Here is how Dr. Sharma summed up the current state of neoadjuvant therapy in triple-negative breast cancer:
The addition of an immune checkpoint inhibitor to neoadjuvant chemotherapy improves long-term outcomes.
This strategy can produce a modest improvement in pathologic complete response and a bigger improvement in event-free survival.
Individual patient selection biomarkers remain elusive.
The addition of carboplatin to AC⇒T improves pathologic complete response and long-term outcomes (in some studies).
No biomarkers of preferential platinum sensitivity are available.
Germline BRCA status does not predict sensitivity to carboplatin over anthracycline.
The combination of docetaxel/carboplatin plus pembrolizumab yields encouraging pathologic complete response rates.
This strategy may be a good alternative for patients with contraindications to anthracycline or lower-risk (node-negative) disease.
De-escalation approaches are being studied.
PARP inhibitors add benefit.
These agents should be added as adjuvant therapy in eligible patients with residual disease.
Pathologic response guides further adjuvant therapy and de-escalation strategies.
Pathologic complete response is associated with excellent long-term outcomes; this can guide de-escalation.
Residual disease is associated with a high risk of recurrence (despite adjuvant capecitabine) and may warrant escalation strategies.
