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Cancer produces a major public health impact in developed countries. The American Cancer Society estimates that 1.5 million patients will be diagnosed with a new cancer each year in the U.S., with an estimated 1 million cases of skin cancer. In men, the most common cancers are prostate (25%), lung (15%), and colorectal cancers (10%). In women, the most common sites are breast (27%), lung (14%), and colorectal (10%).1 Cancer is also a major cause of death; in the U.S., cancer is the second leading cause of death, following heart disease. In 2009, lung cancer was the leading cause of cancer death in men (30%) and women (26%), followed by prostate (9%) and colorectal cancer (9%) in men, breast (15%) and colorectal cancer (9%) in women. Cancer treatment, depending on the type and stage of disease, utilizes chemotherapy, surgery, radiation, or combinations of the three. The chemotherapeutic armamentarium continues to expand, with the addition of new agents and the recognition of new toxicities.

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Chemotherapeutic agents can be categorized into the following categories: alkylating agents, topoisomerase inhibitors, antimitotic agents, antimetabolites, hormonal agents, targeted therapies, and miscellaneous (Table 235.1-1). Toxicities commonly observed can result from the agents themselves, due to tumor breakdown, or due to interaction with the host.

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Table 235.1-1 Chemotherapeutic Agent Classification 
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Alkylating Agents

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Alkylating agents are so named because they attach to an alkyl group in the guanine base of the DNA molecule (Table 235.1-2). This alkylation damages the DNA, preventing replication and cell division. Cancer cells proliferate faster and possess less capacity to correct DNA errors, so they are more sensitive than healthy cells to the damage caused by alkylation. However, normal cells that divide frequently, such as the intestinal epithelium and bone marrow, are susceptible to the alkylating agents. As with other agents that damage DNA, alkylating agents are carcinogenic. Alkylating agents are used to treat lung, breast, and ovarian cancer, sarcoma, as well as the hematologic malignancies of acute and chronic leukemia, lymphoma, ...

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