a concentration ranging from about 0.4 μΜ to about 0.6 μΜ. In embodiments, the ATP synthase inhibitor is added in a concentration of about 0.5 μΜ.

In embodiments, the plurality of cancer cells is then contacted with a detecting agent, as described above. In some embodiments, the detecting agent is a dye. In some embodiments, the detecting agent is a fluorescent dye. In some embodiments, the detecting agent is a potentiometric dye. In certain embodiments, the dye is JC-1, DiOC ₆ , or rhodamine 123 In certain embodiments, the dye is JC-1 or rhodamine 123 In particular embodiments, the dye is DiOC _6. In some embodiments, the plurality of cancer cells, or a portion thereof, is washed prior to being contacted with the detecting agent.

In such embodiments, the plurality of cancer cells may then be analyzed using flow cytometry. In embodiments, determining the percent polarization of the first portion and the second portion of the plurality of cancer cells comprises analyzing the first portion and the second portion of the plurality of cancer cells by flow cytometry. In some embodiments, the third portion of the plurality of cancer cells is also analyzed by flow cytometry.

Any suitable gating may be used in flow cytometry analysis. In embodiments, analyzing the first portion, second portion, and third portion of the plurality of cancer cells by flow cytometry comprises gating on the positive control. In some embodiments, such gating is on the CD45 dim, CD13, CD33, and CD34 high population of blast cells. In other embodiments, such gating is the CD34 dim, CD3 and CD20 high population.

Methods of the disclosure include isolating a plurality of cancer cells from a subject sample; the cells are then labeled; treated with a negative control, a positive control, or a profiling peptide of the disclosure; contacted with a dye; and analyzed with flow cytometry.

Some methods described herein further comprise determining an Mcl-1 dependency percentage for the first portion of the plurality of cancer cells based at least on the percent polarization of the first portion and the second portion of the plurality of cancer cells.

In embodiments, polarized and depolarized cells are counted. The percent polarization can then be calculated by dividing the number of polarized cells by the total number of cells and multiplying by 100. In such embodiments, blasts are gated as described above. The blast gate in then plotted on a histogram for detection agent signal. A gate is then created specifically on the polarized cells, and the percent of cells which respond to treatment with a profiling peptide can be found with the following equation:

NC is the average percent polarization of the second portion of the plurality of cancer cells and PP is the percent polarization of the first portion of the plurality of cancer cells.

In embodiments, the Mcl-1 dependency percentage (MDP) is defined by the following equation:

(2) MDP = C x Avg [Percent Priming]

where C is a calibration factor and AvgfPercent Priming] is the average of the percent priming for one or more replicates.

In embodiments, the calibration factor ranges from about 0.1 to about 3.0. In some embodiments, the calibration factor ranges from about 0.5 to about 2.5. In some embodiments, the calibration factor ranges from about 1.0 to about 2.0. In some embodiments, the calibration factor ranges from about 1.4 to about 1.8. In some embodiments, the calibration factor is about 1.5.

Unless otherwise noted, the Mcl-1 dependency percentages calculated herein correspond to a profiling peptide concentration of 1 μΜ with CCCP as the positive control and water or DMSO as the negative control. In some embodiments, the time occurs over a window from between about 0 to about 300 min to about 0 to about 30 min.

In an illustrative method of the disclosure, a plurality of cancer cells prepared, and sample quality is confirmed. In the case of a frozen sample, samples are quickly thawed, for example, placing them in a 37°C water bath for about 60-70 seconds. After thawing the sample, the cells are transferred to a flask containing warm culture medium. After incubation, the quality (e.g., viability, cell count, etc.) is confirmed. In the case of a fresh sample, mononuclear cells are isolated from bone marrow aspirates following standard laboratory protocol (e.g., Ficoll-Paque separation). The cells are counted and the viability of the isolated cells is determined. The cells are then transferred to a flask containing warm culture medium. The cells are then pelleted and resuspended in a buffer that blocks FC receptors. A mix of monoclonal antibodies is then added and incubated. After incubating with the label, the cells are again pelleted. The cells are again resuspended in a mix of an assay buffer that has a pH ranging from about 7.4 to about 7.6, a diterpenoid (e.g., ryanodine), and an ATP synthase inhibitor (e.g. Oligomycin A). The suspended cells are then aliquoted into three portions. The first portion is mixed with a negative control (e.g., nuclease free water), the second portion is mixed with a positive control (e.g., CCCP), and the third portion is mixed with the profiling peptide (e.g., having the sequence of SEQ ID NO: l). The three portions are then incubated. After the incubation, the cells are pelleted and resuspended in the assay buffer. A dye (e.g., DiOC ₆ ) is then added to each portion of cells.

In the illustrative method, the cells are analyzed via flow cytometry. The control cell lines are analyzed using the live gate. The sample is analyzed by gating single, live cells by plotting forward vs. side scatter. Outliers containing high forward and side scatter values may be assumed to be doublets and dying cells, respectively, and may be excluded from the final analysis. Events that are very low in both forward and side scatter may also be excluded as cellular debris. Generate a dot plot of channel FL5 (PC7 labeled anti-CD45 antibody) against side scatter and identify the CD45 dim population. Using only the events within the "CD45 dim" gate, generate a dot plot of channel FL4 (PC5 labeled anti-CD13, anti-CD33 and anti-CD34 antibodies) against channel FL3 (ECD/PE-Texas Red labeled anti-CD3 and anti-CD20 antibodies). In order to gate exclusively on AML blasts, gate cells that are high in channel FL4 and low in channel FL3 (live cell population). Using only events within the "Blasts" population, generate a histogram of FL1. Determine the cells high in channel FL1. Apply the gates created to all aliquots of all treatments of the same sample.

Some methods described herein further comprise determining an MCL-1 dependency percentage for the first portion of the plurality of cancer cells based at least on the change in mitochondrial integrity.

In embodiments, the MDP is defined by the following equation:

(3) MDP = [l - (^ )] * 100

Where PC is the AUC of the positive control, NC is the AUC of the negative control, and Pep is the AUC of the profiling peptide. Unless otherwise noted, the MCL-1 dependency percentage calculated using this equation correspond to a profiling peptide concentration of 1 μΜ with CCCP as the positive control and water or DMSO as the negative control. The AUC is either area under the curve or signal intensity. In embodiments, the AUC is the median fluorescent intensity (MFI). In some embodiments, the area under the curve is established by homogenous time-resolved fluorescence (HTRF). In some embodiments, the time occurs over a window from between about 0 to about 300 min to about 0 to about 30 min. In some embodiments, the area under the curve is established by fluorescence activated cell sorting (FACS) or microplate assay as known in the art or described herein. In some embodiments, the signal intensity is a single time point measurement that occurs between about 5 min and about 300 min.

In embodiments where more than one profiling peptide is used, the MCL-1 dependency percentage (PP) is defined by the following equation:

In an illustrative method of the disclosure, a plurality of cancer cells are isolated from a subject sample, and sample quality is confirmed. The cells are then pelleted, blocked in BSA, and labeled. After staining, cells are pelleted and separated into three portions and treated with either water or dimethyl sulfoxide (DMSO) (negative control), CCCP (positive control) or a profiling peptide of the disclosure (subject dependency). DiOC ₆ , a cationic mitochondrial dye is added. Later, the cells are analyzed via flow cytometry.

In some embodiments, a plurality of cancer cells are isolated from primary bone marrow aspirates and sample quality is determined. Cells are then pelleted, blocked in BSA and labeled for markers specific to B and T cells, as well as monocyte differentiation markers and blast-specific markers. After staining, cells are pelleted and separated into three portions and treated with either water (negative control), CCCP (positive control) or SEQ ID NO: l (subject dependency). DiOC ₆ , a cationic mitochondrial dye is added. The cells are analyzed via flow cytometry. Blast cells are isolated by gating on the CD45 dim, CD13, CD33, and CD34 high population of each sample. In particular embodiments, a plurality of cancer cells are isolated from primary bone marrow aspirates using density-gradient centrifugation. Sample quality is determined using trypan blue exclusion. Cells are then pelleted, blocked in BSA and labeled for markers specific to B and T cells, as well as monocyte differentiation markers and blast-specific markers. After staining, cells are pelleted and separated into fluorescent-activated cell sorting (FACS) tubes and treated with either water (negative control), CCCP (positive control) or SEQ ID NO: l (subject dependency). DiOC ₆ , a cationic mitochondrial dye is added. The cells are then analyzed via flow cytometry. Blast cells are isolated by gating on the CD45 dim, CD13, CD33 and CD34 high population of each sample.

In any of the above embodiments, the cancer cell, the plurality of cancer cells, or a portion thereof, is not permeabilized, for example with a cell permeabilization agent such as digitonin.

In embodiments, the subject has a MCL-1 dependency percentage of at least 5%. In embodiments, the subject has a MCL-1 dependency percentage of at least 10%. In embodiments, the subject has a MCL-1 dependency percentage of at least 20%. In embodiments, the subject has a MCL-1 dependency percentage of at least 30%. In embodiments, the subject has a MCL-1 dependency percentage of at least 40%. In embodiments, the subject has a MCL-1 dependency percentage of at least 50%. In embodiments, the subject has a MCL-1 dependency percentage of at least 60%. In embodiments, the subject has a MCL-1 dependency percentage of at least 70%. In some embodiments, the subject has a MCL-1 dependency percentage of no more than 70%. In some embodiments, the subject has a MCL-1 dependency percentage of no more than 60%. In some embodiments, the subject has a MCL-1 dependency percentage of no more than 50%. In some embodiments, the subject has a MCL-1 dependency percentage of no more than 40%. In some embodiments, the subject has a MCL-1 dependency percentage of no more than 30%. In some embodiments, the subject has a MCL-1 dependency percentage of no more than 20%.

In embodiments, the subject has a predetermined MCL-1 dependency percentage of at least 5%. In embodiments, the subject has a predetermined MCL-1 dependency percentage of at least 10%. In embodiments, the subject has a predetermined MCL-1 dependency percentage of at least 20%. In embodiments, the subject has a predetermined MCL-1 dependency percentage of at least 30%. In embodiments, the subject has a predetermined MCL-1 dependency percentage of at least 40%. In embodiments, the subject has a predetermined MCL-1 dependency percentage of at least 50%. In embodiments, the subject has a predetermined MCL-1 dependency percentage of at least 60%. In embodiments, the subject has a predetermined MCL-1 dependency percentage of at least 70%. In some embodiments, the subject has a predetermined MCL-1 dependency percentage of no more than 70%. In some embodiments, the subject has a predetermined MCL-1 dependency percentage of no more than 60%. In some embodiments, the subject has a predetermined MCL-1 dependency percentage of no more than 50%. In some embodiments, the subject has a predetermined MCL-1 dependency percentage of no more than 40%. In some embodiments, the subject has a predetermined MCL-1 dependency percentage of no more than 30%. In some embodiments, the subject has a predetermined MCL-1 dependency percentage of no more than 20%.

Accordingly, in particular embodiments, a subject treated using the methods disclosed herein has a predetermined MCL-1 dependency percentage of at least 15%), a predetermined MCL-1 dependency percentage having been obtained by an in vitro method comprising contacting a first portion of a plurality of cancer cells with a profiling peptide comprising a cellular uptake moiety and a predetermined MCL-1 binding domain, a predetermined MCL-1 binding domain having the sequence of SEQ ID NO: 1 or 2. In embodiments, a subject treated using the methods disclosed herein has a predetermined MCL-1 dependency percentage of at least 20%. In embodiments, a subject treated using the methods disclosed herein has a predetermined MCL-1 dependency percentage of at least 30%. In embodiments, a subject treated using the methods disclosed herein has a predetermined MCL-1 dependency percentage of at least 40%). In embodiments, a subject treated using the methods disclosed herein has a predetermined MCL-1 dependency percentage of at least 50%. In embodiments, a subject treated using the methods disclosed herein has a predetermined MCL-1 dependency percentage of at least 60%. In some embodiments, a subject treated using the methods disclosed herein has a predetermined MCL-1 dependency percentage of less than 75%. In some embodiments, a subject treated using the methods disclosed herein has a predetermined MCL-1 dependency percentage of less than 50%. In some embodiments, a subject treated using the methods disclosed herein has a predetermined MCL-1 dependency percentage of less than 30%. In some embodiments, a subject treated using the methods disclosed herein has a predetermined MCL-1 dependency percentage of less than 25%. In some embodiments, a subject treated using the methods disclosed herein has a predetermined MCL-1 dependency percentage of less than 20%. In further embodiments, methods of the present disclosure include administering the therapeutic agents described herein to the subject regardless of mitochondrial integrity and/or MCL-1 dependency data.

Additional profiling peptides and methods of use are disclosed in US 2016/0303101 and US 2018/0172673, which are incorporated by referenced herein for the teachings regarding the same

In some of the foregoing embodiments, the subject has a chromosome

17p deletion.

In some other foregoing embodiments, the BCL-2 inhibitor is Venetoclax (i.e., ABT-199). In some other embodiments the BCL-inhibitor is an antisense oligonucleotide drug (e.g., oblimersen), a BH3 mimetic (e.g., ABT-737, ABT- 737-d8 or navitoclax/ABT-263 or ABT-263-d8), a novel non-peptide inhibitor (e.g., TW-37), a pan-BCL-2 inhibitor (e.g., Sabutoclax, Obatoclax), a BCL-xl/BH3 domain interaction inhibitor (e.g., BH3I-1), a BCL-xl inhibitor (e.g., A-1331852 or A- 1155463), a non-peptidic ligand of BCL-2 (e.g., HA14-1), a Bax activator (e.g., BAM7), a small molecule BCL-2/BH4 domain antagonist (e.g., BDA-366), a flavonoid (e.g., Licochalcone A). In certain specific embodiments the BCL-2 inhibitor is FX1, AT-101, A- 1210477, gambogic acid, UMI-77, Gossypol, (-)-Epigallocatechin Gallate, EM20-25, Nilotinib or Nilotinib-d3, YC137, AG 1024, 3-bromopyruvic acid, Fluvastatin, Piped ongumine, 2,3-DCPE, 2-methoxy-antimycin A3 or Marinopyrrole A (i.e., Maritoclax). In some of the foregoing embodiments, the method provides treating cancer in a subject in need thereof, provided that Venetoclax/ABT-199 is not coadministered with alvocidib or a prodrug thereof. Certain specific embodiments provide a treatment regimen wherein Venetoclax/ABT-199 is not administered in combination with an MCL-1 inhibitor (e.g., alvocidib or a prodrug thereof) during the course of the treatment regimen. For example, in some embodiments the patient first receives a BCL- 2 inhibitor, such as Venetoclax, and after having been found resistant or non-responsive to the BCL-2 inhibitor, the patient is then treated with a regimen comprising an MCL-1 inhibitor, such as alvocidib or a prodrug thereof.

In certain specific embodiments, the treatment regimen comprises alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, cytarabine, and mitoxantrone (ACM). In certain specific embodiments, the treatment regimen comprises alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, cytarabine, and daunorubicin (ACD).

In embodiments, the cancer is a solid cancer. In some embodiments, the cancer comprises a solid tumor. In embodiments, the cancer comprises a colorectal, breast, prostate, lung, pancreatic, renal, or ovarian tumor. In embodiments, the cancer is a non-solid cancer. In various embodiments, the cancer is a pre-metastatic cancer. In various embodiments, the cancer is a metastatic cancer.

In some of the foregoing embodiments, the cancer is a hematologic cancer. In certain related embodiments, the hematologic cancer is selected from the group consisting of acute myelogenous leukemia (AML), multiple myeloma, follicular lymphoma, acute lymphoblastic leukemia (ALL), chronic lymphocytic leukemia, and non-Hodgkin's lymphoma. In specific embodiments, the hematologic cancer is acute myelogenous leukemia (AML). In particular embodiments, the AML is relapsed or refractory AML. In some embodiments, the AML is frontline AML. In another specific embodiment, the hematologic cancer is multiple myeloma. In some embodiments the hematologic cancer is myelodysplasic syndrome (MDS) or chronic lymphocytic leukemia (CLL). In specific embodiments, the hematologic cancer is MDS. In specific embodiments, the hematologic cancer is high risk MDS. In specific embodiments, the hematologic cancer is CLL. In some other embodiments, the invention relates to one or more of the following cancers: acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), adrenocortical carcinoma, AIDS-related cancers, anal cancer, appendix cancer, astrocytoma (e.g., childhood cerebellar or cerebral), basal-cell carcinoma, bile duct cancer, bladder cancer, bone tumor (e.g., osteosarcoma, malignant fibrous histiocytoma), brainstem glioma, brain cancer, brain tumors (e.g., cerebellar astrocytoma, cerebral astrocytoma/malignant glioma, ependymoma, medulloblastoma, supratentorial primitive neuroectodermal tumors, visual pathway and hypothalamic glioma), breast cancer, bronchial adenomas/carcinoids, Burkitt's lymphoma, carcinoid tumors, central nervous system lymphomas, cerebellar astrocytoma, cervical cancer, chronic lymphocytic leukemia (CLL), chronic myelogenous leukemia (CML), chronic myeloproliferative disorders, colon cancer, cutaneous t-cell lymphoma, desmoplastic small round cell tumor, endometrial cancer, ependymoma, esophageal cancer, Ewing's sarcoma, extracranial germ cell tumor, extragonadal germ cell tumor, extrahepatic bile duct cancer, eye cancer, gallbladder cancer, gastric (stomach) cancer, gastrointestinal stromal tumor (GIST), germ cell tumor (e.g., extracranial, extragonadal, ovarian), gestational trophoblastic tumor, gliomas (e.g., brain stem, cerebral astrocytoma, visual pathway and hypothalamic), gastric carcinoid, head and neck cancer, heart cancer, hepatocellular (liver) cancer, hypopharyngeal cancer, hypothalamic and visual pathway glioma, intraocular melanoma, islet cell carcinoma (endocrine pancreas), kidney cancer (renal cell cancer), laryngeal cancer, leukemias (e.g., acute lymphocytic leukemia, acute myelogenous leukemia, chronic lymphocytic leukemia, chronic myeloid leukemia, hairy cell), lip and oral cavity cancer, liposarcoma, liver cancer, lung cancer (e.g., non- small cell, small cell), lymphoma (e.g., AIDS-related, Burkitt, cutaneous T-cell Hodgkin, non-Hodgkin, primary central nervous system), medulloblastoma, melanoma, Merkel cell carcinoma, mesothelioma, metastatic squamous neck cancer, mouth cancer, multiple endocrine neoplasia syndrome, multiple myeloma, mycosis fungoides, myelodysplastic syndromes, myelodysplastic/myeloproliferative diseases, myelogenous leukemia, myeloid leukemia, myeloid leukemia, myeloproliferative disorders, chronic, nasal cavity and paranasal sinus cancer, nasopharyngeal carcinoma, neuroblastoma, non-Hodgkin lymphoma, non-small cell lung cancer, oral cancer, oropharyngeal cancer, osteosarcoma, ovarian cancer, pancreatic cancer, pancreatic cancer, paranasal sinus and nasal cavity cancer, parathyroid cancer, penile cancer, pharyngeal cancer, pheochromocytoma, pineal astrocytoma and/or germinoma, pineoblastoma and supratentorial primitive neuroectodermal tumors, pituitary adenoma, plasma cell neoplasia/multiple myeloma, pleuropulmonary blastoma, primary central nervous system lymphoma, prostate cancer, rectal cancer, renal cell carcinoma (kidney cancer), renal pelvis and ureter, retinoblastoma, rhabdomyosarcoma, salivary gland cancer, sarcoma (e.g., Ewing family, Kaposi, soft tissue, uterine), Sezary syndrome, skin cancer (e.g., nonmelanoma, melanoma, merkel cell), small cell lung cancer, small intestine cancer, soft tissue sarcoma, squamous cell carcinoma, squamous neck cancer, stomach cancer, supratentorial primitive neuroectodermal tumor, t-cell lymphoma, testicular cancer, throat cancer, thymoma and thymic carcinoma, thyroid cancer, trophoblastic tumors, ureter and renal pelvis cancers, urethral cancer, uterine cancer, uterine sarcoma, vaginal cancer, visual pathway and hypothalamic glioma, vulvar cancer, Waldenstrom macroglobulinemia, and Wilms tumor. In some embodiments, the cancer is breast cancer. In some embodiments, the cancer is prostate cancer. In some embodiments, the cancer is lung cancer.

Exemplary Dosages

An effective amount means an amount effective to prevent, alleviate or ameliorate symptoms of disease or prolong the survival of the subject being treated. Determination of an effective amount is well within the capability of those skilled in the art, especially in light of the detailed disclosure provided herein.

For example, for any method for treating described herein, the effective amount or dose can be estimated initially from cell culture assays. Then, the dosage can be formulated for use in animal models so as to achieve a circulating concentration range that includes the IC ₅₀ as determined in cell culture (i.e., the concentration of alvocidib which achieves a half-maximal inhibition of MCL-1 expression). Such information can then be used to more accurately determine useful doses in humans.

Toxicity and therapeutic efficacy of the methods described herein can be determined by standard pharmaceutical procedures in cell cultures or experimental animals, e.g., by determining the IC ₅₀ and the LD ₅₀ . The data obtained from cell culture assays and animal studies can be used in formulating a range of dosage for use in humans. The dosage may vary depending upon the dosage form employed and the route of administration utilized. The exact formulation, route of administration and dosage can be chosen by the individual physician in view of the patient's condition. {See, e.g., GOODMAN & GILMAN'S THE PHARMACOLOGICAL BASIS OF THERAPEUTICS, Ch. 3, 9 ^th ed., Ed. by Hardman, J., and Limbard, L., McGraw-Hill, New York City, 1996, p.46.)

Dosage amount and interval may be adjusted individually to provide plasma levels of the active species which are sufficient to maintain the protein inhibiting effects. These plasma levels are referred to as minimal effective concentrations (MECs). The MEC will vary for each composition but can be estimated from in vitro data, e.g., the concentration necessary to achieve 50-90% inhibition of MCL-1. The amount of alvocidib or a prodrug thereof administered will, of course, be dependent on the subject being treated, the severity of the affliction, the manner of administration, the judgment of the prescribing physician, etc. HPLC assays or bioassays can be used to determine plasma concentrations.

Dosage intervals can also be determined using MEC value. In certain embodiments, methods of treatment should be performed such that plasma levels are maintained above the MEC for about 10 to 90% of the time, preferably between about 30 to 90%) of the time and most preferably between about 50 to 90% of the time.

In some of the foregoing embodiments, the effective amounts may range from approximately 2.5 to 1500 mg/m ² per day. Additional illustrative amounts range from 0.2 to 1000 mg/qid, 2 to 500 mg/qid, and 20 to 250 mg/qid.

In embodiments wherein local administration or selective uptake is of concern, the effective local concentration of alvocidib may not be related to plasma concentration, and other procedures known in the art may be employed to determine the correct dosage amount and interval.

In some specific embodiments, the compounds administered as part of the present methods may, if desired, be presented in a pack or dispenser device, such as an FDA approved kit, which may contain one or more unit dosage forms containing an active ingredient(s). The pack may for example comprise metal or plastic foil, such as a blister pack. The pack or dispenser device may be accompanied by instructions for administration. The pack or dispenser may also be accompanied by a notice associated with the container in a form prescribed by a governmental agency regulating the manufacture, use or sale of pharmaceuticals, which notice is reflective of approval by the agency of the form of the compositions or of human or veterinary administration. Such notice, for example, may be of the labeling approved by the U.S. Food and Drug Administration for prescription drugs or of an approved product insert. Compounds (e.g., alvocidib or a prodrug thereof) in certain embodiments are optionally formulated in a compatible pharmaceutical carrier may also be prepared, placed in an appropriate container, and labeled for treatment of an indicated condition. Suitable conditions indicated on the label may include treatment of a BCL-2 inhibitor resistant cancer, a BCL-2 resistant tumor, and the like.

In additional embodiments, the compounds and methods of treatment described herein can be used in combination with one or more other chemotherapeutic agents. Dosages may be adjusted for any drug-drug reaction. In one embodiment, the additional chemotherapeutic agent is selected from the group consisting of alkylating agents such as thiotepa and CYTOXAN cyclosphosphamide; alkyl sulfonates such as busulfan, improsulfan and piposulfan; aziridines such as benzodopa, carboquone, meturedopa, and uredopa; ethylenimines and methylamelamines including altretamine, triethylenemelamine, trietylenephosphoramide, triethiylenethiophosphoramide and trimethylolomelamine; acetogenins (e.g., bullatacin and bullatacinone); a camptothecin (including the synthetic analogue topotecan); bryostatin; cally statin; CC-1065 (including its adozelesin, carzelesin and bizelesin synthetic analogues); cryptophycins (e.g., cryptophycin 1 and cryptophycin 8); dolastatin; duocarmycin (including the synthetic analogues, KW-2189 and CB 1-TMl); eleutherobin; pancrati statin; a sarcodictyin; spongistatin; nitrogen mustards such as chlorambucil, chlornaphazine, cholophosphamide, estramustine, ifosfamide, mechlorethamine, mechlorethamine oxide hydrochloride, melphalan, novembichin, phenesterine, prednimustine, trofosfamide, uracil mustard; nitrosureas such as carmustine, chlorozotocin, fotemustine, lomustine, nimustine, and ranimnustine; antibiotics such as the enediyne antibiotics (e.g., calicheamicin, especially calicheamicin gammall and calicheamicin omegall (see, e.g., Agnew, Chem. Intl. Ed. Engl., 33 : 183-186 (1994)); dynemicin, including dynemicin A; bisphosphonates, such as clodronate; an esperamicin; as well as neocarzinostatin chromophore and related chromoprotein enediyne antiobiotic chromophores), aclacinomysins, actinomycin, authramycin, azaserine, bleomycins, cactinomycin, carabicin, caminomycin, carzinophilin, chromomycinis, dactinomycin, daunorubicin, detorubicin, 6-diazo-5-oxo-L-norleucine, ADRIAMYCIN doxorubicin (including morpholino- doxorubicin, cyanomorpholino-doxorubicin, 2-pyrrolino-doxorubicin and deoxy doxorubicin), epirubicin, esorubicin, idarubicin, marcellomycin, mitomycins such as mitomycin C, mycophenolic acid, nogalamycin, olivomycins, peplomycin, potfiromycin, puromycin, quelamycin, rodorubicin, streptonigrin, streptozocin, tubercidin, ubenimex, zinostatin, zorubicin; anti-metabolites such as methotrexate and 5-fluorouracil (5-FU); folic acid analogues such as denopterin, methotrexate, pteropterin, trimetrexate; purine analogs such as fludarabine, 6-mercaptopurine, thiamiprine, thioguanine; pyrimidine analogs such as ancitabine, azacitidine, 6- azauridine, carmofur, cytarabine, dideoxyuridine, doxifluridine, enocitabine, floxuridine; androgens such as calusterone, dromostanolone propionate, epitiostanol, mepitiostane, testolactone; anti-adrenals such as minoglutethimide, mitotane, trilostane; folic acid replenisher such as frolinic acid; aceglatone; aldophosphamide glycoside; aminolevulinic acid; eniluracil; amsacrine; bestrabucil; bisantrene; edatraxate; demecolcine; diaziquone; elformithine; elliptinium acetate; an epothilone; etoglucid; gallium nitrate; hydroxyurea; lentinan; lonidainine; maytansinoids such as maytansine and ansamitocins; mitoguazone; mitoxantrone; mopidanmol; nitraerine; pentostatin; phenamet; pirarubicin; losoxantrone; podophyllinic acid; 2-ethylhydrazide; procarbazine; PSK polysaccharide complex (JHS Natural Products, Eugene, Oreg.); razoxane; rhizoxin; sizofuran; spirogermanium; tenuazonic acid; triaziquone; 2,2',2"- trichlorotriethylamine; trichothecenes (e.g., T-2 toxin, verracurin A, roridin A and anguidine); urethan; vindesine; dacarbazine; mannomustine; mitobronitol; mitolactol; pipobroman; gacytosine; arabinoside ("Ara-C"); cyclophosphamide; thiotepa; taxoids, e.g., TAXOL paclitaxel (Bristol-Myers Squibb Oncology, Princeton, N.J.), ABRAXANE Cremophor-free, albumin-engineered nanoparticle formulation of paclitaxel (American Pharmaceutical Partners, Schaumberg, 111.), and TAXOTERE doxetaxel (Rhone-Poulenc Rorer, Antony, France); chloranbucil; GEMZAR gemcitabine; 6-thioguanine; mercaptopurine; methotrexate; platinum analogs such as cisplatin, oxaliplatin and carboplatin; vinblastine; platinum; etoposide (VP-16); ifosfamide; mitoxantrone; vincristine; NAVELBINE. vinorelbine; novantrone; teniposide; edatrexate; daunomycin; aminopterin; xeloda; ibandronate; irinotecan

(Camptosar, CPT-11) (including the treatment regimen of irinotecan with 5-FU and leucovorin); topoisomerase inhibitor RFS 2000; difluoromethylornithine (DMFO); retinoids such as retinoic acid; capecitabine; combretastatin; leucovorin (LV); oxaliplatin, including the oxaliplatin treatment regimen (FOLFOX); lapatinib (Tykerb); inhibitors of PKC-Ϊ, Raf, H-Ras, EGFR (e.g., erlotinib (Tarceva)) and VEGF-A that reduce cell proliferation, dacogen, velcade, and pharmaceutically acceptable salts, acids or derivatives of any of the above.

In addition, some embodiments of the methods described above can be carried out in combination with radiation therapy, wherein the radiation therapy is effective in treating the above diseases. Techniques for administering radiation therapy are known in the art, and these techniques can be used in the combination therapy described herein.

Embodiments of the method comprise administering compounds that are effective over a wide dosage range. For example, in the treatment of adult humans, dosages from 0.01 to 1000 mg, from 0.5 to 100 mg, from 1 to 50 mg per day, and from 5 to 40 mg per day are examples of dosages. An exemplary dosage is 10 to 30 mg per day. The exact dosage will depend upon the route of administration, the form in which the composition is administered, the subject to be treated, the body weight of the subject to be treated, and the preference and experience of the attending physician.

In embodiments, alvocidib or a prodrug thereof is administered in a dose ranging from about 10 mg/m ² to about 150 mg/m ² per day. In embodiments, alvocidib or a prodrug thereof is administered in a dose ranging from about 50 mg/m ² to about 130 mg/m ² per day. In some embodiments, alvocidib or a prodrug thereof is administered in a dose ranging from about 30 mg/m ² to about 50 mg/m ² per day. In some embodiments, alvocidib or a prodrug thereof is administered in a dose ranging from about 35 mg/m ² to about 45 mg/m ² per day. In some embodiments, alvocidib or a prodrug thereof is administered in a dose ranging from about 550 mg/m ² to about 750 mg/m ² per day. In some embodiments, alvocidib or a prodrug thereof is administered in a dose ranging from about 650 mg/m ² to about 675 mg/m ² per day.

In certain embodiments, the dose of alvocidib or a prodrug thereof ranges from about 30 mg/m ² to about 120 mg/m ² per day. In some such embodiments, the dose of alvocidib or a prodrug thereof is administered via two or more routes of administration. In some embodiments, the method comprises administering a single dose. Typically, such administration will be by injection, e.g., intravenous injection, in order to introduce an effective amount of a compound (e.g., alvocidib) quickly. However, other routes are used as appropriate. For example, in some embodiments, a prodrug of alvocidib is orally administered. In some embodiments, a single dose may also be used for treatment of an acute condition.

In embodiments, alvocidib or a prodrug thereof is administered via a bolus injection in a dose ranging from about 15 mg/m ² to about 35 mg/m ² per day. In some embodiments, alvocidib or a prodrug thereof is administered via a bolus injection in a dose ranging from about 20 mg/m ² to about 30 mg/m ² per day. In some embodiments, alvocidib or a prodrug thereof is administered via intravenous infusion in a dose ranging from about 30 mg/m ² to about 60 mg/m ² per day. In embodiments, alvocidib or a prodrug thereof is administered via bolus injection in a dose ranging from about 45 mg/m ² to about 90 mg/m ² per day. In embodiments, alvocidib or a prodrug thereof is administered via intravenous infusion in a dose ranging from about 90 mg/m ² to about 110 mg/m ² per day.

In some embodiments, alvocidib or a prodrug thereof is administered via a bolus injection in a dose ranging from about 20 mg/m ² to about 40 mg/m ² per day. In some embodiments, alvocidib or a prodrug thereof is administered via intravenous infusion in a dose ranging from about 40 mg/m ² to about 80 mg/m ² per day.

In certain embodiments, alvocidib or a prodrug thereof, is administered via a bolus injection in a dose ranging from about 20 mg/m ² to about 40 mg/m ² per day. In some embodiments, alvocidib or a prodrug thereof, is administered via intravenous infusion in a dose ranging from about 40 mg/m ² to about 80 mg/m ² per day. In some embodiments, the method comprises dosing a compound or compounds in multiple doses. In some embodiments, dosing is about once, twice, three times, four times, five times, six times, or more than six times per day. In other embodiments, dosing is about once a month, once every two weeks, once a week, or once every other day. In yet another embodiment the dosing continues for more than about 6, 10, 14, 28 days, two months, six months, or one year. In some cases, continuous dosing is achieved and maintained as long as necessary.

Treatment may continue as long as necessary. In some embodiments, the method of treating is maintained for more than 1, 2, 3, 4, 5, 6, 7, 14, or 28 days. In some embodiments, the method of treating is continued for less than 28, 14, 7, 6, 5, 4, 3, 2, or 1 day. In some embodiments, the method of treating is chronically on an ongoing basis, e.g., for the treatment of chronic effects.

Compositions

In specific embodiments, therapeutic agents (e.g., alvocidib or a prodrug thereof) are formulated in a conventional manner with one or more physiologically acceptable carriers comprising excipients and auxiliaries which facilitate processing of the compounds into preparations which can be used pharmaceutically. Proper formulation is dependent upon the route of administration chosen.

Any additional pharmaceutically acceptable techniques, carriers, and excipients are used as suitable to formulate the pharmaceutical compositions described herein: Remington: The Science and Practice of Pharmacy, Nineteenth Ed (Easton, Pa. : Mack Publishing Company, 1995); Hoover, John E., Remington's Pharmaceutical Sciences, Mack Publishing Co., Easton, Pennsylvania 1975; Liberman, H.A. and Lachman, L., Eds., Pharmaceutical Dosage Forms, Marcel Decker, New York, N.Y., 1980; and Pharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Ed. (Lippincott Williams & Wilkinsl999).

Furthermore, compounds of the invention (e.g., alvocidib or a prodrug thereof) which exist in free base or acid form can be converted to their pharmaceutically acceptable salts by treatment with the appropriate inorganic or organic base or acid by methods known to one skilled in the art. Salts of the compounds used herein can be converted to their free base or acid form by standard techniques.

Suitable routes of administration include, but are not limited to, oral, intravenous, rectal, aerosol, parenteral, ophthalmic, pulmonary, transmucosal, transdermal, vaginal, otic, nasal, and topical administration. In addition, by way of example only, parenteral delivery includes intramuscular, subcutaneous, intravenous, intramedullary injections, as well as intrathecal, direct intraventricular, intraperitoneal, intralymphatic, and intranasal injections.

In certain embodiments, administering is local rather than systemic, for example, via injection directly into an organ, often in a depot preparation or sustained release formulation. In specific embodiments, long acting formulations are administered by implantation (for example subcutaneously or intramuscularly) or by intramuscular injection. Furthermore, in other embodiments, administering comprises delivering a compound in a targeted drug delivery system, for example, in a liposome coated with organ-specific antibody. In such embodiments, the liposomes are targeted to and taken up selectively by the organ. In yet other embodiments, the administering comprises delivering a rapid release formulation, in the form of an extended release formulation, or in the form of an intermediate release formulation. In yet other embodiments, administering comprises topical administration. In some embodiments, the method comprises administering a suspension, solution, and/or emulsion. In certain embodiments, the method of treating comprises administering a mixture of chemical components, such as carriers, stabilizers, diluents, dispersing agents, suspending agents, thickening agents, and/or excipients.

In one embodiment, the method comprises administering a composition formulated in aqueous solution. In specific embodiments, the aqueous solution is selected from, by way of example only, a physiologically compatible buffer, such as Hank's solution, Ringer's solution, or physiological saline buffer. In other embodiments, the composition is formulated for transmucosal administration. In specific embodiments, the composition formulated for transmucosal administration includes penetrants that are appropriate to the barrier to be permeated. In still other embodiments, compositions are formulated for other parenteral injection methods, wherein appropriate formulations include aqueous or non-aqueous solutions. In specific embodiments, such compositions include physiologically compatible buffers and/or excipients.

In some embodiments, compositions may be administered orally. Thus, in these embodiments, the compositions are formulated in oral dosage forms that include, by way of example only, tablets, powders, pills, dragees, capsules, liquids, gels, syrups, elixirs, slurries, suspensions and the like.

In related embodiments, dosage forms, such as dragee cores and tablets, are provided with one or more suitable coating. In specific embodiments, concentrated sugar solutions are used for coating the dosage form. The sugar solutions optionally contain additional components, such as by way of example only, gum arabic, talc, polyvinylpyrrolidone, carbopol gel, polyethylene glycol, and/or titanium dioxide, lacquer solutions, and suitable organic solvents or solvent mixtures. Dyestuffs and/or pigments are also optionally added to the coatings for identification purposes. Additionally, the dyestuffs and/or pigments are optionally utilized to characterize different combinations of active composition doses.

Oral dosage forms include push-fit capsules made of gelatin, as well as soft, sealed capsules made of gelatin and a plasticizer, such as glycerol or sorbitol. In specific embodiments, push-fit capsules contain the active ingredients in ad-mixture with one or more filler. Fillers include, by way of example only, lactose, binders such as starches, and/or lubricants such as talc or magnesium stearate and, optionally, stabilizers. In other embodiments, soft capsules contain one or more composition that is dissolved or suspended in a suitable liquid. Suitable liquids include, by way of example only, one or more fatty oil, liquid paraffin, or liquid polyethylene glycol. In addition, stabilizers are optionally added.

In other embodiments, therapeutically effective amounts of compounds described herein are formulated and delivered via buccal or sublingual administration. Formulations suitable for buccal or sublingual administration include, by way of example only, tablets, lozenges, or gels. In still other embodiments, compounds are formulated and administered via parental injection, including bolus injection or continuous infusion. In specific embodiments, formulations for injection are presented in unit dosage form (e.g., in ampoules) or in multi-dose containers. Preservatives are, optionally, added to the injection formulations. In still other embodiments, the compounds are formulated and administered in a form suitable for parenteral injection as sterile suspensions, solutions or emulsions in oily or aqueous vehicles. Parenteral injections optionally contain formulatory agents such as suspending, stabilizing and/or dispersing agents. In additional embodiments, suspensions are prepared and administered as appropriate oily injection suspensions. Suitable lipophilic solvents or vehicles for use in the methods described herein include, by way of example only, fatty oils such as sesame oil, or synthetic fatty acid esters, such as ethyl oleate or triglycerides, or liposomes. In certain specific embodiments, aqueous injection suspensions contain substances which increase the viscosity of the suspension, such as sodium carboxymethyl cellulose, sorbitol, or dextran. Optionally, the suspension may contain suitable stabilizers or agents which increase solubility to allow for the preparation of highly concentrated solutions. Alternatively, in other embodiments, the method comprises administering a powder form for constitution with a suitable vehicle, e.g., sterile pyrogen-free water, before use.

In still other embodiments, the method comprises topical administration. Topical administration generally includes topically administrable compositions, such as solutions, suspensions, lotions, gels, pastes, medicated sticks, balms, creams or ointments. Such compositions optionally contain solubilizers, stabilizers, tonicity enhancing agents, buffers and preservatives.

In yet other embodiments, the method comprises transdermal administration. In specific embodiments, transdermal administration employs transdermal delivery devices and transdermal delivery patches and can be lipophilic emulsions or buffered, aqueous solutions, dissolved and/or dispersed in a polymer or an adhesive. In various embodiments, such patches are constructed for continuous, pulsatile, or on demand delivery of pharmaceutical agents. In additional embodiments, the transdermal delivery of the composition is accomplished by means of iontophoretic patches and the like. In certain embodiments, transdermal patches provide controlled delivery of the composition. In specific embodiments, the rate of absorption is slowed by using rate-controlling membranes or by trapping the composition within a polymer matrix or gel. In alternative embodiments, absorption enhancers are used to increase absorption. Absorption enhancers or carriers include absorbable pharmaceutically acceptable solvents that assist passage through the skin. For example, in one embodiment, transdermal devices are in the form of a bandage comprising a backing member, a reservoir containing the composition optionally with carriers, optionally a rate controlling barrier to deliver the composition to the skin of the host at a controlled and predetermined rate over a prolonged period of time, and means to secure the device to the skin.

In still other embodiments, the method comprises rectal administration using a rectal composition such as enemas, rectal gels, rectal foams, rectal aerosols, suppositories, jelly suppositories, or retention enemas, containing conventional suppository bases such as cocoa butter or other glycerides, as well as synthetic polymers such as polyvinylpyrrolidone, PEG, and the like. In suppository forms of the compositions, a low-melting wax such as, but not limited to, a mixture of fatty acid glycerides, optionally in combination with cocoa butter is first melted.

In addition, the compositions used in embodiments of the methods described herein optionally include other medicinal or pharmaceutical agents, carriers, adjuvants, such as preserving, stabilizing, wetting or emulsifying agents, solution promoters, salts for regulating the osmotic pressure, buffers, and/or other therapeutically valuable substances.

In some of the foregoing embodiments, the effective amount is formulated in a composition, wherein the effective amount has a concentration less than 100%, 90%, 80%, 70%, 60%, 50%, 40%, 30%, 20%, 19%, 18%, 17%, 16%, 15%, 14%, 13%, 12%, 11%, 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, 0.5%, 0.4%, 0.3%, 0.2%, 0.1%, 0.09%, 0.08%, 0.07%, 0.06%, 0.05%, 0.04%, 0.03%, 0.02%, 0.01%, 0.009%, 0.008%, 0.007%, 0.006%, 0.005%, 0.004%, 0.003%, 0.002%, 0.001%, 0.0009%, 0.0008%, 0.0007%, 0.0006%, 0.0005%, 0.0004%, 0.0003%, 0.0002%, or 0.0001% w/w, w/v or v/v.

In some other embodiments of the foregoing, the effective amount is formulated in a composition, wherein the effective amount has a concentration greater than 90%, 80%, 70%, 60%, 50%, 40%, 30%, 20%, 19.75%, 19.50%, 19.25% 19%, 18.75%, 18.50%, 18.25% 18%, 17.75%, 17.50%, 17.25% 17%, 16.75%, 16.50%, 16.25% 16%, 15.75%, 15.50%, 15.25% 15%, 14.75%, 14.50%, 14.25% 14%, 13.75%, 13.50%, 13.25% 13%, 12.75%, 12.50%, 12.25% 12%, 11.75%, 11.50%, 11.25% 11%, 10.75%, 10.50%, 10.25% 10%, 9.75%, 9.50%, 9.25% 9%, 8.75%, 8.50%, 8.25% 8%, 7.75%, 7.50%, 7.25% 7%, 6.75%, 6.50%, 6.25% 6%, 5.75%, 5.50%, 5.25% 5%, 4.75%, 4.50%, 4.25%, 4%, 3.75%, 3.50%, 3.25%, 3%, 2.75%, 2.50%, 2.25%, 2%, 1.75%, 1.50%, 125% , 1%, 0.5%, 0.4%, 0.3%, 0.2%, 0.1%, 0.09%, 0.08%, 0.07%, 0.06%, 0.05%, 0.04%, 0.03%, 0.02%, 0.01%, 0.009%, 0.008%, 0.007%, 0.006%, 0.005%, 0.004%, 0.003%, 0.002%, 0.001%, 0.0009%, 0.0008%, 0.0007%, 0.0006%, 0.0005%, 0.0004%, 0.0003%, 0.0002%, or 0.0001% w/w, w/v, or v/v.

In some related embodiments, the effective amount has a concentration in the range from approximately 0.0001%) to approximately 50%, from approximately 0.001 ) to approximately 40%, from approximately 0.01% to approximately 30%, from approximately 0.02% to approximately 29%, from approximately 0.03% to approximately 28%, from approximately 0.04% to approximately 27%, from approximately 0.05% to approximately 26%, from approximately 0.06% to approximately 25%, from approximately 0.07% to approximately 24%, from approximately 0.08% to approximately 23%, from approximately 0.09% to approximately 22%, from approximately 0.1% to approximately 21%, from approximately 0.2% to approximately 20%, from approximately 0.3% to approximately 19%), from approximately 0.4% to approximately 18%, from approximately 0.5% to approximately 17%, from approximately 0.6% to approximately 16%, from approximately 0.7% to approximately 15%, from approximately 0.8% to approximately 14%), from approximately 0.9% to approximately 12%, or from approximately 1% to approximately 10% w/w, w/v or v/v.

In some other related embodiments, the effective amount is in the range from approximately 0.001%) to approximately 10%, from approximately 0.01% to approximately 5%, from approximately 0.02% to approximately 4.5%, from approximately 0.03% to approximately 4%, from approximately 0.04% to approximately 3.5%, from approximately 0.05% to approximately 3%, from approximately 0.06% to approximately 2.5%, from approximately 0.07% to approximately 2%, from approximately 0.08% to approximately 1.5%, from approximately 0.09% to approximately 1%, or from approximately 0.1% to approximately 0.9% w/w, w/v or v/v.

In some embodiments, the effective amount is equal to or less than 10 g, 9.5 g, 9.0 g, 8.5 g, 8.0 g, 7.5 g, 7.0 g, 6.5 g, 6.0 g, 5.5 g, 5.0 g, 4.5 g, 4.0 g, 3.5 g, 3.0 g, 2.5 g, 2.0 g, 1.5 g, 1.0 g, 0.95 g, 0.9 g, 0.85 g, 0.8 g, 0.75 g, 0.7 g, 0.65 g, 0.6 g, 0.55 g, 0.5 g, 0.45 g, 0.4 g, 0.35 g, 0.3 g, 0.25 g, 0.2 g, 0.15 g, 0.1 g, 0.09 g, 0.08 g, 0.07 g, 0.06 g, 0.05 g, 0.04 g, 0.03 g, 0.02 g, 0.01 g, 0.009 g, 0.008 g, 0.007 g, 0.006 g, 0.005 g, 0.004 g, 0.003 g, 0.002 g, 0.001 g, 0.0009 g, 0.0008 g, 0.0007 g, 0.0006 g, 0.0005 g, 0.0004 g, 0.0003 g, 0.0002 g, or 0.0001 g.

In some embodiments, the effective amount is more than 0.0001 g, 0.0002 g, 0.0003 g, 0.0004 g, 0.0005 g, 0.0006 g, 0.0007 g, 0.0008 g, 0.0009 g, 0.001 g, 0.0015 g, 0.002 g, 0.0025 g, 0.003 g, 0.0035 g, 0.004 g, 0.0045 g, 0.005 g, 0.0055 g, 0.006 g, 0.0065 g, 0.007 g, 0.0075 g, 0.008 g, 0.0085 g, 0.009 g, 0.0095 g, 0.01 g, 0.015 g, 0.02 g, 0.025 g, 0.03 g, 0.035 g, 0.04 g, 0.045 g, 0.05 g, 0.055 g, 0.06 g, 0.065 g, 0.07 g, 0.075 g, 0.08 g, 0.085 g, 0.09 g, 0.095 g, 0.1 g, , 0.15 g, 0.2 g, , 0.25 g, 0.3 g, , 0.35 g, 0.4 g, , 0.45 g, 0.5 g, 0.55 g, 0.6 g, , 0.65 g, 0.7 g, 0.75 g, 0.8 g, 0.85 g, 0.9 g, 0.95 g, 1 g, 1.5 g, 2 g, 2.5, 3 g, 3.5, 4 g, 4.5 g, 5 g, 5.5 g, 6 g, 6.5g, 7 g, 7.5g, 8 g, 8.5 g, 9 g, 9.5 g, or 10 g.

In some embodiments, the effective amount is in the range of 0.0001-10 g, 0.0005-9 g, 0.001-8 g, 0.005-7 g, 0.01-6 g, 0.05-5 g, 0.1-4 g, 0.5-4 g, or 1-3 g.

The following embodiments are included within the scope of this disclosure. 1. A method for treating a cancer in a subject in need thereof, the method comprising administering an effective amount of a treatment regimen comprising alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, wherein the cancer is BCL-2 inhibitor resistant and wherein the subject is non- responsive or resistant to a prior treatment with a BCL-2 inhibitor, thereby treating the cancer in the subject. 2. A method for treating a cancer in a subject in need thereof, the method comprising:

determining that the cancer is BCL-2 inhibitor resistant; and administering an effective amount of a treatment regimen comprising alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, to the subject, thereby treating the cancer.

3. A method for treating a cancer in a subject in need thereof, the method comprising:

identifying the subject as likely to respond to treatment with alvocidib or a prodrug thereof if the cancer is BCL-2 inhibitor resistant and the subject is non- responsive or resistant to a prior treatment with a BCL-2 inhibitor; and

administering a treatment regimen comprising an effective amount of alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, to the subject. 4. A method for treating a cancer in a subject in need thereof, the method comprising:

administering a treatment regimen comprising alvocidib or a prodrug thereof, or a pharmaceutically acceptable salt thereof, to the subject, the cancer being BCL-2 inhibitor resistant as determined by an in vitro method comprising:

obtaining a cancer cell from the subject; and

i) quantifying expression of BCL-2 and MCL-1 in the cancer cell, wherein an increase in MCL-1 expression relative to BCL-2 expression indicates the subject has a BCL-2 inhibitor resistant cancer;

ii) determining dependency on BCL-2 in the cancer cell, wherein a low BCL-2 dependency indicates the subject has a BCL-2 inhibitor resistant cancer; or

iii) determining dependency on MCL-1 in the cancer cell, wherein a high MCL-1 dependency indicates the subject has a BCL-2 inhibitor resistant cancer. 5. The method of any one of embodiments 1-4, wherein the subject has a chromosome 17p deletion.

6. The method of any one of embodiments 1-5, wherein the cancer is a hematologic cancer. 7. The method of embodiment 6, wherein the hematologic cancer is selected from the group consisting of acute myelogenous leukemia (AML), multiple myeloma, follicular lymphoma, acute lymphoblastic leukemia (ALL), chronic lymphocytic leukemia, and non-Hodgkin's lymphoma.

8. The method of embodiment 7, wherein the hematologic cancer is acute myelogenous leukemia (AML).

9. The method of embodiment 8, wherein the AML is relapsed or refractory AML.

10. The method of embodiment 8, wherein the AML is frontline

AML. 11. The method of embodiment 7, wherein the hematologic cancer is multiple myeloma.

12. The method of embodiment 6, wherein the hematologic cancer is myelodysplasic syndrome (MDS).

13. The method of embodiment 10, wherein the MDS is high risk MDS.

14. The method of embodiment 6, wherein the hematologic cancer is chronic lymphocytic leukemia (CLL). 15. The method of any one of embodiments 1-5, wherein the cancer is a solid cancer.

16. The method of embodiment 15, wherein the solid cancer is prostate cancer.

17. The method of embodiment 15, wherein the solid cancer is breast cancer.

18. The method of embodiment 15, wherein the solid cancer is lung cancer.

19. The method of any one of embodiments 15-18, wherein the solid cancer comprises one or more solid tumors.

20. The method of any one of embodiments 1-19, wherein the treatment regimen further comprises cytarabine and mitoxantrone.

21. The method of any one of embodiments 1-19, wherein the treatment regimen further comprises cytarabine and daunorubicin.

22. The method of any one of embodiments 1-21, wherein the treatment regimen comprises the prodrug of alvocidib.

23. The method of any one of embodiments 1-22, wherein the prodrug of alvocidib is a phosphate prodrug.

24. The method of embodiment 23, wherein the phosphate prodrug of alvocidib has the following structure:

25. The method of any one of embodiments 1-21, wherein the treatment regimen comprises alvocidib.

26. The method of any one of embodiments 2 or 4-25, wherein the subject has received a prior treatment with a BCL-2 inhibitor.

27. The method of embodiment 26, wherein the subject is non- responsive or resistant to the prior treatment with the BCL-2 inhibitor.

28. The method of any one of embodiments 1-27, wherein the BCL-2 inhibitor is Venetoclax. 29. The method of any one of embodiments 1-28, wherein the subject has an MCL-1 dependency percentage of at least 15%, the MCL-1 dependency percentage having been obtained by an in vitro method comprising contacting a first portion of a plurality of cancer cells with a profiling peptide comprising a cellular uptake moiety and an MCL-1 binding domain, the MCL-1 binding domain having the sequence of SEQ ID NO: 1 or SEQ ID NO:2

30. The profiling peptide of embodiment 29, wherein the profiling peptide consists of the sequence of SEQ ID NO: 1 or SEQ ID NO:2.

31. The profiling peptide of embodiment 29, wherein the profiling peptide comprises the sequence of SEQ ID NO: 1. 32. The profiling peptide of embodiment 29, wherein the profiling peptide comprises the sequence of SEQ ID NO:2.

33. The method of any one of embodiments 29-32, wherein the subject has an MCL-1 dependency percentage of at least 20%.

34. The method of any one of embodiments 29-33, wherein the subject has an MCL-1 dependency percentage of at least 30%.

35. The method of any one of embodiments 29-34, wherein the subject has an MCL-1 dependency percentage of at least 40%.

36. The method of any one of embodiments 29-35, wherein the in vitro method further comprises:

contacting a second portion of the plurality of cancer cells with a negative control; and

determining a percent polarization of the first portion and of the second portion of the plurality of cancer cells.

37. The method of embodiment 36, wherein the in vitro method further comprise determining a Mcl-1 dependency percentage (MDP) based at least on the percent polarization of the first portion and of the second portion of the plurality of cancer cells.

38. The method of embodiment 36 or 37, wherein the negative control is water.

39. The method of any one of embodiments 36-38, wherein the in vitro method further comprises contacting a third portion of the plurality of cancer cells with a positive control. 40. The method of embodiment 39, wherein the positive control is Carbonyl cyanide-4-(trifluoromethoxy)phenylhydrazone (FCCP), Carbonyl cyanide m- chlorophenyl hydrazone (CCCP), or N5,N6-bis(2-fluorophenyl)-[l,2,5]oxadiazolo[3,4- b]pyrazine-5,6-diamine (BAM-15). 41. The method of embodiment 39 or 40, wherein the positive control is CCCP.

42. The method of any one of embodiments 39-41, wherein the in vitro method further comprises contacting the first portion, the second portion, and the third portion of the plurality of cells with a detecting agent. 43. The method of embodiment 42, wherein the detecting agent is a dye.

44. The method of embodiment 43, wherein the dye is a 3,3'- Dihexyloxacarbocyanine Iodide (DiOC ₆ ). Embodiments of this disclosure are further illustrated by the following non-limiting examples.

EXAMPLES EXAMPLE 1

DOSE-DEPENDENT MCL-1 PROTEIN REDUCTION IN MV-4-11 CELLS An AML cell line, MV-4-11, expresses MCL-1. MCL-1 is a key anti- apoptotic protein in MV-4-11 cells. Alvocidib, a CDK9 inhibitor, lowers the expression of MCL-1 in mRNA, which is already well documented in the literature. As a result, alvocidib decreases MCL-1 expression in MV-4-11 in a dose dependent manner (Figure 1). The dose dependence is observed by monitoring the relative expression of MCL-1 compared to controls when cells are dosed with alvocidib at concentrations ranging from 0 - 8 μΜ. MV-4-11 cells were treated with alvocidib in vitro, harvested and analyzed to probe for changes relative to controls.

Additionally, other exemplary CDK9 inhibitors (i.e., palbociclib and dinaciclib) were evaluated, along with alvocidib. Each exemplary CDK9 inhibitor showed decreased MCL-1 expression in MV-4-11 cells after a 24 hour treatment. Alvocidib, the most potent CDK9 inhibitor of the group, demonstrated the strongest impact on MCL-1 protein levels (Figure 2).

EXAMPLE 2

IN VIVO AND IN VITRO ACTIVITY OF ALVOCIDIB IN AML CELLS RESISTANT TO VENETOCLAX

Alvocidib was used alone to test in vivo activity in OCI-AML3 cells. The OCI-AML3 cells are highly resistant to Venetoclax/ABT-199 (EC ₅₀ = 2330 nM). To test the in vivo activity, immune deficient mice injected with OCI-AML3 cells were treated with 2.5 mg/kg of alvocidib via intraperitoneal injection or 100 mg/kg of Venetoclax/ABT-199 per os (i.e., oral administration). Each treatment (i.e., alvocidib and Venetoclax/ABT-199) was administered once a day for 21 days. Venetoclax/ABT- 199 showed no decrease in tumor volume relative to vehicle alone treatment while treatment with alvocidib alone demonstrated a remarkable 50 % reduction in tumor growth by day 21 of treatment (Figure 3). The extraordinary reduction in tumor growth demonstrates that treatment of BCL-2 inhibitor-resistant patients with an MCL-1 inhibitor unexpectedly and advantageously provides treatment options beyond Venetoclax/ABT-199.

Alvocidib also shows in vitro activity in OCI-AML3 cells. MCL-1 expression was decreased in OCI-AML3 cells at multiple time points following treatment with alvocidib (Figure 4). EXAMPLE 3

IN VITRO ACTIVITY OF ALVOCIDIB IN ERYTHROLEUKEMIA CELLS RESISTANT TO VENETOCLAX

To assess the effects of alvocidib or Venetoclax treatment on leukemic cells, the erythroleukima cell line, HEL, was cultured in RPMI media supplemented with 10% FBS and penicillin/streptomycin. Cell viability was assessed in treated cells using the CellTiter-Glo reagent (Promega), according to manufacturer protocol. Cells were treated in 96-well plates for 72 hours, before being analyzed in a luminescence compatible plate reader. Curve fitting and analysis was performed using Graphpad Prism software.

EXAMPLE 4

IN VITRO ACTIVITY OF ALVOCIDIB IN MULTIPLE MYELOMA CELLS RESISTANT TO VENETOCLAX

To assess the effects of alvocidib or Venetoclax treatment on multiple myeloma cells, OPM2 cells were cultured in RPMI media supplemented with 10% FBS and penicillin/streptomycin. Cell viability was assessed in treated cells using the CellTiter-Glo reagent (Promega), according to manufacturer protocol. Cells were treated in 96-well plates for 72 hours, before being analyzed in a luminescence compatible plate reader. Curve fitting and analysis was performed using Graphpad Prism software.

From the foregoing it will be appreciated that, although specific embodiments of the invention have been described herein for purposes of illustration, various modifications may be made without deviating from the spirit and scope of the invention. U.S. provisional patent application Serial No. 62/557,635, filed September 12, 2017 is incorporated herein by reference, in its entirety. Accordingly, the invention is not limited except as by the appended claims.