Translational aspects of doxorubicin-induced cardiotoxicity: What we have omitted for the past decades?

Anthracyclines remain the cornerstone of treatment for malignancies with dose-dependent cardiac damage, ranging from oxidative stress and mitochondrial dysfunction to DNA damage and ferroptosis, and continue to compromise patient outcome. Animal models, encompassing rodents, rabbits, pigs, and nonhuman primates, are essential for investigating doxorubicin (DOX)-induced cardiovascular toxicity. Acute models facilitate rapid evaluation of cardiac injury; however, they frequently fail to replicate chronic human cardiomyopathy. In contrast, chronic models represent clinical scenarios more accurately but encounter logistical challenges. Species-specific variations in drug metabolism, cardiac physiology, and compensatory mechanisms further complicate the extrapolation. The primary limitations of existing models include the absence of comorbid conditions, lack of combination chemotherapy protocols, and underrepresentation of sex- and age-specific responses. Addressing these challenges is crucial for the development of effective and personalized cardioprotective strategies in cardio-oncology. This review explores the translational challenges of DOX-induced cardiotoxicity, a critical limitation in the development of new cardioprotective strategies in cardio-oncology despite decades of research. We will elucidate the underlying factors that contribute to the difficulties in translating experimental in vivo results into clinical applications.