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  • Knowledge of drug actions, clinical toxicities, pharmacokinetics, and drug interactions is essential for the safe and effective administration of cancer chemotherapy.

  • Base treatment on evidence from clinical trials.

  • Use established regimens and recheck doses.

  • Choice of a particular drug treatment program should depend on the disease, histology, and stage of the disease and on an assessment of individual patient tolerance.

  • High-dose chemotherapy programs used in autologous and allogeneic hematopoietic cell transplantation result in additional organ toxicities that are not seen at conventional doses.

  • Chemotherapy often targets process of DNA replication.

  • More recently, drugs have been introduced to target specific cellular processes, including receptor signaling, inhibition of oncoproteins, angiogenesis, and membrane cluster of differentiation antigens.


  • Combination chemotherapy uses several drugs simultaneously based on certain empiric principles:

    — Each drug selected has demonstrable antitumor activity against the neoplasm for which it is used.

    — Each drug should have a different mechanism of action.

    — The drugs should not have a common mechanism of resistance.

    — Drug dose-limiting toxicities should not overlap.

    — Specific combinations chosen should be based on preclinical and clinical protocol-based evidence of synergistic activity.


  • Cell cycle–specific agents, such as antimetabolites, kill cells as they traverse the DNA synthetic phase (S phase) of the cell cycle.

    — Diminished killing of resting cells occurs.

    — Prolonged exposure to drug is useful for minimizing effects of asynchronous cell division.

    — High-dose regimens are the most useful.

  • Non–cell cycle–dependent agents do not require cells to be exposed during a specific phase of the cell cycle.

    — Total dose of drug is more important than duration of exposure.

    — Appropriate dose depends on cell cycle dependence, toxicity to marrow and other tissues, pharmacokinetic behavior, interaction with other drugs, and patient tolerance.


  • The basis for drug resistance is spontaneous occurrence of resistant cancer cell mutants and selection of drug-resistant cells under pressure of chemotherapy (clonal selection).

  • Mechanisms such as additional mutations in mismatched repair genes and genes that block apoptosis also operate to impair treatment efficacy.

  • Use of multiple drugs not sharing resistance mechanisms should be more effective than single agents.

  • Multiple agents should be used simultaneously, because the probability of double- or triple-resistant cells is the product of the probabilities of the independent drug-resistant mutations occurring simultaneously in the same cell.



  • Methotrexate is used for maintenance therapy of acute lymphocytic leukemia, combination chemotherapy of lymphomas, and treatment and prophylaxis of meningeal leukemia.

  • This agent inhibits dihydrofolate reductase, which leads to depletion of cellular folate coenzymes and to inhibition of DNA synthesis and cessation of cell replication.

  • Acquired resistance is a result of increased levels of dihydrofolate reductase via gene amplification, defective ...

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