Version July 2025
INTRODUCTION —
Neoadjuvant therapy refers to the systemic treatment of breast cancer prior to definitive surgical therapy (ie, preoperative therapy). While all systemic therapy given for non-metastatic invasive breast cancer is intended to reduce the risk of distant recurrence, the purpose of administering it prior to surgery is to downstage the tumor and provide information regarding treatment response.
While in the past standard neoadjuvant chemotherapy (NACT) differed little between the various breast cancer subtypes, we now have a greater understanding of the biology of these subtypes. We can therefore select regimens with greater antitumor activity, guided by tumor biology, in addition to patient-specific factors such as age and other medical conditions.
Triple-negative breast cancer (TNBC) has often been defined as cancers with less than 1 percent expression of estrogen (ER) and progesterone (PR) receptors by immunohistochemical (IHC) staining and the absence of overexpression or amplification of HER2 by IHC or in-situ hybridization. It makes up about 15 to 20 percent of new breast cancer diagnoses, though this proportion differs by patient age and ethnicity, and accounts for up to 80 percent of cancers diagnosed in patients with germline mutations in the breast cancer gene-1 (BRCA1) gene.
This topic will review selection of chemotherapy regimens for patients with TNBC for whom the decision has been made to pursue NACT. Details on how to select patients for neoadjuvant treatment and the neoadjuvant approach to patients with hormone receptor-positive breast cancer and HER2-positive breast cancer are discussed elsewhere.
●(See "General principles of neoadjuvant management of breast cancer", section on 'Patient selection'.)
●(See "Neoadjuvant management of newly diagnosed hormone receptor-positive, HER2-negative breast cancer".)
●(See "Neoadjuvant therapy for patients with HER2-positive breast cancer".)
Finally, management of patients after NACT is discussed in detail elsewhere, including a discussion of adjuvant therapy, for appropriate candidates.
●(See "General principles of neoadjuvant management of breast cancer", section on 'Adjuvant treatment'.)
PATIENT SELECTION —
Patient selection for NACT is discussed in detail elsewhere. (See "General principles of neoadjuvant management of breast cancer" and "General principles of neoadjuvant management of breast cancer", section on 'Patient selection'.)
Briefly, we administer neoadjuvant therapy to most patients with clinical stage II and III TNBC (algorithm 1). In addition to the standard reasons to administer NACT (eg, facilitating surgical resection), administering NACT to these patients allows the oncologist to identify those who fail to achieve a pathologic complete response (pCR), which is associated with a higher risk of distant disease recurrence and breast cancer-related death. Such patients may benefit from administration of adjuvant therapy with the oral chemotherapeutic agent capecitabine. (See "Selection and administration of adjuvant chemotherapy for HER2-negative breast cancer", section on 'Patients who received neoadjuvant treatment'.)
A patient with clinical stage I TNBC may also benefit from receiving NACT, if shrinking the mass in the breast might simplify its removal, based on size or location, or improve the patient's cosmetic outcome following breast-conserving surgery, though it is not clear whether this group of patients benefit from adjuvant capecitabine if they fail to achieve pCR, given their lower risk of harboring occult metastatic disease.
AGENTS USED IRRESPECTIVE OF DISEASE STAGE
Chemotherapy including an anthracycline and taxane — For patients receiving neoadjuvant treatment, we suggest an anthracycline- and taxane-based combination rather than a non-anthracycline-based treatment (table 1) [1]. Doxorubicin and cyclophosphamide (AC) is usually administered every two weeks (referred to as "dose-dense"), though every three weeks is a reasonable alternative, as the superiority of dose-dense AC has not been demonstrated in the neoadjuvant setting.
Because the primary goal of neoadjuvant therapy is reduction in disease extent to facilitate more limited surgery, it is standard to administer all planned chemotherapy prior to definitive surgery, provided there is no evidence of disease progression during treatment.
Anthracycline-free alternatives are also available, for those who are less likely to tolerate anthracyclines. (See 'Anthracycline-free alternatives' below.)
We extrapolate from the adjuvant setting to support the use of anthracyclines and taxanes in the neoadjuvant setting. The Oxford meta-analysis of adjuvant chemotherapy trials demonstrated reduced recurrences with anthracycline-based regimens over cyclophosphamide, methotrexate, and fluorouracil (CMF), and additional benefit for the sequential administration of a taxane in the adjuvant setting [2]. A subsequent analysis demonstrated a benefit for dose-dense (every two weeks) compared with standard-frequency (every three weeks) adjuvant chemotherapy [3]. Further details are discussed elsewhere. (See "Selection and administration of adjuvant chemotherapy for HER2-negative breast cancer", section on 'Rationale for anthracycline- and taxane-containing regimen'.)
In the neoadjuvant setting, multiple studies have demonstrated that the addition of a taxane to an anthracycline-based regimen, either concurrently or sequentially, is associated with increased response rates [4-11]. As an example, in the NSABP B27 trial, 2411 patients received four cycles of neoadjuvant AC, after which they were randomly assigned to receive no further chemotherapy, four cycles of neoadjuvant docetaxel (100 mg/m2) every three weeks, or to undergo surgery followed by four cycles of adjuvant docetaxel [4]. The addition of docetaxel in the neoadjuvant setting increased the pCR rate from 13 to 26 percent, although the addition of this agent, whether given prior to or after surgery, had no demonstrable impact on overall survival (74 percent with neoadjuvant AC only and 75 percent in the arms containing docetaxel) or disease-free survival (59 and 62 percent).
Choice of taxane to pair with an anthracycline — Among patients receiving anthracyclines, we typically use paclitaxel as our taxane of choice. For patients who have had a previous hypersensitivity reaction to a taxane not amenable to conservative management, or a contraindication to the steroids administered with it, nanoparticle albumin-bound paclitaxel (nabpaclitaxel) is an acceptable alternative. Further details on the approach to taxane hypersensitivity are found below. (See 'Hypersensitivity to taxanes' below.)
ADDITIONAL TREATMENT FOR STAGE II AND III DISEASE —
In patients with clinical stage II and III TNBC without contraindications (eg, an autoimmune disease), we suggest administration of paclitaxel, carboplatin, and pembrolizumab; followed by an anthracycline, cyclophosphamide, and pembrolizumab.
These recommendations are based on results from KEYNOTE-522 and other clinical trials discussed below. Alternatives are available for patients who have a contraindication to treatment with either an anthracycline or immunotherapy. (See 'Anthracycline-free alternatives' below.)
Guidance in the setting of drug shortages has been provided by the American Society of Clinical Oncology [12], and is summarized in the table (table 2).
Incorporation of pembrolizumab with chemotherapy — For patients with stage II or III TNBC receiving NACT who do not have a contraindication to the administration of immunotherapy (eg, a pre-existing autoimmune disorder), we include pembrolizumab with NACT and continue this agent after surgery. In patients with a contraindication to pembrolizumab, such as a pre-existing autoimmune disorder, weekly paclitaxel and carboplatin followed by doxorubicin and cyclophosphamide (AC) or epirubicin and cyclophosphamide (EC) is an acceptable alternative. (See 'Anthracycline-free alternatives' below.)
This recommendation is based on the results of the KEYNOTE-522 trial and the subsequent US Food and Drug Administration approval of this agent in this setting in late July 2021 [13,14]. When incorporating pembrolizumab with NACT, we suggest a carboplatin-containing NACT regimen similar to that administered in the KEYNOTE-522 study.
In the randomized KEYNOTE-522 trial, 1174 patients with previously untreated stage II and III TNBC received weekly paclitaxel with carboplatin, followed by AC or EC (the schedule for weekly versus every-three-week carboplatin and the choice of anthracycline were at physician discretion). The patients were randomly assigned to receive pembrolizumab versus placebo concurrent with their NACT. After surgery, patients resumed their assigned treatment (pembrolizumab versus placebo) for another nine cycles (27 weeks). The addition of pembrolizumab resulted in the following [15,16]:
●An increase in the pathologic complete response (pCR) rate, 63 versus 56 percent. pCR rates increased in both patients with programmed death-ligand 1 (PD-L1)-positive (69 versus 55 percent) and PD-L1-negative (45 versus 30 percent) cancers, as well as in patients who were clinically node-positive (65 versus 44 percent) or node-negative (65 versus 59 percent) at baseline.
●Improvement in 36-month event-free survival (EFS), 85 versus 77 percent (hazard ratio [HR] 0.63, 95% CI 0.48-0.82) [16].
•While the relative benefit of pembrolizumab over placebo was similar in both subgroups, the absolute EFS benefit was larger in those without a pCR to NACT (67 versus 57 percent) than in those with a pCR (94 versus 92 percent). When stratified by extent of residual disease, as defined by Residual Cancer Burden (RCB), patients with moderate amounts of residual disease (RCB class II) received the greatest benefit from pembrolizumab (36-month EFS of 76 versus 56 percent), while the relatively small number of patients with extensive residual disease (RCB class III) did not demonstrate a benefit from this treatment (36-month EFS 26 versus 35 percent) [17].
●Improvements with the addition of pembrolizumab were also seen for overall survival. The estimated overall survival at 60 months was 87 versus 82 percent for pembrolizumab over placebo (absolute difference 4.9 percent, 95% CI 0.3-9.4) [18].
●For the combined neoadjuvant and adjuvant phases of the study, the incidence of grade >3 adverse events were only slightly higher for pembrolizumab compared with placebo (82 versus 79 percent). The incidence and severity of common chemotherapy-related toxicities such as neutropenia, nausea/vomiting, diarrhea and peripheral neuropathy were similar across the two arms, while patients assigned to pembrolizumab were more likely to develop an immune-related adverse event (34 versus 11 percent), including hypo- and hyperthyroidism, severe skin reactions, adrenal insufficiency, and pneumonitis.
Based on this trial, the US Food and Drug Administration (FDA) approved the use of pembrolizumab in the neoadjuvant setting for TNBC in July 2021.
Special considerations with pembrolizumab — While the results of the KEYNOTE-522 study are very encouraging, they raise a number of questions, as discussed in the sections below.
Continuation of pembrolizumab in the adjuvant setting — For patients who initiated pembrolizumab in the neoadjuvant setting, we continue it in the adjuvant setting, irrespective of whether a pCR was achieved. On the other hand, given the uncertain benefit of adjuvant single-agent pembrolizumab (ie, not initiated concurrent with chemotherapy), we do not offer it to patients who completed neoadjuvant chemotherapy without pembrolizumab.
Although there are no data informing use with other adjuvant therapies, we administer it concurrently with either capecitabine (or olaparib, in BRCA carriers) if residual disease is present. Small studies and clinical experience suggest safety with combinations of capecitabine and pembrolizumab [19], and olaparib and pembrolizumab (in other tumor types) [20].
No role for other checkpoint inhibitors — Other immune checkpoint inhibitors have been studied in combination with NACT in TNBC including atezolizumab, durvalumab (table 3), and camrelizumab [21]. However, thus far only pembrolizumab has demonstrated significant improvements in both the pCR rate and long-term outcomes in a large, randomized trial and has been approved in this setting by the US FDA.
Choice of chemotherapy backbone — When incorporating pembrolizumab into NACT, we use the same regimen as was used in KEYNOTE-522 (weekly paclitaxel with carboplatin, followed by an anthracycline and cyclophosphamide), described above. (See 'Incorporation of pembrolizumab with chemotherapy' above.)
In patients with a contraindication to an anthracycline, results from the NeoPACT trial support a taxane and carboplatin, with pembrolizumab [22]. Although not a randomized trial, the pCR rate is only modestly lower than reported from KEYNOTE-522. While the taxane administered in NeoPACT was every-three-week docetaxel, based on results from other trials, we feel it would be reasonable to administer a similar regimen with weekly paclitaxel. This trial is discussed in detail below. (See 'Anthracycline-free alternatives' below.)
We suggest the inclusion of carboplatin in neoadjuvant therapy for clinical stage II and III TNBC, based on multiple trials showing improvements in pCR rates, with some data also suggesting improvements in EFS or disease-free survival (DFS).
●Efficacy – Multiple randomized trials have demonstrated improved pCR rates with the addition of carboplatin to weekly paclitaxel and anthracycline-containing NACT in TNBC, three of which subsequently reported improvements in EFS or DFS (table 4).
Examples of available data are as follows:
•In a randomized trial, 717 patients with TNBC received weekly paclitaxel for eight weeks followed by four cycles of every-two-week or every-three-week AC or EC and were randomized to the addition of weekly carboplatin with the paclitaxel or not. The addition of carboplatin increased the pCR rate from 40 to 54 percent, five-year EFS from 64 to 71 percent, and five-year OS from 67 to 74 percent.
•In the CALGB/Alliance 40603 trial, 443 patients with stage II and III TNBC received weekly paclitaxel followed by every-two-week AC and were separately randomized to every-three-week carboplatin during paclitaxel and/or the antiangiogenic monoclonal antibody bevacizumab throughout NACT. The addition of carboplatin increased the rate of pCR in the breast from 46 to 60 percent and the rate of pCR in the breast and axilla from 41 to 54 percent but did not improve five-year EFS. Further analysis of results from this study suggest that its dose modification criteria, which resulted in a much higher percentage of patients assigned to carboplatin missing multiple doses of paclitaxel, may have affected the EFS results.
●Scheduling considerations – In all of these studies, patients assigned to carboplatin had higher rates of hematologic toxicities and slightly higher rates of early treatment discontinuation, but allowing patients to delay treatment for low blood counts, as in BrighTNess [23], as opposed to skipping treatments, as in CALGB/Alliance 40603, facilitated the delivery of treatment as planned and appears to enhance treatment benefit.
No randomized trial has directly compared every-three-week and weekly carboplatin when administered with weekly paclitaxel during NACT for TNBC. However, in the KEYNOTE-522 trial, where investigators were allowed to choose between every-three-week carboplatin at a dose of area-under-the-curve (AUC) 5 and weekly carboplatin AUC 1.5, weekly carboplatin resulted in similar dose delivery and pCR rates as the every-three-week schedule [24]. While there is concern that more frequent exposures to carboplatin may increase the incidence of hypersensitivity reactions to the drug, this is at least partially offset by lower rates of hematologic and gastrointestinal toxicities with the weekly regimen.
●Efficacy in BRCA carriers versus other patients – In clinical trials, patients without a germline BRCA mutation exhibit a much larger increase in pCR rates than BRCA-mutated patients [25].
•For example, in BrighTNess, the addition of carboplatin increased the pCR rate in BRCA wild-type patients from 29 to 59 percent, while increasing the pCR rate from 41 to 50 percent in BRCA carriers [23]. The magnitude of improvement in EFS with the addition of carboplatin did not differ between BRCA-mutated and BRCA wild-type patients, although the relatively small number of BRCA mutation carriers limits confidence in this result.
•In outcomes analysis from GeparSixto, the absolute improvement in DFS at 35 months with the addition of carboplatin was greater in BRCA wild-type patients (85 versus 74 percent; HR 0.53, 95% CI 0.29-0.96), versus in BRCA-mutated patients (86 versus 82 percent) [25,26].
This was unexpected, given results from the TNT trial in the metastatic setting, which demonstrated the superiority of carboplatin over docetaxel in BRCA1/2 carriers. Based on these results, BRCA mutation status does not influence the decision to add carboplatin to NACT for TNBC.
ANTHRACYCLINE-FREE ALTERNATIVES —
As in the adjuvant setting, an anthracycline-free neoadjuvant regimen may be a preferable option for some patients, particularly those with cardiac disease, advanced age, cardiac risk factors such as hypertension and diabetes mellitus, or those unwilling to accept the rare but serious risks of anthracyclines, including congestive heart failure and secondary leukemia.
Docetaxel-cyclophosphamide (TC) is a reasonable neoadjuvant alternative for patients with TNBC in whom there is a good reason to avoid use of an anthracycline, particularly those with stage I disease. There are relatively few neoadjuvant trials of TC. The available data on its efficacy suggest relatively low pathologic complete response (pCR) rates (7 and 17 percent), but these studies were conducted in cohorts of patients with hormone receptor-positive, HER2-negative cancers, a group known to have a lower likelihood of achieving pCR [27,28]. (See "Selection and administration of adjuvant chemotherapy for HER2-negative breast cancer", section on 'Acceptable alternatives to anthracycline-based treatment'.)
However, given evidence of the benefit of inclusion of a platinum agent in the neoadjuvant and adjuvant settings in patients with TNBC, regimens such as every-three-week docetaxel and carboplatin, or weekly paclitaxel and carboplatin can also be considered, particularly in stage II and III disease. Data from the neoadjuvant and adjuvant settings support this recommendation. These include:
●NeoSTOP was a randomized phase II neoadjuvant study in 100 patients with TNBC that compared 1) paclitaxel (weekly) and carboplatin (every three weeks) followed by dose dense doxorubicin and cyclophosphamide (AC) with 2) six cycles of every-three-week docetaxel and carboplatin [29]. The pCR rate was 54 percent for both arms of the study and, at a median follow-up of 38 months, event-free survival and overall survival were similar. In addition, the anthracycline-free arm was associated with much lower rates of adverse events, including febrile neutropenia (0 versus 19 percent, all during the AC phase of treatment).
●The PATTERN trial was a randomized phase III adjuvant trial that compared paclitaxel and carboplatin administered on days 1, 8, and 15 every 28 days for six cycles with a control regimen of cyclophosphamide, epirubicin, and fluorouracil followed by docetaxel (CEF-T). Five-year disease-free survival was superior with the paclitaxel/carboplatin regimen (86 versus 80 percent), which was also associated with a lower rate of febrile neutropenia (1 versus 9 percent), though a higher rate of grade 3 peripheral neuropathy (4 versus 1 percent) [30].
●In the NeoPACT trial, of 115 patients with TNBC who received six cycles of neoadjuvant every-three-week docetaxel and carboplatin with pembrolizumab, 58 percent achieved a pCR [22]. The pCR rates were higher for patients who were axillary node-negative prior to treatment (65 versus 46 percent for node-positive) and for those whose cancer expressed programmed death-ligand 1 (PD-L1; 76 versus 39 percent for PD-L1 negative), but little different in patients whose cancers were weakly estrogen receptor (ER)-positive (1 to 10 percent; 53 versus 59 percent in patients whose cancers had less than 1 percent ER staining).
ON TREATMENT EVALUATIONS —
Patients with either TNBC undergoing neoadjuvant treatment should undergo periodic clinical evaluations to assess response and tolerability and ensure that their cancer is not progressing on treatment. While there are no formal guidelines for these assessments, our approach is as follows:
●We perform a clinical examination every two to four weeks (typically prior to start of each cycle of treatment), including physical examination of the affected breast and ipsilateral axilla (and supraclavicular space, especially in patients with palpable supraclavicular nodes at presentation).
●Imaging studies (ultrasound of the breast and/or axilla or magnetic resonance imaging [MRI]) are typically performed only if disease progression is suspected based on clinical examination or symptoms, outside of clinical trials where subsequent treatment may be determined by imaging response. Discussion of the management of patients progressing on neoadjuvant therapy is found elsewhere. (See "General principles of neoadjuvant management of breast cancer", section on 'Poor response to or progression on neoadjuvant therapy'.)
Clinicians should be aware that lack of imaging response (as opposed to overt disease progression) can be misleading, as this may lag pathologic improvement. In rare instances, biopsy of the residual breast tumor may be helpful to assess residual viable disease and determine subsequent management.
●The performance of repeat imaging after completion of NACT, with mammography, ultrasound, or MRI is usually dictated by the needs of the breast surgeon to determine optical surgical management of the breast and axilla. (See "General principles of neoadjuvant management of breast cancer", section on 'Clinical assessment and indications for imaging'.)
SPECIAL CONSIDERATIONS
Hypersensitivity to taxanes — With appropriate premedication (eg, glucocorticoids and antihistamines) the rate of severe hypersensitivity reactions (HSR) to standard paclitaxel and docetaxel is less than 5 percent. Further details on the presentation of taxane HSRs are found elsewhere. (See "Infusion reactions to systemic chemotherapy", section on 'Taxanes'.)
Many patients who experience a mild HSR to a taxane can safely resume treatment with the same agent, often the same day, after interruption of treatment to allow their symptoms to resolve and receipt of additional intravenous doses of diphenhydramine and dexamethasone. Even patients with moderately severe reactions can often be successfully rechallenged with the same agent a day or more later, after more intensive and prolonged (at least 24 hours) steroid premedication and H1- and H2-receptor antagonists, and initiation of infusion of the agent at a slower rate, with close monitoring. This is discussed in detail elsewhere. (See "Infusion reactions to systemic chemotherapy", section on 'Rechallenge'.)
For patients who have an initial life-threatening HSR to a taxane, or a repeat reaction to the same agent despite the precautions listed above, we suggest switching to an alternative agent rather than attempting to desensitize the patient to their original agent (table 5). Since most taxane-induced HSRs are caused by the detergent used to solubilize the hydrophobic taxane molecule, rather than to the taxane itself, and since different detergents are used for standard paclitaxel and docetaxel, it is often safe to switch from one to the other. The other alternative is to switch to nabpaclitaxel; binding paclitaxel to albumin creates a polar molecule that does not require the addition of a detergent for solubility.
Data regarding nabpaclitaxel are as follows:
●The GeparSepto trial compared neoadjuvant weekly nabpaclitaxel (initially at 150 mg/m2, subsequently reduced to 125 mg/m2 due to excessive hematologic and neurologic toxicities at the original dose), to standard paclitaxel (80 mg/m2) followed by epirubicin and cyclophosphamide in 1200 patients with various breast cancer subtypes [31,32]. Overall, patients who received nabpaclitaxel had a higher pathologic complete response (pCR) rate (38 versus 29 percent), with much of that increase seen in patients with TNBC (48 versus 26 percent). Treatment with nabpaclitaxel was also associated with improvements in four-year invasive disease-free survival for the overall study population (84 versus 76 percent) and in patients with TNBC (79 versus 70 percent). Treatment with nabpaclitaxel was associated with higher rates of serious (grade >3) adverse events, including higher rates of grade 3 or higher peripheral neuropathy (11 versus 3 percent), even after the dose was reduced.
●In the ETNA trial, among 695 patients with HER2-negative breast cancer, neoadjuvant nabpaclitaxel versus paclitaxel (in either case followed by an anthracycline-based regimen), improved pCR rates in all patients (22 versus 19 percent) and in patients with TNBC (41 versus 37 percent) [33]. Overall, 16 percent of patients had at least one serious adverse event in the nabpaclitaxel arm compared with 11 percent in the paclitaxel arm. Peripheral neuropathy of grade 3 or higher occurred in 4.5 versus 1.8 percent, respectively.
Despite the encouraging results with nabpaclitaxel, we only use it for patients who did not tolerate standard paclitaxel or docetaxel, largely on the bases of toxicity and cost, as well as limited data on the addition of carboplatin and pembrolizumab to nabpaclitaxel.
Management or residual disease after chemotherapy — Among patients who experience a partial response to chemotherapy, use of capecitabine, or olaparib for BRCA carriers, is discussed elsewhere. (See "Selection and administration of adjuvant chemotherapy for HER2-negative breast cancer", section on 'Patients who received neoadjuvant treatment'.)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breast cancer".)
SUMMARY AND RECOMMENDATIONS
●Introduction – Neoadjuvant therapy refers to the systemic treatment of breast cancer prior to definitive surgical therapy (ie, preoperative therapy). (See 'Introduction' above.)
●Patient selection for neoadjuvant therapy – In general, patients with stage II and III triple-negative breast cancer (TNBC) receive neoadjuvant rather than adjuvant treatment (algorithm 1). The decision regarding whether a patient with clinical stage I TNBC receives neoadjuvant treatment depends on whether the response to treatment might enhance their surgical management. (See 'Patient selection' above.)
●Choice of regimen
•All patients with TNBC – In patients with TNBC receiving neoadjuvant treatment, we suggest a regimen that includes both an anthracycline and a taxane (Grade 2C). (See 'Agents used irrespective of disease stage' above.)
•Additional treatment for stage II or III cancers – For patients with stage II or III TNBC receiving neoadjuvant chemotherapy (NACT), we recommend the addition of pembrolizumab to NACT (Grade 1B), to be initiated concurrently with NACT and continued as a single agent in the adjuvant setting, provided that the patient does not have a contraindication to immunotherapy.
In patients with a contraindication to pembrolizumab (eg, a pre-existing autoimmune disorder), weekly paclitaxel and carboplatin followed by doxorubicin and cyclophosphamide (AC) or epirubicin and cyclophosphamide (EC) is an acceptable alternative. (See 'Anthracycline-free alternatives' above.)
For patients with stage II or III TNBC, we also suggest incorporation of carboplatin into the NACT regimen (Grade 2C), irrespective of whether pembrolizumab is administered. (See 'Choice of chemotherapy backbone' above and 'Incorporation of pembrolizumab with chemotherapy' above and 'Additional treatment for stage II and III disease' above.)
•Alternative regimens – In patients with contraindications to anthracyclines, docetaxel-cyclophosphamide (TC) is a reasonable neoadjuvant alternative, particularly in those with stage I disease. In those with stage II and III disease, if an anthracycline cannot be used, every-three-week docetaxel and carboplatin, or weekly paclitaxel and carboplatin are acceptable alternatives, given evidence of the benefit of inclusion of a platinum agent in the neoadjuvant and adjuvant settings in patients with TNBC. (See 'Chemotherapy including an anthracycline and taxane' above.)
Alternative agents are available for patients with taxane hypersensitivity (table 5). (See 'Hypersensitivity to taxanes' above.)
●Monitoring on treatment – For patients receiving NACT, we perform a physical examination (including the breast and ipsilateral axilla) every two to four weeks (ie, prior to each cycle of treatment). Imaging studies (ultrasound or MRI) should only be performed on treatment if disease progression is suspected based on clinical exam or symptoms. However, clinicians should be aware that interval imaging can be misleading, as radiologic response may lag clinical response. Discussion of the management of patients who experience progression during neoadjuvant treatment is found elsewhere. (See "General principles of neoadjuvant management of breast cancer", section on 'Poor response to or progression on neoadjuvant therapy'.)
