Camptothecin (CPT) and its derivative irinotecan inhibit DNA topoisomerase I (TOP1), inducing replication stress by stabilizing the TOP1 cleavage complex. This prevents DNA re-ligation, resulting in single-stranded breaks that, if unresolved, can cause DNA replication fork collapse and double-stranded breaks. Cells respond to TOP1 inhibitors through homologous recombination (HR) repair and fork protection, with RAD51 playing a central role. However, the full mechanisms of how cells react to TOP1 inhibitors are not fully understood. Here, we systematically investigated cellular responses to TOP1 inhibitors, assessing the effects on DNA damage repair (DDR), replication, and cell viability. Using state-of-the-art quantitative image-based cytometry and single-molecule analyses, we reveal a dose and time-dependent mechanistic switch in DDR pathways, which differentially affects DNA replication. While the replication forks arrest after minutes in the presence of CPT, unexpectedly, after two hours of CPT exposure, the fork speed is faster than in the controls. Furthermore, we explain some of the contrasting effects of the replication fork dynamics and DDR activation triggered by TOP1 inhibition. Finally, we identify cancer genetic vulnerabilities, such as HR deficiency, that may be exploitable with low-dose TOP1 inhibitors.
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