Cell-resolved high-dimensional imaging analysis, therapeutic modeling, and a Phase Ib clinical study validate BCL-2 as a target across heterogeneous CRPC subtypes

BCL-2 has been implicated in prostate cancer (PCa) progression and development of castration-resistant disease (CRPC). However, it remains unclear how the BCL-2- and AR-expressing PCa cell populations evolve across the PCa continuum, how AR molecularly regulates BCL-2 and whether BCL-2 represents a common therapeutic target in heterogeneous CRPC. Importantly, BCL-2 inhibitors have yet to be approved for treating PCa patients. Here we first show the selective induction of BCL-2 by AR pathway inhibitors (ARPIs) in both patient specimens and xenograft models. Vectra-based quantitative multiplex immunofluorescence (qmIF) and image mass cytometry (IMC) analyses with single-cell resolution reveal markedly expanded BCL-2+ (AR+ or AR-) PCa cell populations in CRPC. Mechanistically, AR represses BCL-2 transcription through genomic binding via several AR binding sites and ARPIs relieve this repression, leading to BCL-2 upregulation. Comprehensive therapeutic studies in cells, organoids and xenografts establish that castration-induced BCL-2 is not merely associated with resistance but represents a shared and actionable vulnerability as the BCL-2 inhibitor ABT-199 potently suppressed the growth of multiple subtypes of CRPC. A Phase Ib clinical trial (NCT03751436) combining enzalutamide and BCL-2 inhibitor venetoclax demonstrated reduced circulating tumor cells in responding patients. Together, our findings elucidate the AR+/-BCL-2+/- PCa cell subpopulation dynamics during PCa progression, reveal a direct mechanistic link between AR inhibition and BCL-2-mediated resistance, and provide a strong rationale for targeting BCL-2 from the outset to eliminate emerging resistant subpopulations, inhibit treatment-induced cellular heterogeneity and plasticity, and improve therapeutic outcomes in CRPC.