Neoadjuvant pembrolizumab plus chemotherapy in older patients with early-stage triple-negative breast cancer: real-world insights from neo-real/GBECAM-0123.

This multicenter real-world study from Brazil and Argentina assessed the KEYNOTE-522 neoadjuvant chemo-immunotherapy regimen in 724 patients with stage II–III triple-negative breast cancer, focusing on the 80 patients (11%) aged ≥65 years.

Key baseline differences in older patients:

• Fewer high-grade (grade 3) tumors and fewer tumors with Ki-67 ≥50%.
• Lower frequency of germline BRCA1/2 mutations.
• Worse performance status was more common.

Efficacy:

• Pathologic complete response (pCR) was 54.9% in patients ≥65 vs 64.5% in younger patients.
• After adjustment for other baseline factors, age itself was not an independent predictor of pCR.

Tolerability and safety:

• Older patients had a substantially higher toxicity burden, with more:
  • Treatment discontinuations
  • Dose reductions
  • Treatment delays
  • Hospitalizations
  • Grade ≥3 neutropenia

Clinical implications:

• Older patients with TNBC show distinct clinical/biologic features and slightly lower pCR rates, but age alone does not drive response when other factors are considered.
• The significantly higher toxicity in older patients highlights the need for individualized treatment planning, better geriatric and toxicity assessment, and trials specifically designed for this population.