The first 60 days: Metastatic triple-negative breast cancer

Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.

These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.

• Medical oncologistNamed in the standard of care for: First line, combined positive score 10 or more, First line, PD-L1-negative or immunotherapy-ineligible, Germline BRCA carriers, Second line and beyond and 1 more.
• Clinical oncologist (radiotherapy)Named in the standard of care for: Brain metastases.

A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.

Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.

1. 1.First line, combined positive score 10 or more

   Pembrolizumab with chemotherapy (KEYNOTE-355) or with sacituzumab govitecan (ASCENT-04).

   PembrolizumabKEYNOTE-355Sacituzumab govitecanASCENT-04 / KEYNOTE-D19Combined positive score (CPS)
2. 2.First line, PD-L1-negative or immunotherapy-ineligible

   Datopotamab deruxtecan (TROPION-Breast02) or sacituzumab govitecan (ASCENT-03); a taxane or platinum where antibody-drug conjugates are unavailable.

   Datopotamab deruxtecanTROPION-Breast02Sacituzumab govitecanASCENT-03Paclitaxel / nab-paclitaxelCarboplatin
3. 3.Germline BRCA carriers

   Olaparib (OlympiAD) or talazoparib (EMBRACA) after or instead of first-line chemotherapy; platinum chemotherapy is also more active.

   OlaparibOlympiADTalazoparibEMBRACACarboplatinGermline BRCA mutation (gBRCA)
4. 4.Brain metastases

   Stereotactic radiosurgery or whole-brain radiotherapy with continued systemic therapy; antibody-drug conjugates have early evidence of intracranial activity.

   Stereotactic radiosurgery (Gamma Knife, CyberKnife, linac SRS)Brain metastases (intracranial disease)
5. 5.Second line and beyond

   Whichever TROP2 antibody-drug conjugate has not been used (ASCENT); trastuzumab deruxtecan for HER2-low tumours (DESTINY-Breast04); izalontamab brengitecan where available; eribulin, capecitabine or gemcitabine with carboplatin.

   Sacituzumab govitecanASCENTTrastuzumab deruxtecanDESTINY-Breast04Izalontamab brengitecanEribulinCapecitabineGemcitabine

Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.

Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.

• A Clinical Trial of SHR-A1811 in the Treatment of Triple-negative Breast CancerPhase 3 · recruiting · NCT07111832A Phase III, Multicenter, Randomized, Open-label, Active-controlled Study of SHR-A1811 Plus SHR-1316 Versus Toripalimab Plus Nab-paclitaxel in PD-L1-positive Locally Recurrent Unresectable or Metastatic Triple-negative Breast Cancer
• A Multi-center, Randomized, Open-label, Phase III Study Comparing PD-1 Inhibitor Combined With Antivascular Therapy and Anthracycline/Taxane-based Adjuvant ChemPhase 3 · recruiting · NCT05862064A Multi-center, Randomized, Open-label, Phase III Study Comparing PD-1 Inhibitor Combined With Antivascular Therapy and Anthracycline/Taxane-based Adjuvant Chemotherapy Versus Anthracycline/Taxane-based Adjuvant Chemotherapy Alone in Patients With Operable Triple-negative Breast Cancer
• A Phase III Study of ESG401 for Unresectable Recurrent or Metastatic Triple-Negative Breast CancerPhase 3 · recruiting · NCT06732323A Randomized, Open-label, Phase III Study of ESG401 Versus Investigator's Choice Chemotherapy as First-line Treatment in Patients With Unresectable Recurrent or Metastatic Triple-Negative Breast Cancer
• A Phase III Study of JSKN016 Versus Treatment of Physician's Choice in Patients With Triple-Negative Breast Cancer Who Have Failed Standard of CarePhase 3 · recruiting · NCT07533123A Randomized, Controlled, Open-Label Study of JSKN016 Versus Treatment of Physician's Choice in Patients With Unresectable Locally Advanced, Recurrent, or Metastatic Triple-Negative Breast Cancer Who Have Failed at Least Two Lines of Prior Systemic Therapy
• A Randomized Controlled Trial of Neoadjuvant Weekly Paclitaxel Versus Weekly Paclitaxel Plus Weekly Carboplatin In Women With Large Operable or Locally AdvancedPhase 3 · active · NCT03168880A Randomized Controlled Trial of Neoadjuvant Weekly Paclitaxel Versus Weekly Paclitaxel Plus Weekly Carboplatin In Women With Large Operable or Locally Advanced, Triple Negative Breast Cancer

Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.

• Free in oncologyFree testing, helplines, rides and lodging, second opinions and trial travel help, with who is eligible.
• Financial helpManufacturer programmes, national schemes and charities by country and product.
• Second opinionExpert centres for this cancer in your country and how referral works.

• Metastatic triple-negative breast cancer: the full pageThe treatment of triple-negative breast cancer that has spread has been transformed since 2020, though it is not yet curable. By PD-L1 score, first treatment is pembrolizumab with chemotherapy or with sacituzumab govitecan, or datopotamab deruxtecan or sacituzumab govitecan alone; BRCA carriers can take a PARP inhibitor tablet; and trastuzumab deruxtecan reaches the third of tumours with low HER2.
• One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
• Treatment sequencingWhich treatment tends to follow which, line by line.
• NavigatorStandard of care for your stage, what you have tried, and trials near you.