DNA topoisomerase I (TOP1) is an essential nuclear enzyme that relaxes supercoiled DNA during transcription and replication by catalyzing transient single-strand breaks. This enzyme is encoded by a single-copy gene located on human chromosome 20q12. TOP1 activity is critical for normal cellular processes, including embryonic development and immune function. Notably, TOP1 inhibitors, such as camptothecin and its derivatives topotecan and irinotecan, are among the most effective anticancer drugs used clinically. These agents function as TOP1 poisons by stabilizing the TOP1-DNA cleavage complex (TOP1cc), converting it into a lethal DNA lesion that triggers cell death. However, cancer cells often develop resistance through mechanisms involving TOP1 downregulation, enhanced repair pathways (e.g., TDP1 activation), or altered DNA damage responses. Recent therapeutic advances include antibody-drug conjugates (ADCs) that deliver TOP1 inhibitors specifically to tumor tissues, as well as combination strategies targeting both TOP1 and DNA damage response pathways to overcome resistance.