Tumors initiate when a population of proliferating cells accumulates a certain number and type of genetic and/or epigenetic alterations. The population dynamics of such sequential acquisition of (epi)genetic alterations has been the topic of much investigation. The phenomenon of stochastic tunneling, where an intermediate mutant in a sequence does not reach fixation in a population before generating a double mutant, has been studied using a variety of computational and mathematical methods. However, the field still lacks a comprehensive analytical description since theoretical predictions of fixation times are available only for cases in which the second mutant is advantageous. Here, we study stochastic tunneling in a Moran model. Analyzing the deterministic dynamics of large populations we systematically identify the parameter regimes captured by existing approaches. Our analysis also reveals fitness landscapes and mutation rates for which finite populations are found in long-lived metastable states. These are landscapes in which the final mutant is not the most advantageous in the sequence, and resulting metastable states are a consequence of a mutationselection balance. The escape from these states is driven by intrinsic noise, and their location affects the probability of tunneling. Existing methods no longer apply. In these regimes it is the escape from the metastable states that is the key bottleneck; fixation is no longer limited by the emergence of a successful mutant lineage. We used the so-called Wentzel-Kramers-Brillouin method to compute fixation times in these parameter regimes, successfully validated by stochastic simulations. Our work fills a gap left by previous approaches and provides a more comprehensive description of the acquisition of multiple mutations in populations of somatic cells.KEYWORDS stochastic modeling; population genetics; cancer; Moran process; WKB method U NDERSTANDING the dynamics of an evolving population structure has long been the goal of population genetics. Several authors have constructed probabilistic models to study allele frequency distributions in populations subject to mutation, selection, and genetic drift (Fisher 1930;Wright 1931;Moran 1962). The mathematical analysis of these models leads to an improved understanding of the underlying system and has been crucial for the interpretation of the laws of evolution. This is most evident in the quantitative analysis of cancer, which has seen numerous studies throughout the 20th century that addressed the kinetics of cancer initiation and progression (Nordling 1953;Armitage and Doll 1954;Fisher 1958;Knudson 1971;Moolgavkar 1978). Due to these and other studies (see Weinberg 2013 for a review), we now know that human cancer initiates when cells within a proliferating tissue accumulate a certain number and type of genetic and/or epigenetic alterations. These alterations can be point mutations, amplification and deletion of genomic material, structural changes such as translocations, loss or gain of DNA methylation...