Autophagy and cancer therapy cardiotoxicity: From molecular mechanisms to therapeutic opportunities

Cardiotoxicity is a major drawback of anticancer therapies, often hindering optimal management of cancer. Among the most cardiotoxic agents are anthracyclines (AC) that, despite being cardiotoxic, are highly effective in the treatment of a wide variety of cancers, spanning from hematological malignancies to solid tumors. Modern imaging techniques can identify patients at risk of developing cardiotoxicity, but treatment options are still limited and ineffective, partly because the molecular mechanisms underlying AC cardiac side effects are still incompletely understood. Although AC cardiotoxicity was initially ascribed to the trigger of cell-damaging oxidative stress, antioxidants fail to prevent anthracycline-induced cardiotoxicity (AIC), suggesting the involvement of additional mechanisms. Among these, the cellular recycling process, named autophagy, recently emerged to play a key role in AIC, but whether autophagy activation is beneficial or detrimental in this context is still controversial. This review will summarize recent evidence on the role of autophagy in AIC in the attempt to reconcile the controversial findings in the field. Finally, we will describe major regulator of cardiac autophagy that may represent good candidates for therapeutic intervention in AIC.