Doxorubicin (DOX) remains a cornerstone in the treatment of various malignancies, but its clinical use is limited by cardiotoxicity, a leading cause of heart failure in cancer survivors. While oxidative stress and direct myocardial injury have long been implicated in DOX-induced cardiotoxicity (DIC), emerging evidence highlights the central role of immune dysregulation in disease progression. In particular, neutrophils, macrophages, and T cells orchestrate inflammatory responses that contribute to cardiomyocyte injury, adverse remodeling, and fibrosis. Recent findings also point to novel mediators that may serve as biomarkers or therapeutic targets. This review synthesizes current evidence on immune mechanisms underlying DIC and discusses how improved understanding of these pathways may inform immunomodulatory strategies to reduce cardiac injury without compromising anticancer efficacy.

© 2025 The Author(s). Published by Elsevier Ltd.