How would you modify neoadjuvant chemotherapy for a stage 2-3 triple negative breast cancer who has baseline grade 2-3 neuropathy?

There are a few options I would consider. First, I would administer 4 cycles of dose-dense AC - assuming she has normal cardiac function at baseline - which typically has no significant neurotoxicity. If the patient has a very good response, I might stop there and send her to surgery. If she has had a suboptimal response to the AC, I would consider administering docetaxel at 60 mg/m2 every 3 weeks, which is associated with less neurotoxicity than paclitaxel, for up to 4 cycles, while watching closely for any worsening of her neuropathy. If she has bulky (stage III) disease and a poor response to AC, I would consider adding carboplatin AUC 5 to the every 3 week docetaxel.

The grade 2-3 chronic neuropathy poses a challenge for taxane chemotherapy. I would not use taxane in this setting. It would be helpful to know what is the etiology for the neuropathy and whether the comorbid condition also put her at a risk for anthracycline related cardiac toxicities. Oral CMF regimen would be reasonable.

Depends on the degree of the pre-existing neuropathy and if related to DM can be monitored or the dose altered in any case I would have a discussion with the patient and monitor closely if giving a taxane