What neoadjuvant regimen would you consider using for a healthy patient with node positive TNBC who is refusing anthracycline?

In a patient with node-positive TNBC not eligible for an anthracycline, or refusing an anthracycline, I would strongly consider proceeding with a platinum + taxane + pembrolizumab, mirroring the NeoPACT trial presented by @Dr. First Last at ASCO 2022, which is the same regimen of carboplatin/docetaxel but with the addition of pembrolizumab. About 40% of patients in this study had node-positive tumors, and the pCR rate was 58% (and pCR + RCB-1 was 69%) - the 2y EFS for all patients treated with this regimen was nearly 90%.

Until more data are available, I would think of platinum/taxane or cyclophosphamide/taxane without immunotherapy primarily for lower-risk, node-negative patients, or those with contraindications for immunotherapy.

For node positive TNBC patients who are not eligible for anthracycline, or who refuse anthracycline, I would use 6 cycles of TC per the West German Plan B trial (Nitz et al., PMID 30785826). This study randomized patients with high-risk localized breast cancer to epirubicin/cyclophosphamide x 4 followed by docetaxel x 4, vs TC x 6. The primary endpoint, DFS, as well as OS were identical in the two arms. Caveats are that the number of patients with TNBC was low, at just over 200 in each arm, and that both regimens were given at 3-week intervals. It is possible that a dose-dense regimen for the anthracycline arm would have demonstrated some advantage. If there was residual disease after neoadjuvant chemotherapy, I would use capecitabine per C...