Initial tumor composition shapes resistance evolution and treatment outcomes in non-small cell lung cancer

Drug resistance is a leading cause of treatment failure in non-small cell lung cancer (NSCLC), yet how resistance evolves during treatment and whether its fitness consequences depend on tumor composition remains poorly understood. Using a game-theoretic mathematical model fitted to longitudinal in-vitro data from alectinib-sensitive and alectinib-resistant H3122 NSCLC cells grown under different treatment and microenvironmental conditions, we found that the fitness effect of evolving resistance depended critically on the initial proportion of resistant cells in the tumor. When resistant cells were initially rare, resistance evolved faster and increasing resistance was associated with a growth advantage. When resistant cells were initially frequent, increasing resistance was associated with a fitness cost. In both cases, increasing resistance eroded treatment efficacy. In the gain-of-resistance regime, stabilization therapy could maintain a stable tumor equilibrium only if resistant cells were excluded. Maximum tolerated dosing was not always optimal for maximizing time to progression; intermediate doses performed better when they kept the initial tumor growth rate close to zero. These results suggest that evolutionary therapy for NSCLC should account not only for the abundance of resistant cells, but also for how resistance is evolving and what fitness consequences it currently carries in individual patients.