33TP53 mutations in cancer are associated with poor patient outcomes and resistance to 34 DNA damaging therapies 1-3 . However, the mechanisms underlying treatment resistance 35 in p53-deficient cells remain poorly characterized. Here, we show that p53-deficient 36 cells exhibit hyperactive repair of therapy-induced DNA double strand breaks (DSBs), 37 which is suppressed by inhibition of DNA-dependent protein kinase (DNA-PK). Single-38 cell analyses of DSB repair kinetics and cell cycle state transitions reveal an essential 39 role for DNA-PK in suppressing S phase DNA damage and mitotic catastrophe in p53-40 deficient cells. Yet, a subset of p53-deficient cells exhibit intrinsic resistance to 41 therapeutic DSBs due to a repair pathway that is not sensitive to DNA-PK inhibition. 42We show that p53 deficiency induces overexpression of DNA Polymerase Theta (Pol ), 43 which mediates an alternative end-joining repair pathway that becomes hyperactivated 44 by DNA-PK inhibition 4 . Combined inhibition of DNA-PK and Pol restores therapeutic 45 DNA damage sensitivity in p53-deficient cells. Thus, our study identifies two targetable 46 DSB end joining pathways that can be suppressed as a strategy to overcome resistance 47The mechanisms for therapeutic resistance in p53-deficient cells remains poorly 57 characterized. Past work has suggested a role for loss of p53-mediated apoptosis 12,15 . 58However, the response of epithelial cancer cells to DNA damaging therapy is often 59 determined by the efficiency of inducing senescence or mitotic catastrophe, rather than 60 apoptosis 16,17 . p53 is also a transcription factor that responds to DNA double strand 61 breaks (DSBs) to determine cellular fate 7,18 . Recent insights have revealed the 62 importance of p53-signaling waves in regulation of cellular fate decisions of quiescence 63 versus cell cycle re-entry after DNA damage 19,20 . However, the mechanisms that 64 determine such cell fate decisions upon DNA damage induction in p53-mutant epithelial 65 cells have not been established, and may lead to novel strategies to restore treatment 66
sensitivity. 67In this study, we investigate altered DNA repair mechanisms in p53 deficiency as 68 a major contributor to resistance to DNA damaging therapies. We find that p53-deficient 69 cells exhibit hyperactive repair and accelerated resolution of DNA damage foci. Utilizing 70 live-cell imaging, we show that this ability to resolve DNA damage rapidly is partially 71 dependent on DNA-PK, a critical serine/threonine kinase in the non-homologous end 72 joining (NHEJ) pathway 21 . Inhibition of DNA-PK using the small molecule inhibitor 73 NU7441 partially sensitizes p53-deficient cells to DSB inducing agents. We further show 74 that this effect is specifically due to propagation of S phase related damage leading to 75 mitotic catastrophe, highlighting a role for DNA-PK in S phase DNA damage repair that 76 was previously under appreciated. Furthermore, using chromosomal break repair 77 assays we show that in the context of inhibitor t...