How do you determine whether to choose a non-anthracycline neoadjuvant chemotherapy regimen in a fit patient with TNBC?

Optimal neoadjuvant chemotherapy (NAC) regimen for TNBC has not been established and treatment regimens are usually mirrored from adjuvant trials. When choosing neoadjuvant chemotherapy regimen, the goal should be to achieve pathological complete response (pCR), since patients who do not achieve a pCR with NAC have worse outcome with higher loco-regional and systemic failure that may affect survival. Improving pCR by addition of Platinum and bevacizumab has however failed to show improvement in overall survival.

I would base my recommendation on using a non-anthracycline based NAC regimen (TC, Docetaxel and Cyclophosphamide) from results of Anthracyclines in Early Breast Cancer: The ABC Trials—USOR 06-090, NSABP B-46-I/USOR 07132, and NSABP...

There were several interesting updates on this topic at the SABCS last week: GeparX (neodjuvant Carbo/nab-paclitaxel with different nab-paclitaxel schedules, followed by EC then surgery) and two IO trials, KEYNOTE-522 (neoadjuvant Pembro/Carbo/Taxol followed by Pembro/AC-->Surgery) and NeoTRIP (neodjuvant Atezolizumab/Carbo/nab-paclitaxel). @Dr. First Last from Columbia lead a discussion lecture following these updates. We know that with some agents, pCR predicts clinical benefit. The GeparX showed an increased pCR with weekly Carbo/nab-paclitaxel, but this was followed by an anthracycline prior to surgery. Both IO trials looked at pCR, residual cancer burden, and PDL1+ subsets, stage/nodal status subsets. Both trials demonstrated an increa...

I have to disagree with both of the answers submitted thus far. While I will occasionally administer TC (docetaxel and cyclophosphamide) x 4 in the adjuvant setting in low risk (T1N0) TNBC, in the neoadjuvant setting I prefer to include carboplatin, especially if trying to avoid giving an anthracycline. And, as @Dr. First Last noted, in KEYNOTE-522 and GeparX patients also received an anthracycline in their neoadjuvant regimen. My preferred anthracycline-free neoadjuvant regimen for TNBC is the every 3-week docetaxel and carboplatin regimen utilized by Priyanka Sharma and colleagues in the NeoSTOP study presented at ASCO 2019 - in this randomized phase II study, 52% of patients achieved pCR with 6 cycles of this regimen, compared to 55% wit...