Fig. 1: Combined fulvestrant, CDK4/6i and AKTi is required to significantly and durably inhibit growth in ER+ fulvestrant-resistant breast cancer cell lines.

The effect of fulvestrant (Fulv, 100 nM), CDK4/6 inhibitor (CDK4/6i, palbociclib, 200 nM in the MCF-7 and T47D cell models; 5 µM in the ZR-75-1 cell model) and AKT inhibitor (AKTi, capivasertib, 500 nM in the MCF-7 cell model; 200 nM in the T47D model; 150 nM in the ZR-75-1 cell model), as single agents or in double and triple combinations, was assessed in all cell lines by crystal violet growth assay (A, B, E, F, I and J) and CellTiter-Blue viability assay (C, D, G, H, K, and L) performed over 6 days. Outgrowth of resistant colonies was investigated in MCF-7 (M and N) and T47D models (O and P) by weekly evaluation of the percentage of 48 wells at 50% or greater confluence (positive wells) over 12 weeks. Experiments were conducted in three biological replicates and data are shown as mean ± SEM. Asterisks indicate significant differences in the one-way ANOVA test at day 6 (*0.01 < p < 0.05, **0.001 < p < 0.01, ***0.0001 < p < 0.001, and ****p < 0.0001).