(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.