Thymidylate synthase (TYMS) is an important target for chemotherapy drugs, such as 5-fluorouracil (5FU) and methotrexate. Over-expression of TYMS is linked to resistance to TYMS-targeted chemotherapy drugs. Currently there is no protocol for selecting cancer patients at risk for drug resistance prior to chemotherapy treatment. Three polymorphisms in the 5' and 3' untranslated regions (5'UTR and 3'UTR) of the thymidylate synthase gene have been shown to influence TYMS expression. Preliminary data has suggested a poorer response rate to 5FU or methotrexate is seen in patients with 3 copies of a 28 bp tandem repeat in the 5'UTR enhancer region (TSER polymorphism) and this relationship may be further clarified by the presence of a single nucleotide polymorphism (SNP) with the second repeat of the 3 repeat (TSER(*)3) allele. A 6 bp deletion in the 3'UTR of the TYMS gene has also been shown to affect TYMS RNA expression and has a significant association with poor outcome in 5FU treated patients. Evidence linking all 3 TYMS polymorphisms with TYMS expression and patient response to TYMS-targeted chemotherapy treatment will be highlighted.