Anticancer Drugs

Cancer
• Cancer is a large group of diseases that can start in almost any organ or tissue of the
body.
• Cancer is a disease in which some of the body’s cells grow uncontrollably and go
beyond their usual boundaries to invade adjoining parts of the body and/or spread to
other organs.
• Cancerous tumors spread into, or invade, nearby tissues and can travel to distant
places in the body to form new tumors. This latter process is called metastasis and is
a major cause of death from cancer.
• A neoplasm and malignant tumor are other common names for cancer.
• Many cancers form solid tumors, but cancers of the blood, such as leukemias,
generally do not.
 Cancer
• Normally, human cells grow and multiply through a process
called cell division to form new cells as the body needs them. When cells
grow old or become damaged, they die, and new cells replace them.
• In cancer, this orderly process is disrupted, and abnormal or damaged
cells grow and multiply when they shouldn’t.
• Unlike normal cells, cancer cells ignore signals to stop dividing, or to die
and be shed. Growing in an uncontrollable manner and unable to
recognize its own natural boundary.
 Cancer
• Cancer is the second leading cause of death globally, accounting for an estimated 9.6 million
deaths, or one in six deaths, in 2018.
• Cancer is a genetic disease—that is, it is caused by changes to genes that control the way our
cells function, especially how they grow and divide.
• A normal cell turns into a cancer cell because of one or, more often, several mutations in its
DNA- neoplastic transformation
These genetic changes can be inherited or acquired. Acquired genetic changes can occur due to
certain environmental exposures such as:
Radiation- Exposure to radiation (UV,and ionizing radiation such as X-rays, gamma rays) has been
well documented as a significant risk factor for a number of cancers, including acute leukemias,
thyroid cancer, breast cancer, lung cancer, etc.,
Viruses - Several viruses have been implicated in the etiology of human cancers. For example,
hepatitis B (HBV) and hepatitis C (HCV) are associated with the development of hepatocellular
cancer.
 Chemical carcinogens e.g. tobacco products, asbestos, azo dyes.
 Genetic changes can also occur due to errors during cell division.
For example in breast cancer, women who inherit a single defective copy of either of the tumour
suppressor genes BRCA1 and BRCA2 have a significantly increased risk of developing breast cancer.
• Lung, prostate, colorectal, stomach and liver cancer are the most common types of cancer in men,
while breast, colorectal, lung, cervical and thyroid cancer are the most common among women.
The genetic changes that contribute to cancer tend to affect
three main types of genes:

• Proto-oncogenes
• Tumor suppressor genes
• DNA repair genes.
These genetic changes are sometimes called “drivers” of cancer.

About 30 tumour suppressor genes and 100 dominant oncogenes have been
identified. The changes that lead to malignancy are a result of point mutations,
gene amplification or chromosomal translocation.
The 10 Hallmarks of Cancer
 Pathogenesis of Cancer
Genetic changes underlying the pathogenesis of cancer include:
1.The activation of proto-oncogenes to oncogenes. Proto-oncogenes are genes that normally
control cell division, apoptosis and differentiation , but mutations or amplifications due to
carcinogens or viruses can convert them to oncogenes (a gene that is a mutated form of a gene
involved in normal cell growth) that induce cancer development.
2.The inactivation of tumour suppressor genes. Normal cells contain tumour suppressor genes
that suppress uncontrolled cell division and cancerous growth. Mutations or deletions of these
genes are commonly involved in many different cancers. The loss of function of tumour
suppressor genes can be the critical event in carcinogenesis.
The p53 gene is the best-known tumor suppressor gene identified to date, and the normal wild-
type gene appears to play an important role in suppressing malignant transformation. More than
50% of human tumors (including liver, breast, colon, lung, cervix, bladder, prostate, and skin)
have mutations in the p53 gene.
3. DNA repair genes are involved in fixing damaged DNA. Cells with mutations in these genes
tend to undergo duplications and deletions of chromosome parts. Together, these mutations
may cause the cells to become cancerous.
However, carcinogenesis is a complex multistage process, usually involving more than one
genetic change as well as other factors that increase the likelihood that the genetic mutation(s)
will eventually result in cancer. The accumulation of such genetic alternations overtime lead to
carcinogenesis.
 Features of Cancer
Cancer cells manifest, to varying degrees, four characteristics that distinguish them from normal
cells. These are:
1. Uncontrolled proliferation-cancer cells have escaped from the mechanisms that normally regulate
cell division and tissue growth; the normal brakes on cell division, present in a healthy cell are lost.
Uncontrolled growth can result from changes in cellular systems such as:
• Growth factors ,overexpression of GFs their receptors and overactivation of their signaling
pathways.
• Defects in cell cycle regulators, for example, cyclins, cyclin-dependent kinases (cdks) which are a
family of multifunctional enzymes that serve as cell-cycle checkpoints and facilitate the
progression of cell cycle stages.
• the apoptotic machinery-Apoptosis is programmed cell death and mutations in apoptotic genes
are usually a prerequisite for cancer; indeed, resistance to apoptosis is a hallmark of malignant
disease. Apoptosis normally disposes off abnormal cells. Mutations leading to inactivation of pro-
apoptotic factors or by activation of anti-apoptotic factors might be responsible for uncontrolled
cell growth.
• telomerase expression- With each round of cell division, a portion of the telomere is eroded, so
that eventually it becomes non-functional. At this point, DNA replication ceases and the cell
becomes senescent .Malignant tumours express telomerase enzymes to continuously rebuild the
telomere end and extend the cell’s replicative ability, thus elongating the telomere ends and
effectively conferring ‘immortality’ on cancer cells.
• local blood supply-blood supply determines the actual growth of a solid tumour. Tumours 1–2 mm
in diameter can obtain nutrients by diffusion, but their further expansion requires angiogenesis,
the development of new blood vessels in response to growth factors produced by the growing
tumour itself.
A telomere is a region of repetitive DNA sequences at the end of a
chromosome. Telomeres protect the ends of chromosomes from becoming
degradation, rearrangement and fusion with other chromosomes. Each time
a cell divides, the telomeres become slightly shorter. Eventually, they
become so short that the cell can no longer divide successfully, and the cell
dies.
 Features of Cancer
2. De-differentiation and loss of function- A hallmark of many malignant tumors is dedifferentiated (immature)
cells bearing little or no resemblance to the normal cells from which the cancer originated. These cells acquire
stem-cell like properties. Indeed, it is now well established that a small subpopulation of cells, referred to as
tumor stem cells, reside within a tumor mass. They retain the ability to undergo repeated cycles of proliferation,
cause metastasis, and are resistant to chemotherapy. In general, poorly differentiated cancers carry a worse
prognosis than well-differentiated cancers. Well-differentiated cancer cells look more like normal cells and tend
to grow and spread more slowly than poorly differentiated or undifferentiated cancer cells. Tumour
differentiation is used in tumor grading systems. Cancer stem cells (CSCs)

3. Invasiveness- Normal cells are not generally found outside their ‘designated’ tissue of origin. However, cancer
cells have lost, through mutation, the restraints that act on normal cells, and secrete enzymes (e.g. matrix
metalloproteinases, aka MMPs) that break down the extracellular matrix, enabling them to move around and
invade surrounding healthy tissue.

4. Metastasis- Metastases are secondary tumours formed by cells that have been released from the initial
or primary tumour and which have reached other sites through blood vessels or lymphatics or, as a result of
being shed into body cavities. Cancer cells that metastasise have undergone a series of genetic changes that
enable them to establish themselves ‘extraterritorially’. For example, metastases of mammary cancers are often
found in brain, lung, bone and liver. As such, metastases are the principal cause of mortality and morbidity in
most solid tumours and constitute a major problem for cancer therapy.
Metastatic cancer has the same
name and the same type of cancer
cells as the original, or primary,
cancer. For example, breast cancer
that forms a metastatic tumor in the
lung is metastatic breast cancer,
not lung cancer.
General Principles of Cytotoxic Anticancer Drugs
• Cancer chemotherapy aims to cause a lethal cytotoxic event or apoptosis in the
cancer cells that can arrest a tumor’s progression.
• Cytotoxic agents, affect only one characteristic aspect of cancer cell biology – cell
division – but have no specific inhibitory effect on invasiveness, the loss of
differentiation or the tendency to metastasise.
• In case of cytotxic drugs, the attack is generally directed toward DNA or against
metabolic sites essential to cell replication, for example, they affect the availability
of purines and pyrimidines, which are the building blocks for DNA or RNA
synthesis.
• Ideally, it is desirable that anticancer drugs only interfere with cellular processes
that are unique to malignant cells. Unfortunately, most currently available
chemotherapy drugs do not specifically recognize neoplastic cells but, rather,
affect all kinds of proliferating cells, both normal and abnormal.
 Considerations for Cancer Treatment
Goals of treatment: The ultimate goal of chemotherapy is a cure (that is, long-
term, disease-free survival, DFS). A true cure requires the eradication of every
neoplastic cell.
When the tumor remains localized at the time of diagnosis, about one-third of
patients are cured with local treatment strategies, such as surgery or radiotherapy.
However, in locally advanced disease and early metastases, systemic
chemotherapy is required for effective cancer management.
If all neoplastic cells cannot be eradicated, then the goal becomes to control the
disease (prevent the cancer from enlarging and spreading), to control/minimize
tumor-related symptoms, to extend survival and maintain the best quality of life
(QOL). In such cases, neoplastic cell burden can initially be reduced (debulked),
either by surgery and/or by radiation, followed by chemotherapy, immunotherapy,
or a combination of these treatment modalities.
In advanced/terminal stages of cancer, if the likelihood of controlling the cancer is
nearly impossible, the goal is palliation (alleviation of symptoms and avoidance of
life-threatening toxicity), i.e. we have to go for palliative therapy. This means that
chemotherapeutic drugs may be used to relieve symptoms caused by the cancer
and improve the quality of life, even though the drugs may not extend survival.
 Considerations for Cancer Treatment
Indications for chemotherapy:
Chemotherapy is presently used in three main clinical settings:
1. Primary induction chemotherapy: To treat advanced cancer or for cancers for which there
are no other effective treatment approaches. This has been the main approach in treating
patients with advanced metastatic disease and blood cancers. The goals of therapy are to
relieve tumor related symptoms, improve overall quality of life, and prolong time to tumor
progression.
2. Neoadjuvant chemotherapy: for patients who present with localized disease, and for
whom local forms of therapy such as surgery or radiation or, both, are inadequate by
themselves. The goal of the neoadjuvant approach is to reduce the size of the primary
tumor prior to surgery so that surgical resection can be made easier and more effective.
3. Adjuvant chemotherapy : administered as an adjuvant to local methods of treatment,
including surgery, radiation therapy, or both. In this setting, chemotherapy is administered
after surgery, and the goal of chemotherapy is to attack micrometastases following
surgery, to prevent both local and systemic recurrence and to improve the overall survival
(OS) of patients. Adjuvant chemotherapy is effective in prolonging both disease-free
survival (DFS) and overall survival (OS) in patients with breast cancer, colon cancer, gastric
cancer etc.
4. Maintenance chemotherapy: chemotherapy given to maintain remission from the cancer.
 Considerations for Cancer Treatment
 Tumor susceptibility and the growth cycle: The fraction of tumor
cells that are in the replicative cycle (“growth fraction”) influences
their susceptibility to most cancer chemotherapeutic agents.
Rapidly dividing cells are generally more sensitive to chemotherapy,
whereas slowly proliferating cells are less sensitive to chemotherapy.
In general, non-dividing cells (those in the G0 phase, aka quiscence)
usually are not very sensitive to cytotoxic drugs and survive the toxic
effects of these agents. The problem is that these G0 phase cells have
the potential to enter G1 and start dividing later after chemotherapy is
over.
a. Cell cycle specificity of drugs: The number of cells that are in various
stages of the cycle may differ in normal and neoplastic tissues.
Chemotherapeutic agents that are effective only against replicating
cells are said to be cell cycle specific, whereas other agents are said to
be cell cycle nonspecific.
The cell-cycle nonspecific drugs, although having generally more
toxicity toward the replicating cells, are also useful against tumors that
have a low percentage of replicating cells.
A cell cycle is a series of events that takes place in a cell as it
grows and divides. A cell spends most of its time in what is called
interphase, and during this time it grows, replicates its
chromosomes, and prepares for cell division. The cell then leaves
interphase, undergoes mitosis, and completes its division. The
resulting cells, known as daughter cells, each enter their own
interphase and begin a new round of the cell cycle.

Cell cycle has different stages called G1, S, G2, and M.

 G1 is the stage where the cell is preparing to divide. It grows in size,

copies organelles and synthesizes proteins for DNA replication.

 In the S phase where the cell copies all the DNA in its nucleus. It also
duplicates a microtubule-organizing structure called the centrosome.
The centrosomes help separate DNA during M phase.

 After the DNA is copied, the cell moves into the G2 stage, where it
organizes and condenses the genetic material, or starts to condense
the genetic material, replenishes energy stores, synthesizes proteins,
grows further and prepares to undergo mitosis.

 The next stage is M. M stands for mitosis. This is where the cell
actually partitions the two copies of the genetic material into the two
daughter cells. After M phase completes, cell division occurs and two
cells are left, and the cell cycle can begin again.
 Taxanes, vinca alkaloids
bleomycin

antimetabolites
etoposide
 Considerations for Cancer Treatment

Tumor growth rate: The growth rate of most solid tumors in

vivo is initially rapid, but growth rate usually decreases as the
tumor size increases . This is due to the unavailability of
nutrients and oxygen caused by inadequate vascularization
and lack of blood circulation.
Tumor burden can be reduced through surgery, radiation, or
by using cell cycle nonspecific drugs to promote the
remaining cells into active proliferation, thus increasing their
susceptibility to cell cycle– specific chemotherapeutic
agents.
Chemotherapy regimens and scheduling
• Chemotherapy drug dosages are usually calculated on the basis of body
surface area (BSA), in an effort to tailor the medications to each patient.
• BSA is calculated using the patient’s height and weight. The dosage is usually
reported in mg of drug per m2 .
• Chemotherapy is given in cycles. Most cycles range from 2 to 6 weeks.
• Commonly given by IV, oral or sometimes topical route.
• For example, a patient may get a dose of chemotherapy on the first day and
then have 3 weeks of recovery time before repeating the treatment. Each 3-
week period is called a treatment cycle. Several cycles make up a course of
treatment.
• Therapy is scheduled intermittently (approximately 21 days apart) to allow
recovery from side effects or rescue of the patient’s immune system, which
is affected by the chemotherapeutic agents, thus reducing the risk of serious
infections.
• Some cancers are treated with less recovery time between cycles. This is
called a dose-intense schedule. It can make chemotherapy more effective
against some cancers. But it also increases the risk of side effects.
 Chemotherapy Combinations
Combinations of drugs: Combination chemotherapy is more successful than single-
drug treatment in most of the cancers for which chemotherapy is effective.
Cytotoxic agents with qualitatively different toxicities, and with different molecular
sites and mechanisms of action, are usually combined at full doses. This results in
higher response rates, due to additive and/or potentiated cytotoxic effects, and non-
overlapping host toxicities.
In contrast, agents with similar dose-limiting toxicities, such as myelosuppression,
nephrotoxicity, or cardiotoxicity, can be combined safely only by reducing the doses
of each.
 Advantages of drug combinations: The advantages of such drug combinations are
that they
1) Provide maximal cell killing within the range of tolerated toxicity
2) Are effective against a broader range of cell lines in the heterogeneous tumor
population having cells with different genetic abnormalities.
3) May delay or prevent the development of resistant cell lines.
 Selection of drugs for effective combination chemotherapy
Efficacy: Only drugs known to have some level of clinical efficacy when used alone against a given tumor should be
selected for use in combination. If available, drugs that produce complete remission in some fraction of patients are
preferred to those that produce only partial responses

Toxicity: A drug should be selected on the basis of toxicity that does not overlap with the toxicity of other drugs in
the combination. Although such selection leads to a wider range of adverse effects, it minimizes the risk of a lethal
effect caused by multiple insults to the same organ system by different drugs and allows dose intensity to be
maximized.

Optimum scheduling: Drugs should be used in their optimal dose and schedule, and drug combinations should be
given at consistent intervals. Because long intervals between cycles negatively affect dose intensity, the treatment-
free interval between cycles should be the shortest time necessary for recovery of normal tissues, usually the bone
marrow.

Mechanism of interaction: Drug interactions must be avoided to allow for maximal antitumor effect. Omission of a
drug effect from a combination may allow overgrowth by a tumor clone sensitive to that drug alone and resistant to
other drugs in the combination.

Avoidance of arbitrary dose changes: An arbitrary reduction in the dose of an effective drug in order to add other
less effective drugs may reduce the dose of the most effective agent below the threshold of effectiveness and
destroy the ability of the combination to cure disease in a given patient.
Problems associated with chemotherapy- Resistance
• A fundamental problem in cancer chemotherapy is the development of cellular drug
resistance. Some neoplastic cells (for example, melanoma) are inherently resistant to
most anticancer drugs without any prior exposure to cytotoxic agents.

• Acquired resistance develops in response to exposure to a given anti-cancer agent by

developing mutations, particularly after prolonged administration of sub-optimal drug
doses. The development of drug resistance is minimized by short-term, intensive,
intermittent therapy with combinations of drugs.

• Multidrug-resistance occurs, due to increased expression of the MDR1 gene, which

encodes a cell surface transporter glycoprotein called P-glycoprotein. This causes
increased ATP– dependent drug efflux out of the cell and reduced intracellular
accumulation of a broad range of structurally unrelated anti-cancer agents.
Problems associated with chemotherapy- Resistance
Problems associated with chemotherapy- Toxicity
Therapy aimed at killing rapidly dividing cancer cells also affects normal cells
undergoing rapid proliferation (for example, cells of the buccal mucosa, bone
marrow, gastrointestinal mucosa, and hair follicles), contributing to the toxic
manifestations of chemotherapy.
• Common adverse effects: Severe vomiting, mucositis (inflamed and sore mouth
and gut), damage to GI epithelium, bone marrow suppression (leading to
reduced RBC, neutrophil, and platelet counts), and alopecia (hair loss) occur to
some extent during therapy with all antineoplastic agents.
• Vomiting is often controlled by administration of antiemetic drugs.
Myelosuppression, which increases the risk of infections, is common to many
chemotherapeutic agents.
• Other adverse reactions are confined to specific agents, such as bladder toxicity
with cyclophosphamide, cardiotoxicity with doxorubicin, and pulmonary fibrosis
with bleomycin. The duration of the side effects varies widely. For example,
alopecia is transient, but the cardiac, pulmonary, and bladder toxicities can be
irreversible.
• Infertility (ovaries stop releasing eggs), carcinogenicity (because most
antineoplastic agents are mutagens).
To summarize…
Revision checklist
Types of chemotherapy
Treatment strategy for localized disease and advanced localized
disease and metastatic disease.
Cell-cycle specific cytotoxic drugs
Cell-cycle non-specific drugs
Combination chemotherapy- advantages and devising the drug
regimen.
 Classes of Anticancer Drugs
1. Alkylating agents and related compounds, which act by transferring alkyl
groups to cell constituents by forming covalent bonds with DNA and thus
inhibiting DNA replication;
2. Antimetabolites, which block one or more of the metabolic pathways
involved in DNA synthesis;
3. Cytotoxic antibiotics, i.e. substances of microbial origin that prevent
mammalian cell division;
4. Microtubule Inhibitors (vinca alkaloids and taxanes)- these specifically affect
microtubule function and hence the formation of the mitotic spindle.
5. Topoisomerase Inhibitors- make single or double stranded DNA cuts and
consequently prevent DNA replication.
6. Protein kinase inhibitors, a form of targeted chemotherapy. These are small
molecule inhibitors which inhibit tyrosine kinase signaling.
7. Monoclonal antibodies- targeted therapy/immunotherapy-which are
antibodies that are designed to bind to specific target antigens on cancer
cells.
8. Steroid hormone and their antagonists- slow or stop the growth of hormone-
sensitive tumors, which require certain hormones to grow. Hormone
therapies act by preventing the body from producing the hormones or by
interfering with the action of the hormones.
 Antimetabolites
• Antimetabolites are structurally similar and related (also known
as structural analogues) to normal compounds/metabolites that
exist within the cell.

• Antimetabolites generally interfere with the availability of normal

purine or pyrimidine nucleotide precursors, either by inhibiting
their synthesis or by competing with them in DNA or RNA
synthesis.

• They are cell-cycle specific and their maximal cytotoxic effects

are in the S-phase.

Folate antagonist- Methotrexate (MTX)

Purine antagonist- 6-mercaptopurine

Pyrimidine antagonist- 5-fluoruracil (5-FU) and cytarabine

 Antimetabolites-Methotrexate
1. Methotrexate (anti-folate agent)

Folic acid is essential for DNA replication and cell division. Folic acid is obtained mainly from dietary sources and
from that produced by intestinal flora.

 Methotrexate (MTX), is an anti-folate agent or a folate antagonist.

 Upon entering cells it is activated by forming MTX-polyglutamate metabolites with the addition of up to 5-7
glutamate residues.

 MTX is structurally related to folic acid and acts as an antagonist of folate by inhibiting mammalian dihydrofolate
reductase (DHFR), the enzyme that normally converts folic acid to its active, coenzyme form, tetrahydrofolic
acid (FH4).

 Tetrahydrofolate (THF), is crucial for enzymatic processes involved in de novo synthesis of purine and pyrimidine
nucleotides, as well as the amino acids serine and methionine. Inhibition of these metabolic processes
interferes with the synthesis of DNA, RNA, and key cellular proteins.

 Intracellular formation of polyglutamate metabolites, is critically important for the therapeutic action of MTX.
These polyglutamates are selectively retained within cancer cells, and they display increased inhibitory effects on
enzymes involved in de novo purine nucleotide and thymidylate biosynthesis, making them important
determinants of MTX’s cytotoxic action.

 MTX is specific for the S-phase of the cell cycle.

Folates consist of three elements: a pteridine ring, p-aminobenzoic acid and
glutamic acid; methotrexate is structurally closely related.
Also inhibits the conversion of
dUMP to d TMP, thereby
preventing thymidylate
synthesis, which is a pyrimidine
nucleotide required for DNA + 1 carbon unit or methylene
synthesis.
group (-CH2-)is added

Mechanism of action of
methotrexate .
FH2 = dihydrofolate;
FH4 = tetrahydrofolate;
dTMP = deoxythymidine
monophosphate;
dUMP = deoxyuridine
monophosphate.
 Antimetabolites
Therapeutic uses:

• MTX, usually used in combination with other drugs, is effective against acute lymphocytic
leukemia, lymphoma in children, breast cancer, bladder cancer, and head and neck
carcinomas (HNC).

• In addition, low-dose MTX is effective as a single agent against certain inflammatory diseases,
such as severe psoriasis and rheumatoid arthritis, as well as Crohn’s disease (IBD/IBS).

Resistance to MTX:

Non-proliferating cells are resistant to MTX, probably because of a relative lack of DHFR, and
thymidylate synthase enzymes.

Resistance can occur due to amplification (production of additional copies) of the gene that
codes for DHFR, resulting in increased levels of this enzyme.

The affinity of the enzyme for MTX may also be diminished.

Resistance can also occur from a reduced influx of MTX, apparently caused by a change in the
carrier-mediated transport responsible for pumping the drug into the cell.
Pharmacokinetics of MTX

• Oral, intramuscular, intravenous, intrathecal routes of administration.

• High doses of MTX undergo hydroxylation at the 7 position and become
7-hyroxymethotrexate. This derivative is less water soluble than MTX
and may lead to crystalluria (cloudy urine due to crystal formation ).
Therefore, it is important to keep the urine alkaline (it will dissolve the
crystals) and the patient well hydrated to avoid renal toxicity.
• Excretion of the parent drug and the 7-OH metabolite occurs primarily
via urine.
Methotrexate Adverse effects
• Nausea, vomiting, diarrhea GIT toxicity
• MTX causes stomatitis (inflammation of the mucous membrane of the mouth),
• Myelosuppression (in which bone marrow activity is decreased resulting in fewer red
blood cells, white blood cells, and platelets),
• Erythema (redness of the skin or mucous membranes, caused by hyperemia of
superficial capillaries),
• rash, urticaria (a kind of skin rash), and alopecia (hair loss).
• High-dose regimens can lead to nephrotoxicity- this is caused by precipitation of the
drug or its metabolite in the renal tubules.
• Care must also be taken when MTX is used in the presence of drugs such as aspirin,
nonsteroidal anti-inflammatory agents, penicillin, and cephalosporins, as these agents
inhibit the renal excretion of MTX.
 Methotrexate Adverse effect - Rescue
• The biologic effects of MTX can be reversed by administration of the
reduced folate leucovorin (5-formyltetrahydrofolate), also called
folinic acid.
• Leucovorin bypasses the blocked DHFR enzyme and replenishes the
folate pool.
• Leucovorin rescue is used in conjunction with high-dose MTX
therapy to rescue normal cells from undue toxicity.
• Usually administered 24 hours after methotrexate so that it does
not interfere with the therapeutic effect of methotrexate.
 6-Mercaptopurine (purine antagonist)

• 6-MP and 6-thioguanine were the first purine analogs to prove

beneficial for treating neoplastic disease.
• 6-MP is used principally in the maintenance of remission in
acute lymphoblastic leukemia.
• 6-MP and its analog, azathioprine, are also beneficial in the
treatment of Crohn’s disease.
Purine Biosynthesis Pathway

The key nucleotide precursor for

the synthesis of AMP and GMP
required for DNA synthesis
 6-Mercaptopurine
Mechanism of action:
1. Nucleotide formation: 6-MP is inactive in its parent form and must be
converted by hypoxanthine-guanine phosphoribosyl transferase
(HGPRT) to form the monophosphate nucleotide 6-thioinosinic acid
(TIMP).
2. Inhibition of purine synthesis: TIMP can inhibit several enzymes leading
to inhibition of the first step of de novo purine nucleotide biosynthesis.
It also blocks the conversion of inosine monophosphate (IMP) to AMP,
and XMP (which in turn gives rise to GMP) nucleotides that are building
blocks for RNA and DNA.
3. Incorporation into nucleic acids: TIMP is converted to thioguanine
monophosphate (TGMP), which after phosphorylation to di- and
triphosphates can be incorporated into RNA and DNA resulting in both
nonfunctional RNA and DNA.
Inhibits purine nucleotide
synthesis.

Non-functional RNA
and DNA
6-Mercaptopurine
Resistance: Resistance is associated with
1. An inability to biotransform 6-MP to the corresponding nucleotide because of
decreased levels of HGPRT (hypoxanthine– guanine phosphoribosyltransferase)
enzyme.
2. Increased dephosphorylation or
3. Increased metabolism of the drug to thiouric acid or other metabolites.
Pharmacokinetics:
• Oral absorption is erratic and incomplete.
• The drug gets widely distributed after oral administration except for the cerebrospinal
fluid.
• Metabolized in the liver, 6-MP is converted to the 6-ethylmercaptopurine derivative or
to thiouric acid.
• The parent drug and its metabolites are excreted by the kidney.
6-Mercaptopurine

Adverse effects:
• Myelosuppression and immunosuppression are the
principal toxicity.
• Anorexia, nausea, vomiting, and diarrhea.
• Occurrence of hepatotoxicity in the form of jaundice has
been reported in about one third of adult patients.
5-Fluorouracil (Fluoropyrimidines)

5-Fluorouracil (5-FU ), a pyrimidine analog, has a stable fluorine atom in

place of a hydrogen atom at position 5 of the uracil ring.
The fluorine interferes with the conversion of deoxyuridine
monophosphate (dUMP) to deoxythymidine monophosphate (dTMP), thus
depriving the cell of thymidine, one of the essential precursors for DNA
synthesis.
5-FU is employed primarily in the treatment of slowly growing solid
tumors (for example, colorectal, breast, ovarian, pancreatic, and gastric
carcinomas).
It produces the anticancer effect in the S phase of the cell cycle.
Pyrimidine biosynthesis pathway
Mechanism of action:
1. 5-fluorouracil is converted in to 5-fluoro-deoxyuridine
monophosphate (5-FdUMP), which competes with
deoxyuridine monophosphate (dUMP) for thymidylate
synthase enzyme, thus inhibiting its action.
 So,5-FdUMP, forms a covalently bound complex with the
enzyme TS preventing de novo synthesis of thymidine. DNA
synthesis decreases due to lack of thymidine, leading to
imbalanced cell growth and “thymidine-less death” of rapidly
dividing cells.

1. 5-FU is converted to 5-fluorouridine-5′- triphosphate (5-

FUTP), which is incorporated into RNA, where it interferes
with RNA processing and mRNA translation producing
cytotoxic effect.

2. 5-FU is also converted to 5-fluorodeoxyuridine-5′-

triphosphate (FdUTP), which is subsequently incorporated
into cellular DNA, resulting in inhibition of DNA synthesis and
function.

Thus, the cytotoxicity of 5-FU is thought to be mediated by the

combined effects of both DNA- and RNA-mediated events.
It produces the anticancer effect in the S phase of the cell cycle.
2 3

5-FdUTP
1

Directly incorporated into

cellular DNA, resulting in
inhibition of DNA synthesis
and function.
 5-FU (continued)
Resistance:

Resistance develops when the cells have lost their ability to convert 5-FU into its active form (5-
FdUMP) or when they have altered or increased thymidylate synthase levels.

Pharmacokinetics:

Because of its severe toxicity to the GI tract, 5-FU is given IV or, in the case of skin cancer,
topically.

The drug penetrates well into all tissues, including the CNS.

The dose of 5-FU must be adjusted in impaired hepatic function.

Adverse effects: Diarrhea, alopecia, severe mucositis, myelosuppression, “hand-foot syndrome”

(redness, swelling and blistering on the palms of the hands and soles of the feet upon continuous
infusion), coronary vasospasm (a sudden constriction of coronary arteries that reduces blood
supply to part of the heart).
 Alkylating Agents

1. Nitrogen mustards e.g. cyclophosphamide

2. Nitrosoureas e.g. lomustine
3. Platinum compounds e.g. cisplatin cause intras-
trand linking in DNA.
 Alkylating agents
• The alkylating agents exert their cytotoxic effects via transfer of their alkyl groups to
various cellular constituents. Alkylation of DNA is the major cytotoxic reaction that is
lethal to the tumor cells.
• They exert their cytotoxic effects by covalently binding to nucleophilic groups
(electron donor groups) to transfer their alkyl groups to various cell constituents, eg:
DNA.
• The major site of alkylation within DNA is the N7 position of guanine; however, other
bases are also alkylated albeit to lesser degrees including N1 and N3 of adenine, N3 of
cytosine, and O6 of guanine.
• the first step is the formation of a carbonium ion (species with a positively charged
carbon center). Such ions are highly reactive and react instantaneously with an
electron donor such as an amine, hydroxyl or sulfhydryl group. Most of the cytotoxic
anticancer alkylating agents are bifunctional, i.e. they have two alkylating groups. This
bifunctional agent, by reacting with two groups, can cause-
intra- or inter-chain cross-linking in DNA
abnormal base pairing (guanine with thymine instead of cytosine)
DNA strand breakage.
They interfere not only with transcription, but also with DNA replication, causing cell
cycle arrest.
Alkylating agents
 Alkylating agents
• Alkylating agents do not discriminate between cycling and resting cells,
even though they are most toxic for rapidly dividing cells-Cell cycle
non-specific drugs.
• They are used in combination with other agents to treat a wide variety of
lymphatic and solid cancers.
• In addition to being cytotoxic, all are mutagenic and carcinogenic and
can lead to secondary malignancies such as acute leukemia.
Nitrogen mustards are related to
the ‘mustard gas’ used during the
First World War, their basic
formula (R-N-bis-[2-chloroethyl])
(1) is shown in figure on the top-
left.

In the body, each 2-chloroethyl

side-chain undergoes an
intramolecular cyclisation with the
release of a Cl−.

The highly reactive ethylene

immonium derivative (2, 3)
containing a carbocation can
interact with DNA.
 Cyclophosphamide and ifosfamide

Cyclophosphamide is the most commonly used alkylating agent. These drugs are very closely
related mustard agents that share most of the same primary mechanisms and toxicities. They
are cytotoxic only after generation of their alkylating species, which are produced through
hydroxylation by cytochrome P450 (CYP450).
Mechanism of action:
1. Both cyclophosphamide and ifosfamide biotransformed to hydroxylated intermediates
primarily in the liver by the CYP450 system.
2. Such species are highly reactive and react instantaneously with a nucleophile (electron
donor) such as an amine.
3. The hydroxylated intermediates then undergo breakdown to form the active compounds,
phosphoramide mustard (cytotoxic agent) and acrolein (toxic by-product).
4. The nitrogen at position 7 (N7) of guanine, being strongly nucleophilic, is the main
molecular target for alkylation in DNA.
5. Reaction of the phosphoramide mustard with DNA is considered to be the cytotoxic step.
6. It causes inter- and intra- crosslinking of DNA, abnormal base pairing , DNA strand
breakage, inhibition of cell division, and eventually cell death by apoptosis.
 Alkylating agents
Pharmacokinetics:
Cyclophosphamide is available in oral or IV preparations, whereas
ifosfamide is IV only. Cyclophosphamide is metabolized in the liver to
active and inactive metabolites, and minimal amounts are excreted in the
urine as unchanged drug. The parent drug and its metabolites are
primarily excreted in urine.
Resistance:
Resistance results from -
1. increased DNA repair mechanisms through increased expression and
activity of DNA repair enzymes,
2. decreased cellular transport of the alkylating drug, and
3. increased expression or activity of glutathione and glutathione-
associated proteins, which are needed to conjugate the alkylating
agent, or increased glutathione S-transferase activity, which catalyzes
the conjugation.
 Alkylating agents- Adverse effects
The adverse effects associated with alkylating agents are generally
dose-related and occur primarily in rapidly growing tissues such as
bone marrow (myelosuppression), gastrointestinal tract (diarrhea),
and reproductive system (depression of gametogenesis). Nausea
and vomiting also can be a serious issue with a number of these
agents.
In addition, they are potent vesicants (cause blistering) and can
damage tissues at the site of administration.
As a class, alkylating agents are carcinogenic in nature, and there is
an increased risk of secondary malignancies due to prolonged use,
especially acute myelogenous leukemia.
A unique toxicity of cyclophosphamide is hemorrhagic cystitis, which
can lead to fibrosis of the bladder. Bladder toxicity has been
attributed to acrolein in the urine in the case of cyclophosphamide
and to toxic metabolites of ifosfamide.
 Alkylating agents - Nitrosoureas
• Examples
include lomustine and carmustine.

• As they are lipid soluble and cross the

blood–brain barrier, they are used to
treat tumours of the brain and
meninges. However, most nitrosoureas
have a severe cumulative depressive
effect on the bone marrow that starts
3–6 weeks after initiation of treatment.
 Alkylating agents- Platinum compounds
• Three platinum analogs are currently used in clinical practice: cisplatin,
carboplatin, and oxaliplatin.
• Cisplatin is a water-soluble planar coordination complex containing a central
platinum atom surrounded by two chlorine atoms and two ammonia groups. Its
action is analogous to that of the alkylating agents. When it enters the cell, Cl–
dissociates, leaving a reactive complex that reacts with water and then interacts
with DNA.
• They kill tumor cells in all stages of the cell cycle through the formation of
intrastrand and interstrand cross-links, thereby leading to inhibition of DNA
synthesis and function. The primary binding site is the N7 position of guanine,
but covalent interaction with the N3 position of adenine and O6 position of
cytosine also can occur.
• In addition to targeting DNA, the platinum analogs have been shown to bind to
both cytoplasmic and nuclear proteins, which may also contribute to their
cytotoxic and antitumor effects.
• Cisplatin has major antitumor activity in the treatment of solid tumours of the
testes and ovary, non-small cell and small cell lung cancer. Therapeutically, it is
given by slow intravenous injection or infusion.
• It is seriously nephrotoxic, and strict regimens of hydration and diuresis must be
instituted. It has low myelotoxicity but causes very severe nausea and vomiting.
• The platinum complexes appear to synergize with certain other anticancer drugs,
including other alkylating agents, fluoropyrimidines, and taxanes.
Alkylating agents- Platinum compounds

• Carboplatin is a second-generation platinum analog with a similar

mechanism of action.
• carboplatin has broad-spectrum activity against a wide range of
solid tumors. However, in contrast to cisplatin, it exhibits significantly
less renal and gastrointestinal toxicity.
• Oxaliplatin is another platinum-containing compound used against
colorectal cancer. Neurotoxicity is the most severe adverse effect of
this agent.
Recap
 Antimetabolites:
• Types?
• Examples?
• Mechanism of Action?

 Alkylating agents
• Main types?
• Examples?
• Mechanism?
Cytotoxic Antibiotics - Anthracyclines
 The Anthracycline antibiotics are obtained from Streptomyces bacteria and are among the
most widely used cytotoxic anti-cancer drugs.
 They exert their cytotoxic action primarily by direct interactions with DNA, leading to
disruption of DNA function.
 They can intercalate within DNA, inhibit topoisomerases (I and II) enzymes and produce free
radicals, which play a major role in their cytotoxic effect.
 They are cell cycle non-specific EXCEPT for bleomycin which attacks cells in the G2 phase.

Anthracyclines: Doxorubicin, daunorubicin, idarubicin, epirubicin, and mitoxantrone

Doxorubicin and daunorubicin are classified as anthracycline antibiotics

Doxorubicin is the hydroxylated analog of daunorubicin. Idarubicin, the 4-demethoxy analog of

daunorubicin, epirubicin and mitoxantrone are also available.

Applications for these agents differ despite their structural similarity and their apparently
similar mechanisms of action.
 Cytotoxic antibiotics - Doxurubicin
Mechanism of action:
Doxorubicin and other anthracyclines induce cytotoxicity through several
different mechanisms:
1. Doxurubicin intercalates in between DNA/RNA base-pairs and inhibits DNA
and RNA synthesis.
2. Doxurubicin inhibits the action of topoisomerase II enzyme thereby halting
DNA replication. Topoisomerase II is responsible for preventing the
supercoiling of DNA at the replication fork during DNA replication. It does so
by creating nicks in both the DNA strands, relaxing them and subsequently
resealing them. Dox stabilizes the DNA-topoisomerase II complex after the
strands have been nicked thus inhibiting the replication process further.
3. Doxorubicin-derived free radicals (ROS such as superoxide radical, hydroxyl
radicals, hydrogen peroxide) can induce cell-membrane lipid peroxidation,
direct oxidation of purine or pyrimidine bases, thiols, and amines, eventually
leading to DNA strand scission(breakage) . For eg., oxidation of guanine by
ROS is very common.
This figure illustrates the mechanism by which doxorubicin intercalates the DNA and
stabilizes the activity of Topo II, inhibiting replication of the cell. DOX enters the cell
through channel proteins, interacts with DNA molecule and intercalates it leading to
inhibition in the function of Topo II and thus blocking replication of DNA.

(Roychoudhury, Kumar, Bhatkar, & Sharma, 2020)

Cytotoxic Antibiotics
Pharmacokinetics:
The anthracycline drugs must be administered IV, because they are inactivated in
the GI tract.
Extravasation (the leakage of an anticancer drug, from a blood vessel or tube into
the tissue around it )is a serious problem that can lead to tissue necrosis.
The anthracycline antibiotics bind to plasma proteins as well as to other tissue
components, where they are widely distributed.
They do not penetrate the blood–brain barrier or the testes.
Because of the dark red color of the anthracycline drugs, the veins may become
visible surrounding the site of infusion, and red discoloration of urine may occur.

Therapeutic use: Doxorubicin is one of the most important and widely used anticancer
drugs. It is used in combination with other agents for treatment breast cancer and
lung cancer, as well as, for treatment of acute lymphocytic leukemia and lymphomas.
Cytotoxic antibiotics
Adverse effects:
Anthracycline chemotherapy leads to dose-dependent cardiotoxicity: cardiomyocyte
injury and death leading to left ventricular dysfunction and heart failure.
The acute form occurs within the first 2–3 days and presents as arrhythmias and
conduction abnormalities, pericarditis, and myocarditis. This form is usually transient.
The chronic form is a dose-dependent, dilated cardiomyopathy associated with heart
failure.
The main mechanism is thought to due to inhibition of topoisomerase 2β resulting in
generation of free radicals, activation of apoptosis and inhibition of mitochondrial
biogenesis.
It is the most serious adverse reaction and is more common with daunorubicin and
doxorubicin than with idarubicin and epirubicin.
There has been some success with the iron chelator, Dexrazoxane in protecting against
the cardiotoxicity of doxorubicin.
Dexrazoxane administration with anthracycline interferes with binding to topoisomerase
2β and reduces both cardiotoxicity and subsequent heart failure in high-risk patients.
Cardiomyocyte injury and death due to free radicle induced apoptosis and
inhibition of mitochondrial biogenesis occurs due to these drugs. This causes
dilated cardiomyopathy.

In this condition, the ventricles become dilated (enlarged) and the cardiac
muscle especially on the left ventricle becomes thin and weak. This leads to
impaired/reduced contraction and inability of the heart to pump sufficient
blood to meet the demands of the body.
 Decreased expression of
cardiac-specific genes . Eg:
contractile proteins leading to
reduced myocardial contraction

 Doxorubicin appears to induce

toxic damage to the
mitochondria of
cardiomyocytes. Causes
mitochondrial dysfunction and
reduced mitochondrial
biogenesis (new mitochondria
are generated from the ones
already existing).

 ROS generation

 Activation of apoptosis

 Leading to death of
cardiomyocytes
 Leading to cardiovascular
dysfunction/LV dysfunction

(Henriksen, 2018)
 Cytotoxic antibiotic- Bleomycin
• Bleomycins are a a mixture of different metal-chelating (copper or
ferrous) glycopeptides that, like the anthracycline antibiotics,
cause scission of preformed DNA by an oxidative process.
• Unlike other athracyclines, Bleomycin is cell cycle specific and
causes cells to accumulate in the G2 phase which are unable to
progress to the mitosis phase.
• It is primarily used in the treatment of testicular cancers and
Hodgkin’s lymphoma.
Mechanism of action: A DNA–bleomycin–Fe2+ complex appears to
undergo oxidation to bleomycin–Fe3+. The liberated electrons react
with oxygen to form superoxide or hydroxyl radicals, which, in turn,
attack the phosphodiester bonds of DNA, resulting in strand
breakage and chromosomal aberrations.
Adverse effects: Mucocutaneous reactions and alopecia are
common. Hypertrophic skin changes and hyperpigmentation of the
hands are prevalent. There is a high incidence of fever and chills.
 Pulmonary toxicity is the most serious adverse effect, progressing
from rales, cough, and infiltrate to potentially fatal fibrosis.
 The pulmonary fibrosis that is caused by bleomycin is often
referred as “bleomycin lung.”
 Myelosuppression is rare with Bleomycin.
Topoisomerase Inhibitors
• These agents act via inhibition of topoisomerase enzymes, a class of enzymes that
relaxes supercoiling of DNA.
• During DNA replication, as DNA helicase unzips the DNA along the replication fork,
the segments of DNA ahead of the fork start to overwind (forms supercoils) due to
build up of tension. This overwinding at one point can prevent further unzipping of
the DNA strand, halting DNA replication and causing cell death.
• Topoisomerase enzymes relieve the tension in the supercoiled DNA by making
double or single strand cuts , relaxing the DNA supercoils and resealing them again.
 Toposiomerase inhibitors- Camptothecins
• Camptothecins are plant alkaloids originally isolated from the Chinese tree Camptotheca.
• Irinotecan and topotecan are semisynthetic derivatives of camptothecin.
• Topotecan is used in metastatic ovarian cancer when primary therapy has failed and also in the
treatment of small cell lung cancer.
• Irinotecan is used with 5-FU and leucovorin for the treatment of colorectal carcinoma.
Mechanism of action:
• These drugs are S-phase specific and inhibit topoisomerase I, which is essential for the replication
of DNA in human cells .
• Irinotecan is a prodrug that is converted mainly in the liver by the carboxylesterase enzyme to the
SN-38 metabolite, which is 1000-fold more potent as an inhibitor of topoisomerase I than the
parent compound.
• Normally, Topoisomerase I relieves torsional strain in DNA by causing reversible, single-strand
breaks.
• Topotecan inhibits the activity of TOPI enzyme after creating single-stranded break, preventing
re-ligation of DNA and halting further replication .
• Produces a single-strand cut
https://youtu.be/EYGrElVyHnU
Normally, these TOPO enzymes are able
to alleviate torsional stress (i.e., remove
superhelical twists) in duplex DNA.

They remove superhelical twists from

DNA and resolve knotted or tangled
duplex molecules (McClendon &
Osheroff, 2007).
Topoisomerase Inhibitors-Camptothecins
Adverse effects:
Myelosuppression and diarrhea are the two most common adverse events.
• Bone marrow suppression, particularly neutropenia (low neutrophil count in blood,
leading to infection), is the dose-limiting toxicity for topotecan.
• Frequent blood counts should be performed on patients taking this drug.
Myelosuppression is also seen with irinotecan.
• Acute and delayed diarrhea-There are two forms of diarrhea: an early form that
occurs within 24 hours after administration and is thought to be a cholinergic event
effectively treated with atropine given during infusion, and a late form that usually
occurs 2–10 days after treatment. The late diarrhea can be severe, leading to
significant electrolyte imbalance and dehydration in some cases. High doses of
loperamide could be helpful to alleviate this.
Topoisomerase inhibitors- Etoposide
• Etoposide is a semisynthetic derivative of the plant alkaloid, podophyllotoxin,
which is extracted from the may apple root (Podophyllum peltatum).
• It blocks the cells in the late S- to G2 phase of the cell cycle. Its major target is
Topoisomerase II enzyme.

Mechanism:
Normally, Topoisomerase II forms transient double stranded breaks in the DNA to
manage DNA tangles and supercoils which is followed by resealing of the transient
breaks.
Etoposide binds to the TOPII enzyme–DNA complex, resulting in persistence of the
transient, cleavable form of the complex and, thus, prevents the re-ligation of the
DNA strands, causing irreversible double-stranded breaks.

Therapeutic use:
Etoposide finds its major clinical use in the treatment of lung cancer and in
combination with bleomycin and cisplatin for testicular carcinoma.
Etoposide may be administered either IV or orally.

Adverse effect: Dose-limiting myelosuppression (primarily leukopenia) is the major

toxicity.
Microtubule Inhibitors- Vinca alkaloids
The mitotic spindle is essential for the equal partitioning of DNA into the two
daughter cells that are formed when a eukaryotic cell divides.
Several plant-derived substances used as anticancer drugs disrupt this
process by affecting the equilibrium between the polymerized and
depolymerized forms of the microtubules, thereby causing cytotoxicity.

The Vinca alkaloids are derived from the Madagascar periwinkle plant,
Vinca rosea. The principal members of the group are vincristine
and vinblastine.
These drugs are all cell cycle specific and phase specific, because they
block mitosis in metaphase stage (M-phase).
Mechanism of action:
1. The drugs bind to the protein, tubulin and inhibit its polymerisation into
microtubules.
2. Instead, paracrystalline aggregates consisting of tubulin dimers bound to
the alkaloid drug are formed which cannot polymerize to assemble the
spindle apparatus.
3. This results in dysfunctional spindle apparatus, mitotic arrest in
metaphase, preventing chromosomal segregation and cell division.
 Vinca alkaloids
Pharmacokinetics:
• These drugs are potent vesicants and so IV injection of these agents leads to
rapid cytotoxic effects and cell destruction. This, in turn, can cause
hyperuricemia (hyperuricemia is elevated uric acid level in the blood) due to
the oxidation of purines that are released from fragmenting DNA molecules.
• The vinca alkaloids are concentrated and metabolized in the liver by the
CYP450 pathway and eliminated in bile and feces.
• Thus, doses must be modified in patients with impaired hepatic function or
biliary obstruction.
Therapeutic Use:
Vincristine is used in the treatment of acute lymphoblastic leukemia in
children, Wilms tumor, Ewing soft tissue sarcoma, and Hodgkin and non-
Hodgkin lymphomas, as well as some other rapidly proliferating neoplasms.
Vinblastine is administered with bleomycin and cisplatin for the treatment of
metastatic testicular carcinoma. It is also used in the treatment of systemic
Hodgkin and non-Hodgkin lymphomas.
 Vinca Alkaloids
Adverse effects: Vincristine and vinblastine have certain toxicities in common.
These include phlebitis or cellulitis, if the drugs extravasate during injection, as
well as nausea, vomiting, diarrhea, and alopecia.
Vincristine has very mild myelosuppressive activity but is highly neurotoxic
and commonly causes peripheral neuropathy (paresthesias, loss of reflexes,
foot drop, and ataxia), abdominal pain and weakness. Neurotoxicity is due to
the high affinity of the drug towards axonal microtubules.
Vinblastine is less neurotoxic but causes myelosuppression, particularly,
leukopenia(low white blood cell count).
These agents should not be administered intrathecally. This potential drug
error can result in death, and special precautions should be in place for
administration.
Microtubule inhibitors- Taxanes
Paclitaxel and docetaxel
• Paclitaxel was the first member of the taxane family to be used in
cancer chemotherapy.
• Semisynthetic derivative- docetaxel

• Uses: Paclitaxel has shown good activity against advanced ovarian

cancer and metastatic breast cancer.
• They are generally used to treat breast and lung cancer.
• Paclitaxel, given with carboplatin, is the treatment of choice for
ovarian cancer.
• Docetaxel is commonly used in prostate, breast, GI, and non–small
cell lung cancers.
 Paclitaxel and docetaxel
Mechanism of action:
Both drugs are active in the M-phase of the
cell cycle, but unlike the Vinca alkaloids, they
promote polymerization and stabilization of
the polymer rather than disassembly, leading
to the accumulation of microtubules .
The overly stable microtubules formed are
nonfunctional, and chromosome segregation
does not occur.
This results in inhibition of mitosis and
eventually cell death.
Adverse effects: The dose-limiting toxicities
of paclitaxel and docetaxel are neutropenia
and leukopenia.
 Targeted therapy
• Targeted cancer therapies are drugs or other substances that block the growth and
spread of cancer by interfering with specific molecular targets that are involved in the
growth, progression, and spread of cancer.
• Targeted cancer therapies are sometimes called "molecularly targeted drugs,"
"molecularly targeted therapies," "precision medicines.“
Targeted therapies differ from standard chemotherapy in several ways:
Targeted therapies act on specific molecular targets that are associated with cancer,
whereas most standard chemotherapies act on all rapidly dividing normal and
cancerous cells.
Targeted therapies are deliberately chosen or designed to interact with their target,
whereas many standard chemotherapies were identified because they kill cells.
Targeted therapies are often cytostatic (that is, they block tumor cell proliferation),
whereas standard chemotherapy agents are cytotoxic (that is, they kill tumor cells).
Potential molecular targets for targeted therapy can be:
A protein/receptor that is highly expressed in cancer cells compared to normal cells.
A mutant protein that is expressed only by cancer cells or one that drives cancer
progression or both.
 Targeted Therapy
Most targeted therapies are either small molecules or monoclonal
antibodies.
• Small-molecule compounds are typically developed for targets that are
located inside the cell because such agents are able to enter cells
relatively easily.
• Monoclonal antibodies are relatively large and generally cannot enter
cells, so they are used only for targets that are outside cells or on the cell
surface.
Many different targeted therapies have been approved for use in cancer
treatment. These therapies include:
Hormone therapies, signal transduction inhibitors, gene
expression modulators, apoptosis inducers, angiogenesis
inhibitors, immunotherapies, and toxin delivery molecules.
 Tyrosine Kinase Inhibitors (Signal transduction inhibitors)
• Receptor tyrosine kinases (RTKs) are a family of integral cell surface membrane
receptors important for triggering diverse intracellular signaling cascades in response to
extracellular stimuli.
• They include receptors for growth factors and cytokines. For eg. Epidermal growth
factors, insulin, platelet derived growth factor.
• They play a major role in events controlling cell growth and differentiation, survival.
• These receptors have a tyrosine kinase moiety in their intracellular domain. A tyrosine
kinase is an enzyme that can transfer a phosphate group from ATP to the tyrosine
residues of specific proteins inside a cell.
• Binding of ligands to RTK monomers induces dimerization and conformational changes,
leading to activation of the intracellular TKDs, trans-autophosphorylation of intracellular
tyrosine residues and recruitment/activation of intracellular signaling proteins-
activating downstream signaling pathways.
• Due to their inherent roles in proliferation and survival, dysregulated RTK signaling is
implicated in many cancers.
• In cancer, RTKs can become aberrantly activated without any ligand binding,via
mechanisms driven by overexpression, mutation/translocation and atypical ligand
induction. This promotes uncontrolled cell proliferation and survival.
Signal transduction generally involves dimerisation
of receptors, followed by autophosphorylation of
tyrosine residues. The phosphotyrosine residues
act as acceptors for the SH2 domains of a variety
of intracellular proteins, thereby allowing control
of many cell functions.
Tyrosine kinase inhibitors-Imatinib
• A type of Targeted chemotherapy
• Tyrosine kinase inhibitors (TKIs) are small-molecule inhibitors that
prevent downstream signalling triggered by oncogenic kinases.
• For examples Imatinib occupies the ATP-binding pocket on the
oncogenic kinase Bcr/Abl, which is considered to be a unique feature
in the pathogenesis of chronic myeloid leukaemia (CML).
• This inhibits the binding of ATP to the kinase and subsequent
phosphorylation of intracellular protein substrates which promote
cell proliferation and survival.
• As a result, downstream signaling pathway of the oncogenic kinase
Bcr/Abl is inhibited and cell proliferation is inhbited.
• Video: https://www.youtube.com/watch?v=nP8-9WWp5ZQ
When imatinib occupies the ATP
binding site, it prevents
phosphorylation of the substrate.
This molecule in turn fails to
activate the effector protein and
inhibits the downstream signaling
pathway
Tyrosine kinase inhibitors- Imatinib

• Therapeutic use: used for the treatment of chronic myelogenous

leukemia (CML) as well as GI stromal tumors.
• The drug is given orally. The half-life is about 18 h, and the main site
of metabolism is in the liver, where approximately 75% of the drug is
converted to a metabolite that is also biologically active. The bulk
(81%) of the metabolised drug is excreted in the faeces.
• Unwanted effects include GI symptoms (pain, diarrhoea, nausea),
fatigue, headaches and sometimes rashes.
• Resistance to imatinib, resulting from mutation of the kinase gene, is
a growing problem.
 Recap
 Cytotoxic antibiotics
Doxurubicin and daunurubicin
 Toposiomerase II inhibitors
Topotecan (Camptothecins)
Etoposide (Podophyllotoxins)
 Microtubule inhibitors
Vincristine and Vinblastine (Vinca alkaloids)
Paclitaxel and docetaxel (Taxanes)
 What is targeted therapy?
 How is targeted therapy different from chemotherapy?
Targeted therapies act on specific molecular targets that are associated with cancer,
whereas most standard chemotherapies act on all rapidly dividing normal and
cancerous cells.
Potential molecular targets for targeted therapy can be:
A protein/receptor that is highly expressed in cancer cells compared to normal cells.
A mutant protein that is expressed only by cancer cells or one that drives cancer
progression or both.
 Hormones
• Some cancers depend on hormones to grow.
• Tumors arising in hormone-sensitive tissues (e.g. breast, uterus, prostate
gland) may be hormone-dependent, due to the presence of hormone receptors
in them. In such cases, removal of a hormonal stimulus can cause tumor
regression.
• For example, estrogen-dependent cancers(ER+), like breast cancer,
ovarian cancer and endometrial (uterine) cancer, rely on estrogen to develop
and grow. In addition, prostate cancer depends on androgens such as
testosterone for growth.
• Thus, their growth can be inhibited by hormone therapy which include:
Hormone antagonists which interfere with the way hormones exert their
effect
 Agents that inhibit the synthesis of the hormone.
Hormone agonists which can cause desensitization or produce negative
feedback
• Hormone therapy is used to slow tumor growth and minimize the symptoms
of the cancer, and thus play an important part in the clinical management of
sex hormone-dependent tumours.
• Used as neoadjuvant, adjuvant and maintenance therapy.
Types of hormone therapy for breast cancer

Selective estrogen receptor modulators (SERMs), such as tamoxifen

Aromatase inhibitors (AIs), such as anastrozole, and letrozole
Estrogen receptor antagonists, such as fulvestrant
Luteinizing hormone-releasing hormone (LHRH) agonists, such as
goserelin, leuprolide
 Tamoxifen
Tamoxifen is an estrogen antagonist with some estrogenic activity, and it is
classified as a selective estrogen receptor modulator (SERM).

• Selective estrogen receptor modulators (SERMs) constitute a group of

chemical compounds that bind and interact with estrogen receptors and
exert selective antagonist or agonist effects in different estrogen target
tissues.
• It is used for first-line therapy in the treatment of estrogen receptor–
positive breast cancer. It is used for adjuvant treatment of breast cancer
as well as for metastatic BC. In addition, Tamozifen is also used
prophylactically to reduce breast cancer occurrence in women who are at
high risk.
 Tamoxifen- Mechanism of action
Tamoxifen competes with endogenous oestrogen and binds to intracytoplasmic
estrogen receptors in the breast tissue, but the complex is unable to translocate into
the nucleus and fails to induce the transcription of estrogen-responsive genes. As a
result, mRNA synthesis does not ensue. The result is an inhibition of the growth-
promoting effects of estrogen leading to suppression of tumour growth.
 Tamoxifen
• Tamoxifen is effective after oral administration. It is partially metabolized
by the liver.
• Side effects caused by tamoxifen include hot flashes, nausea, vomiting,
skin rash, and vaginal bleeding and discharge (due to estrogenic activity
of the drug and some of its metabolites).
• Tamoxifen has the potential to cause endometrial cancer due to its
estrogenic properties. Other toxicities include thromboembolism and
impaired vision.
Aromatase inhibitors
• The aromatase enzyme is responsible for the synthesis of estrogen from
androgens (androstenedione), which takes place in liver, adipose tissue, muscle,
skin, and breast tissues, including breast malignancies.
• These drugs inhibit extragonadal synthesis of estrogen and reduces circulating
levels of estrogen.
• Peripheral aromatization is an important source of estrogen in postmenopausal
women.
• Aromatase inhibitors such as anastrozole, letrozole suppress the synthesis of
peripheral oestrogen from androgens (but not in the ovary), are effective in the
treatment of breast cancer in postmenopausal (but not in premenopausal)
women, in whom they are somewhat more effective than tamoxifen.

(Wood, Smith, & Dowsett, 2009)

 Immunotherapy for Cancer
• Immunotherapy is a type of biological therapy that helps to boost the body’s
own immune system to fight cancer.
• Normally, our immune system detects and destroys abnormal cells which most likely
prevents or slows down the growth of cancers.
• Even though the immune system can prevent or slow cancer growth, cancer cells have
ways to evade destruction by the immune system. For example, cancer cells may:
Cancer cells can downregulate expression of MHC molecules that present tumor
antigens to T-cells, and suppress tumor antigen presentation by APCs, thereby avoiding
recognition by T-cells.
They produce antigens with reduced immunogenicity
Overexpress checkpoint proteins on their surface that turn off immune response by the
T cells.
They can recruit immunosuppressive cells to their surroundings (Tregs) and release
immunosuppressive chemicals (IL-10,TGF-B).
Immunotherapy helps the body’s immune system to better act against cancer.
They are a form of highly targeted therapy without many of the side effects of
conventional chemotherapy.
• Video: https://youtu.be/jDdL2bMQXfE
 Types of Immunotherapy
• Monoclonal antibodies, Monoclonal are identical immunoglobulins, generated
from a single B-cell clone. These antibodies recognize and bind to a unique
epitope on a single target antigen on cancer cells. Some monoclonal antibodies
interfere with growth factor signaling, some mark cancer cells so that they would
be recognized and destroyed by complement mediated lysis or natural killer cells
or T cells.
• Immune checkpoint inhibitors, which are drugs that block immune checkpoints.
These checkpoints are a normal part of the immune system which promote self-
tolerance and prevents autoimmunity. By blocking them, ICIs allow immune system
to mount a strong immune response against tumor cells.
• T-cell transfer therapy, which is a treatment that boosts the natural ability of the
patient’s T cells to fight cancer. There are two main types of T-cell transfer
therapy: tumor-infiltrating lymphocytes (or TIL) therapy and CAR T-cell therapy.
Both involve collecting the patient’s T-cells, genetically engineering them, growing
them in large numbers in the lab, and then giving the cells back to the patient.
Mainly approved for B-cell lymphoma.
• Treatment vaccines, which enhance the immune system to recognize cancer and
destroy them. Typically involves the administration of selected tumour antigens
with adjuvants to stimulate the immune system. Treatment vaccines are different
from the ones that help prevent disease. They are therapeutic vaccines.
 Monoclonal antibodies
Monoclonal antibodies (mAbs) are produced by introducing the target antigen to a
mouse.
Resulting B cells (plasma cells) from immunized mice are then extracted from the
spleen and fused with “immortal” myeloma cells (cancerous B-cells) .
The resulting hybridoma cells can be individually cloned, and each clone will
continue to produce antibodies directed against a single antigen type.
Recombinant technology has led to the creation of “humanized” antibodies that
overcome the immunologic problems previously observed following administration
of mouse (murine) antibodies.
There are four types of monoclonal antibodies:
•Murine (-omab): entirely derived from a murine source. They can lead to an
allergic reaction in humans.
•Chimeric (-ximab): the variable regions are of murine origins whereas the
constant regions are human. These can also cause an allergy.
•Humanized (-zumab): mostly derived from a human source except for the part
of the antibody which binds to its target.
•Human (-umab) : entirely derived from a human source
Binding of the monoclonal antibody to its target
may destroy cancer cells by various ways :
-By activating the host’s immune mechanisms and killing the cancer cells by
complement-mediated cytotoxicity (CDC)
-By antibody dependent cellular cytotoxicity (ADCC) carried out by NK cells.
-By activating CD4+ T-cells and CD8+ cytotoxic killer T-cells
-Monoclonal antibodies may attach to and inactivate growth factors or their
receptors on cancer cells, thus inhibiting their survival pathway and promoting
apoptosis.
 Rituximab
Rituximab is a genetically engineered, chimeric monoclonal antibody directed against CD20, antigen that is
found on the surfaces of malignant B lymphocytes and normal B-cells. It targets and destroys both normal
and malignant B cells.

Rituximab was the first monoclonal antibody to be approved for the treatment of cancer.

Rituximab is effective in the treatment of lymphomas, including non-Hodgkin’s lymphoma, chronic

lymphocytic leukemia, and rheumatoid arthritis.

• Mechanism of action: Binding of rituximab to cell surface CD20 on the B lymphocytes results in
destruction of the lymphocytes by 3 potential mechanisms, including complement-dependent
cytotoxicity, antibody-dependent cytotoxicity, stimulation of apoptosis. Following tumour cell lysis,
antigen-presenting cells can present tumour-derived peptides on MHC class II molecules and promote
CD4+ T cell activation. Additionally, in a process known as cross-presentation, tumour-derived peptides
can be presented on MHC class I molecules, resulting in activation of CD8+ cytotoxic T cells. Complement-
mediated cytotoxicity most likely is the dominant mechanism (Selewski, Shah, Mody, Rajdev, & Mukherji,
2010).

• It provides progression-free survival in 40%–50% of cases when combined with standard chemotherapy (R-
CHOP; rituximab–cyclophosphamide, hydroxydaunorubicin [doxorubicin], oncovin [vincristine] plus
prednisolone).
• The drug is given by IV infusion, and its plasma half-life is approximately 3 days when first given, increasing
with each administration to about 8 days by the fourth administration.
Antibody-dependent cell-mediated cytotoxicity
(ADCC) is the killing of an antibody-coated target cell
by a cytotoxic effector cell (NK cells) through the
release of cytotoxic granules /granzymes/perforins.
CDC is the mechanism by
which antibody-coated
target cells recruit and
activate components of
the complement cascade,
leading to the formation
of a Membrane Attack
Complex (MAC) on the
cell surface and
subsequent cell lysis due
to leakage of cell
components.

(Selewski, Shah, Mody, Rajdev, & Mukherji, 2010)

 Rituximab
• Adverse effects: Severe adverse reactions have been fatal.
• Infusion reactions: Hypotension, bronchospasm, and angioedema may occur. Chills and
fever commonly accompany the first infusion, because of rapid activation of complement
which results in the release of tumor necrosis factor-α (TNF-α) and interleukins. It is
important to infuse rituximab slowly.
• Pretreatment with diphenhydramine, acetaminophen, and corticosteroids can ameliorate
these problems.
• Tumor lysis syndrome has been reported within 24 hours of the first dose of rituximab.
Tumor lysis syndrome (TLS) is a condition that occurs when a large number of cancer cells
die within a short period, releasing their contents in to the blood. This syndrome comprises
of hyperkalemia, hyperuricemia (due to inceased purine catabolism), hyperphosphatemia
(an abnormally high level of phosphates in the blood), hypocalcemia (due to precipitation of
Ca with phosphates), and acute renal failure that may require dialysis.
 Trastuzumab
• Trastuzumab (Herceptin) is a humanised murine monoclonal antibody that is used for the
treatment of HER2-positive breast cancer .
• HER2 (human epidermal growth factor receptor 2 )overexpression is observed in 20 to 30% of
invasive breast carcinomas and the cancer proliferates rapidly (poor prognosis) (Hudis, 2009).
• HER2 normally regulates cell growth, differentiation, survival, as well as adhesion and migration.
It exerts its effect by binding to the EGF.
• HER2 overexpression is also noted in gastric and gastroesophageal cancers.
• Trastuzumab specifically targets the extracellular domain of the HER2 growth receptor that has
intrinsic tyrosine kinase activity.

Mechanism of action: Trastuzumab binds to HER2 sites in breast cancer, gastric cancer, and
gastroesophageal tissues and inhibits the proliferation of cells that overexpress the HER2 protein.
By binding to HER2, it blocks downstream signaling pathways halting the growth of tumour cells.
Moreover, it induces antibody-dependent cytotoxicity.

Adverse effects: The most serious toxicity associated with the use of trastuzumab is congestive
heart failure. The toxicity is worsened if given in combination with anthracyclines. Extreme caution
should be exercised when giving the drug to patients with preexisting cardiac dysfunction
 Bevacizumab

Bevacizumab is a humanised monoclonal antibody that is

used for the treatment of colorectal cancer and a wide range
of other cancers.
Antiangiogenic drug
It neutralises VEGF (vascular endothelial growth factor),
thereby preventing the angiogenesis that is crucial to
tumour survival.
It attaches to and inactivates VEGF, preventing VEGF-
mediated endothelial cell proliferation and formation of
new blood vessels (neovascularization).
Without new blood vessels, tumors do not receive the
oxygen and essential nutrients necessary for growth and
proliferation.
It is administered by intravenous infusion and is generally
combined with other agents.
 Immune checkpoint inhibitors
The development of immune checkpoint inhibitors (ICIs) is a revolutionary milestone in the
field of immuno-oncology.
Immune checkpoints are a normal part of the immune system. They are inhibitory
regulators of the immune system. Their role is to downregulate T-cell responses, to
promote self-tolerance, to protect the body from autoimmune responses and maintain the
duration and extent of immune responses to prevent collateral damage to healthy cells.
Cancer cells take advantage of immune checkpoint pathways to evade immunosurvelliance.
Immune checkpoints dampen T-cell activation- suppressing destruction of tumour cells.
Thus, interfering with these immune checkpoint pathways can induce an anti-tumour
immune response and convey therapeutic benefits in patients with cancer.
Immune checkpoints engage when proteins on the surface of T-cells recognize and bind to
protein ligands on tumor cells.
When the checkpoint and their corresponding ligands bind together, they send an “off”
signal to the T cells. This can prevent the immune system from destroying the cancer.
Immune checkpoint inhibitors are monoclonal antibodies which work by blocking
checkpoint proteins from binding with their ligands. This prevents the “off” signal from
being activated, allowing the T cells to kill cancer cells.

(“Immune Checkpoint Inhibitors - National Cancer Institute,” n.d.)

Immune checkpoint inhibitors
 Immune checkpoint inhibitors-Ipilimumab

 Ipilimumab , fully human monoclonal antibody targets the immune

checkpoint system known as cytotoxic T-lymphocyte-associated protein
4 (CTLA-4) which functions to ‘stand down’ or downregulate the
activation of T-cells.
• Approved in 2011 for the treatment of melanoma
• Ipilimumab has been used in the treatment of melanoma, with efficacy
shown in combating lung and pancreatic cancers. (diagram in next slide)
 Ipilimumab Anti- cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) antibody
 It is a Monoclonal antibody that targets the
immune checkpoint protein CTLA-4.

 T-cell activation requires two signals: first,

antigen recognition by the T cell receptor
(TCR) following antigen presentation by
major histocompatibility complex (MHC)
class II molecules on the surface of antigen-
presenting cells; and, second, a co-
stimulatory signal, which is mainly
mediated by the interaction of CD28 with
one of the B7-1 and B7-2 molecules (CD80
and CD86).

 CTLA4 located on the surface of T-cells

competes with CD28 to bind to B7-1/B7-2
to modulate T-cell reponse. This binding
dampens T-cell activation and prevents
priming of the T cells to recognize tumor
cells. So, they are not able to kill tumor cells
in the body (left panel).

 Blocking the binding of B7-1/B7-2 to CTLA-4

with an immune checkpoint inhibitor (anti- (“Immune Checkpoint Inhibitors - National Cancer Institute,” n.d.)
CTLA-4 antibody) removes this inhibitory
signal, allowing the T cells to be activated Video : https://youtu.be/YZP0Yelymxc

and to recognize and kill tumor cells (right https://youtu.be/Ff-b-Jfi190

panel).
 Nivolumab

 Nivolumab is a fully human monoclonal antibody (mAb)

against Programmed cell Death protein-1 (PD-1) which is a cell
surface receptor that dampens down the immune system to promote
self-tolerance and suppress aberrant T-cell activation. Its ligand is
PD-L1.
 Nivolumab has been used to re-prime the immune system so that it
will recognize and destroy cancer cells that have previously evaded
immunosurveillance.
 It has been approved for the treatment of metastatic melanoma,
lymphoma, lung, kidney and head and neck cancers (diagram in the
next slide).
 PD-1 is a surface receptor that is Nivolumab
expressed by T cells and
suppresses T cell activation
through its interaction with its
ligand, PD-L1, which is expressed
by tumour cells.
 These immune checkpoint
proteins are highly expressed on
some tumour cells, allowing them
to evade immunodetection.

 The binding of PD-L1 to PD-1

switches off the T-cells and keeps
them from killing tumor cells in the
body.

 Blocking the binding of PD-L1 to

PD-1 with an immune checkpoint
inhibitor (anti-PD-L1 or anti-PD-1)
allows the T cells to be activated
and eventually kill tumor cells
through cytotoxic action (right
panel).

Adapted from National Cancer

Institute

(“Immune Checkpoint Inhibitors - National Cancer Institute,” n.d.)

 Adverse effects
• Immune-related adverse events (iRAEs)
• This happens because turning off the immune checkpoints leads to unchecked
autoimmune response within normal tissues .
• These effects are often treatable and reversible; however, some adverse effects
can be severe and lead to permanent disorders or can be life threatening.
• The spectrum of organ systems affected by irAEs is very broad; as such, toxicities
can affect almost any organ, with varying frequencies and severities.
• More frequent with CTLA4 inihibitors. Whilst, PD-1 inhibitors are more tolerable.
• Colitis, diarrhea (GI toxicity), nephritis (renal toxicity), neurotoxicity,
dermatologic toxicity in the form of severe skin rashes, joint pain, hepatitis,
pulmonary toxicity, endocrine toxicity such as hypothyroidism are commonly
seen.
• The frequency of immune-related adverse events (irAEs) is dependent on the
agents used, exposure time, the administered dose and on the patient’s intrinsic
risk factors; conversely, the timing of appearance is often dictated by the affected
organ systems.

(Martins et al., 2019)

Immune-checkpoint inhibitors (ICIs) promote
the activation and expansion of T cells. Owing
to the diversity of the T cell population and
the ability of these cells to infiltrate most
organs, ICIs can cause a wide range of
immune-related adverse events (irAEs), and
these can affect virtually any organ.

The most frequently affected organs and the

most common specific irAEs are highlighted
in boxes.

The frequency of immune-related adverse

events (irAEs) is dependent on the agents
used, exposure time and the administered
dose but also on the patient’s intrinsic risk
factors; conversely, the timing of
appearance is often dictated by the
affected organ systems.

(Martins et al., 2019)

Summary and Comparison of ICIs
Recommended reading
Lippincott’s pharmacology
Rang and Dale’s Pharmacology

Additional reading: Papers cited in the slides

Revision
When do we use hormone therapy?
What type of hormone therapies are available?
How can cancer cells avoid immunosurveillance?
What is the rationale behind using immunotherapy for cancer?
Types of immunotherapy?
What are monoclonal antibodies? Name the mAbs we have discussed.
What are immune checkpoint proteins?
How do immune checkpoint inhibitors stop the growth and
proliferation of cancer?