From the Guidelines
Neoadjuvant chemotherapy is recommended for patients with triple-negative breast cancer (TNBC) who have tumors larger than 1 cm (T1c or greater) or node-positive disease, as it is the standard for T1c/N0 or greater TNBC 1. The indications for neoadjuvant chemotherapy in TNBC include:
- Tumors larger than 1 cm (T1c or greater)
- Node-positive disease The standard regimen typically includes an anthracycline and cyclophosphamide followed by a taxane, such as dose-dense doxorubicin and cyclophosphamide (AC) for 4 cycles followed by paclitaxel weekly for 12 weeks, or docetaxel every 3 weeks for 4 cycles. Some key points to consider:
- The addition of carboplatin may be beneficial for patients with germline BRCA mutations
- Neoadjuvant chemotherapy offers several advantages, including assessment of tumor response to treatment, potential for breast-conserving surgery, and provision of important prognostic information based on pathologic response
- Achieving pathologic complete response (pCR) is associated with improved long-term outcomes, particularly in TNBC
- Patients should undergo clinical staging with imaging prior to starting treatment, and tumor site marking (with clips) should be performed to facilitate surgical planning after treatment
- Multidisciplinary discussion involving medical oncology, surgical oncology, and radiation oncology is essential before initiating neoadjuvant therapy to ensure appropriate patient selection and treatment planning 1. The preferred neoadjuvant regimen for stage II/III TNBC is that of KN522 trial: ChT with taxanes, carboplatin, anthracyclines, cyclophosphamide, and with concurrent pembrolizumab 1.
From the Research
Indications for Neoadjuvant Chemotherapy in Triple-Negative Breast Cancer
The indications for neoadjuvant chemotherapy (chemo) in triple-negative breast cancer (TNBC) can be summarized as follows:
- Neoadjuvant chemotherapy is used to improve subsequent surgical intervention and to test novel therapies or combinations 2
- TNBC has responded well to neoadjuvant chemotherapy, with rates of pathological complete response (pCR) commonly higher than for other breast tumor types 2
- The lack of drug-targetable receptors on TNBC tumors has made improving the available interventions in TNBC an area of important medical need 2
- Neoadjuvant anthracycline/taxane combinations are commonly used in TNBC, and ongoing investigations are supplementing their use with other types of agents, such as platinums and inhibitors of poly-ADP ribose polymerase 2
Patient Selection for Neoadjuvant Chemotherapy
Patient selection for neoadjuvant chemotherapy in TNBC can be based on the following factors:
- Tumor size: neoadjuvant chemotherapy can be used for tumors more than 2 cm in diameter or node-positive breast cancer 3
- Node status: sentinel node biopsy and axillary resection should be performed with caution in TNBC patients 3
- BRCA1/2 mutation status: BRCA1/2 mutation is an independent predictor of early clinical response (ECR) to neoadjuvant chemotherapy 4
- Ki-67 status: Ki-67 ≥ 65% is an independent predictor of ECR to neoadjuvant chemotherapy 4
Benefits of Neoadjuvant Chemotherapy
The benefits of neoadjuvant chemotherapy in TNBC can be summarized as follows:
- Achievement of pCR is strongly associated with early clinical response (ECR) 4
- pCR is a surrogate endpoint for event-free survival in TNBC 5
- Neoadjuvant chemotherapy can improve survival outcomes in TNBC patients, especially those who achieve pCR 4
- The addition of platinum salts to standard neoadjuvant chemotherapy can benefit early responders, especially those with Ki-67 ≥ 65% and persisted lymph node involvement 4