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Early triple-negative breast cancer is treated to cure. For tumours over 2 cm or with node involvement, chemotherapy plus the immunotherapy pembrolizumab before and after surgery has raised cure rates; BRCA carriers with cancer left at surgery add a year of olaparib, and others with residual cancer are offered capecitabine. Whether the tumour has vanished by surgery guides what comes next.
Early triple-negative disease is basal-like in most cases, almost always TP53-mutant, carries a germline BRCA1 or BRCA2 mutation in roughly one in five patients and is the breast cancer with the most immune infiltration. Because there is no receptor to block, chemotherapy has carried the curative burden, and it is given before surgery whenever the tumour is over 2 cm or the nodes are involved, both to shrink it and because the response at surgery, measured as pathological complete response or residual cancer burden, is the strongest predictor of relapse. Platinum added to a taxane and anthracycline raised complete response rates in GeparSixto, CALGB 40603 and BrighTNess, and tumours under 1 cm without node involvement often need no chemotherapy at all, with high tumour-infiltrating lymphocytes marking a group whose outcome is excellent regardless.
KEYNOTE-522 rewrote the standard. It randomised 1,174 patients with stage II or III disease to pembrolizumab or placebo with carboplatin and paclitaxel then an anthracycline and cyclophosphamide before surgery, followed by pembrolizumab or placebo for nine cycles after. Pathological complete response rose from 51.2 to 64.8 percent, event-free survival improved (hazard ratio 0.63) and, unusually for a neoadjuvant trial, overall survival did too, with the seven-year update showing 85.1 against 77.2 percent alive; the FDA approved the regimen in July 2021 and it is given whatever the PD-L1 score. IMpassion031 showed atezolizumab raises complete response in the same setting (58 against 41 percent) but never became a standard.
What follows surgery depends on what the pathologist finds. Women with a complete response finish their year of pembrolizumab and whether they need it at all is being tested in OptimICE-pCR. Women with residual disease and a germline BRCA mutation take olaparib for a year: OlympiA randomised 1,836 such patients with HER2-negative disease, about four in five triple-negative, and improved invasive disease-free survival (hazard ratio 0.58) and overall survival (hazard ratio 0.72). Others are offered six to eight cycles of capecitabine on the strength of CREATE-X, a Japanese trial of 910 women with residual HER2-negative disease in which five-year disease-free survival rose from 67.6 to 74.1 percent with the largest survival gain in the triple-negative group. None of these post-surgery trials included pembrolizumab, so how the pieces combine is unknown, and ASCENT-05 is testing sacituzumab govitecan with pembrolizumab in residual disease while SCARLET asks whether the anthracycline can be dropped and circulating tumour DNA is being studied to find the women who still harbour disease.
Most of the roughly 200,000 triple-negative breast cancers diagnosed each year are found before they have spread; relapses cluster in the first three years, so what happens around surgery decides most outcomes.
Most cancers start in the ducts and drain first to the axillary nodes, which is why the armpit is checked and a sentinel node is sampled.
Same organ: Triple-negative breast cancer (TNBC), Breast cancer (all types), HR-positive / HER2-negative breast cancer, HER2-positive breast cancer, Male breast cancer, Ductal carcinoma in situ (DCIS), High-risk early HR-positive breast cancer, HR-positive metastatic breast cancer after CDK4/6 inhibitors, HER2-low and HER2-ultralow metastatic breast cancer, Early HER2-positive breast cancer, HER2-positive breast cancer with brain metastases, Metastatic triple-negative breast cancer, Basal-like 1 triple-negative breast cancer (BL1), Basal-like 2 triple-negative breast cancer (BL2), Mesenchymal triple-negative breast cancer (M), Mesenchymal stem-like triple-negative breast cancer (MSL), Luminal androgen receptor triple-negative breast cancer (LAR), Immunomodulatory triple-negative breast cancer (IM), Metaplastic breast carcinoma, Carcinoma with medullary pattern (medullary breast cancer), Adenoid cystic carcinoma of the breast, Apocrine carcinoma of the breast, Secretory carcinoma of the breast, BRCA-associated triple-negative breast cancer, Inflammatory breast cancer, Paget disease of the nipple, Phyllodes tumour of the breast, Invasive lobular carcinoma of the breast, Invasive breast carcinoma of no special type (invasive ductal carcinoma), Tubular carcinoma of the breast, Mucinous carcinoma of the breast, Papillary carcinomas of the breast (encapsulated, solid and invasive papillary), Invasive cribriform carcinoma of the breast, Invasive micropapillary carcinoma of the breast, Neuroendocrine neoplasms of the breast, Lobular carcinoma in situ (LCIS)
Surgery with sentinel node biopsy and radiotherapy; chemotherapy for tumours over 1 cm, often omitted below that, with tumour-infiltrating lymphocytes guiding de-escalation trials.
Pembrolizumab with carboplatin and paclitaxel, then with doxorubicin or epirubicin and cyclophosphamide, followed by surgery (KEYNOTE-522).
Pembrolizumab to complete a year and radiotherapy by stage; omission of adjuvant pembrolizumab is under test (OptimICE-pCR).
Pembrolizumab to complete a year; olaparib for one year in germline BRCA carriers (OlympiA); capecitabine for six to eight cycles otherwise (CREATE-X); sacituzumab govitecan with pembrolizumab under study (ASCENT-05).
Breast conservation with whole-breast radiotherapy or mastectomy, sentinel node biopsy after neoadjuvant therapy, and post-mastectomy radiotherapy for node-positive disease.
Trials recruiting now, the landmark trials, the trials held by this cancer's subtypes, the key papers and what they mean, the latest literature, and the milestones year by year.
The targets of this cancer's medicines and the ones linked to it directly.
Cases by country, the UK and NHS pathway and other country lenses, the expert centres with trials on record, and the centres named on this cancer's subtypes.
One section per setting: the options named, what each is for, the trials behind them, the recorded trade-offs and the questions to ask.
Bleeding that does not stop by itself, bleeding from more than one site, or new bruising in several places or one large area.
A swollen painful calf, or sudden breathlessness with chest pain; venous thromboembolism including pulmonary embolism is a labelled warning.
Persistent headache with extreme tiredness, nausea, dizziness on standing or low blood pressure. Vomiting, severe weakness or collapse is adrenal crisis.
Cumulative dose: risk rises steeply above 400-550 mg/m² (see the anthracycline calculator).
Avoid grapefruit and Seville oranges.
No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.
See all on the product pages:CapecitabineCarboplatinCyclophosphamideDoxorubicinEpirubicinOlaparibPaclitaxel / nab-paclitaxelPembrolizumab·Printable cards in the navigator
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Everything in development, the medicines held by this cancer's subtypes, the open problems and what is being done about them, the roadmaps, and what changed on this record.
Every connected record, the notes, the JSON, Markdown and RDF twins, and where the record came from and when it was checked.