Edited by Patrick SungCombining DNA-damaging drugs with DNA checkpoint inhibitors is an emerging strategy to manage cancer. Checkpoint kinase 1 inhibitors (CHK1is) sensitize most cancer cell lines to DNA-damaging drugs and also elicit single-agent cytotoxicity in 15% of cell lines. Consequently, combination therapy may be effective in a broader patient population. Here, we characterized the molecular mechanism of sensitization to gemcitabine by the CHK1i MK8776. Brief gemcitabine incubation irreversibly inhibited ribonucleotide reductase, depleting dNTPs, resulting in durable S phase arrest. Addition of CHK1i 18 h after gemcitabine elicited cell division cycle 7 (CDC7)-and cyclin-dependent kinase 2 (CDK2)-dependent reactivation of the replicative helicase, but did not reinitiate DNA synthesis due to continued lack of dNTPs. Helicase reactivation generated extensive singlestrand (ss)DNA that exceeded the protective capacity of the ssDNA-binding protein, replication protein A. The subsequent cleavage of unprotected ssDNA has been termed replication catastrophe. This mechanism did not occur with concurrent CHK1i plus gemcitabine treatment, providing support for delayed administration of CHK1i in patients. Alternative mechanisms of CHK1i-mediated sensitization to gemcitabine have been proposed, but their role was ruled out; these mechanisms include premature mitosis, inhibition of homologous recombination, and activation of double-strand break repair nuclease (MRE11). In contrast, single-agent activity of CHK1i was MRE11-dependent and was prevented by lower concentrations of a CDK2 inhibitor. Hence, both pathways require CDK2 but appear to depend on different CDK2 substrates. We conclude that a small-molecule inhibitor of CHK1 can elicit at least two distinct, context-dependent mechanisms of cytotoxicity in cancer cells. . 2 The abbreviations used are: CHK1i, checkpoint kinase 1 inhibitor; ssDNA, single-strand DNA; TBS, Tris-buffered saline; FBS, fetal bovine serum; HRP, horseradish peroxidase; RPA, replication protein A; ␥H2AX, pSer-139 histone 2AX; PCNA, proliferating cell nuclear antigen; CDK, cyclin-dependent kinase; ATR, ATM and Rad3-related; DAPI, 4Ј,6-diamidino-2-phenylindole.Figure 11. Proposed mechanism of replication catastrophe from gemcitabine plus delayed CHK1i. The normal firing of early replication origins involves CDC7-dependent phosphorylation of the MCM2-7 DNA helicase core and CDK2-dependent loading of the helicase co-factor, CDC45. Gemcitabine arrests replication by depleting dNTPs. Accumulation of RPA at stalled replication forks activates the DNA-damage response through ATR and CHK1. Over time, replication machinery dissociates from stalled replication forks, preventing their restart. CHK1 prevents firing of dormant origins. Inhibition of CHK1 activates CDK2 which, in concert with CDC7, leads to CDC45 loading and dormant origin firing. Active helicases unwind DNA, but in the continued absence of dNTPs, extensive single-strand DNA is produced that exceeds the ability of replication protein A to p...