Review your notes on cancer chemotherapy and assess the answer to the question below.

How
would you mark this answer? How could it be improved?

Question

1. Cyclophosphamide and 5-Fluorouracil are used in combination to treat colorectal cancer. Describe
the pharmacology of these two drugs including mechanism of action, reasons for selectivity, dose
limiting toxicities and mechanisms of resistance, and explain why combination therapies are often
more effective than single agents.

Marking scheme

For Cyclophosphamide & 5-FU

MOA 1.5
Selectivity 0.5
Toxicity 1.5
Resistance 1

Combinations 1

Answer

Cyclophosphamide is a prodrug that gives rise to an alkylating agent, nornitrogen mustard. This
occurs through enzymatic and non-enzymatic reactions. Commented [HOF1]: Be specific.

The nornitrogen mustard is highly reactive and reacts with proteins and nucleic acid. The alkylation
of DNA is thought to be the most relevant activity for anti-cancer activity. This leads to cancer cell
death. Cyclophosphamide is selective for rapidly proliferating cells, like cancer cells, but can also kill
non-cancer cells that are proliferating. This means cyclophosphamide can kill cells of the immune Commented [HOF2]: 0.5
system in the bone marrow. It can also cause diarrheoa as the GIT also contains a high proportion of
proliferating cells. Cyclophosphamide is not selective for any particular phase of the cell cycle. Commented [HOF3]: 0.75. Mention liver resistance to
cyclophosphamide because of metabolic inactivation.
The formation of nornitrogen mustard is accompanied by the formation of acrolein, a second reactive
molecule that accumulates in the bladder. Acrolein can react with the bladder epithelium, causing
damage that leads to another dosing limiting toxicity: haemorrhagic cystisis. Commented [HOF4]: 1

Resistance to cyclophosphamide is associated with increased expression of glutathione-S-transferase,

an enzyme that can catalyse the detoxification of the nornitrogen mustard. Commented [HOF5]: 0.5. Also repair of DNA damage.

5-Fluoruracil is also a prodrug that undergoes metabolic activation, this time to 5dUMP. 5dUMP can
either be misincorporated into RNA in place of uracil or it can inhibit and enzyme, thymidylate
synthetase (TS). TS is a key enzyme for DNA synthesis as it generates dTTP. In the absence of Commented [HOF6]: 0.75. Explain significance of incorporation
into RNA
sufficient dTTP, DNA synthesis is stalled. DNA breaks can be induced and the cancer cell dies. This
mechanism of action means that5-FU acts primarily on cells in S phase when DNA is being actively
synthesized. Commented [HOF7]: 0.5

The dose limiting toxicities for 5-FU include bone marrow suppression and diarrheoa, for the same
reasons as cyclophosphamide. Commented [HOF8]: 1.0
Resistance to 5-FU has been associated with changes in the enzymes that catalyse activation of the
prodrug. However, the most common molecular change associated with clinical drug resistance is
amplification of the TS gene. 5-FU is an irreversible inhibitor of TS that binds and inactivates the
enzyme. This means that cells with high levels of TS can survive 5-FU treatment as the drug is
consumed in the act of inhibition. Commented [HOF9]: 0.75 explain amplification. Explain why
amplification causes resistance better
Combination therapies are often used in cancer chemotherapy for two main reasons. First, combining
drugs that act through different mechanisms reduces the probability of resistance emerging as the
tumour must contain cancer cells that have acquired two independent resistance causing mutations.
The second reason is that the dose of chemotherapeutic required is reduced when drugs are used in
combination. This reduces the likelihood of dose-limiting toxicities. Commented [HOF10]: 1

6.75 out of 10.