Liposomal doxorubicin in breast cancer: new preparation. Much ado about nothing

(1) There is no reference first-line cytotoxic chemotherapy protocol for metastatic breast cancer, but anthracycline combinations are commonly used. In addition to their myelotoxicity, anthracyclines can cause heart failure, both problems during and after treatment. (2) A liposomal formulation of doxorubicin, an anthracycline, has been developed with the aim of reducing this cardiotoxicity. The marketing terms specify that it must be used in combination with cyclophosphamide, in the first-line treatment of metastatic breast cancer. (3) According to the current evaluation file, which chiefly includes data from three comparative trials, liposomal doxorubicin is no more effective, in terms of the duration or quality of survival, than standard doxorubicin or epirubicin. (4) During comparative trials of liposomal doxorubicin, alone or in combination with cyclophosphamide, signs of cardiotoxicity, as measured by ultrasound, were slightly less frequent than with standard doxorubicin but no less frequent than with epirubicin. Given the possibility of late cardiac events, which were not studied in these trials, there is no evidence that liposomal doxorubicin is really less cardiotoxic than either standard doxorubicin or epirubicin. As regards other adverse effects, liposomal doxorubicin has no advantages over standard doxorubicin or epirubicin. (5) Liposomal doxorubicin is far more difficult to prepare than standard doxorubicin. (6) In France, liposomal doxorubicin is about 15 times more expensive than standard doxorubicin and 4 times more expensive than epirubicin. (7) In practice, standard doxorubicin can still be used, at doses appropriate for the individual patient and with cardiac monitoring.