Criticality in Tumor Evolution and Clinical Outcome

Abstract How mutation and selection determine the fitness landscape of tumors and hence clinical outcome is an open fundamental question in cancer biology, crucial for the assessment of therapeutic strategies and resistance to treatment. Here we explore the mutation-selection phase-diagram of 6721 primary tumors representing 23 cancer types, by quantifying the overall somatic point mutation load ( ML ) and selection ( dN/dS ) in the entire proteome of each tumor. We show that ML strongly correlates with patient survival, revealing two opposing regimes around a critical point. In low ML cancers, high number of mutations indicates poor prognosis, whereas high ML cancers show the opposite trend, due to mutational meltdown. Although the majority of cancers evolve near neutrality, deviations are observed at extreme MLs . Cancers with the highest ML evolve under purifying selection, whereas those with the lowest ML show signatures of positive selection, demonstrating how selection affects cancer fitness. Moreover, different cancers occupy specific positions on the ML-dN/dS plane, revealing a diversity of evolutionary trajectories. These results support and expand the theory of tumor evolution and its non-linear effects on survival. Significance Statement It remains an open fundamental question how mutation and selection co-determine the course of cancer evolution. We construct a selection-mutation phase diagram, using tumor mutation load and selection strength as key variables, and assess their association with clinical outcome. We demonstrate the existence of a biphasic evolutionary regime, whereby beyond a critical ML , the fitness of tumors decreases with the number of mutations, while the proteome evolves near neutrality. Deviations from neutrality in extreme ML elucidate how positive and purifying selections maintain tumor fitness. These results empirically corroborate the existence of a critical state in cancer evolution predicted by theory, and have fundamental and likely clinical implications.