What does BCL-2 do? From new molecular insights to the clinical implications.

It took decades from the discovery of BCL-2, initially identified in chromosomal translocations associated with lymphoid malignancies, to understand how BCL-2 and its family members regulate apoptosis, launching a transformative journey in cancer biology often called "the road to ruin". Developing powerful BCL-2 inhibitors for clinical use required decades. Yet, this remains as one of the most successful achievements in a field that started ~40 years ago, as recounted by its pioneers. BCL-2 was later found to inhibit apoptosis by preventing mitochondrial outer membrane permeabilization (MOMP), a breakthrough that clarified its role in cancer pathogenesis. Such effects of BCL-2 on MOMP prevent cytochrome c release and caspase activation, while its family members-anti-apoptotic proteins (e.g. BCL-2, BCL-XL) and pro-apoptotic proteins (e.g. BAX, BAK, BH3-only proteins)-orchestrate a delicate balance in cell death regulation. MicroRNAs like miR-15/16, often deleted in chronic lymphocytic leukaemia (CLL), modulate BCL-2 expression, driving oncogenesis. Mechanistically, BAX/BAK oligomerization forms mitochondrial pores, with sublethal MOMP triggering inflammation via cGAS-STING and NF-κB pathways. Alternative MOMP inducers (e.g. BOK) and mitochondrial dynamics further refine apoptotic control. Clinically, the BCL-2 inhibitor venetoclax has revolutionized CLL and acute myeloid leukemia (AML) treatment, showing efficacy in TP53-mutant CLL and elderly AML patients when combined with CD20 antibodies or hypomethylating agents. However, resistance, driven by BCL-2 mutations (e.g. Gly101Val) or MCL-1 upregulation, poses challenges. Limited success in solid tumors underscores the complexity of BCL-2 family dependencies. Future directions include novel inhibitors targeting MCL-1 or BCL-XL, BH3 profiling for precision therapy, and combinations with immune or DNA repair modulators. Non-apoptotic roles of BCL-2 in metabolism also warrant exploration. This review highlights the clinical success of BCL-2 inhibitors, addresses resistance mechanisms, and explores future directions, including sublethal MOMP, inflammatory outcomes, and novel inhibitors. Celebrating the collaborative, interdisciplinary efforts that transformed fundamental discoveries into life-saving therapies, this account underscores both the triumphs and the "potholes" encountered on the path to understanding apoptosis, while identifying open questions for ongoing research.