Triple-negative breast cancer, stage II-III

Triple-negative breast cancer (TNBC) →

About a year of active treatment: chemotherapy with immunotherapy before surgery, surgery, then immunotherapy for nine more cycles, with radiotherapy alongside, followed by five years of check-ups.

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Typical sequence for stage II-III (operable) disease; durations are protocol values (cycle counts and lengths, fraction schedules, guideline follow-up intervals), not averages of real patients. Your team's plan will differ in detail.

Phase by phase

1. Diagnosis and staging
weeks 0-4
Core biopsy with receptor testing (ER, PR, HER2), breast imaging, and staging scans for stage II-III; germline BRCA testing.
Histopathology & immunohistochemistry Mammography & tomosynthesis MRI Germline (hereditary) testing
Source
2. Pembrolizumab + carboplatin/paclitaxel
weeks 2-14
Four 3-week cycles of pembrolizumab with weekly paclitaxel and carboplatin (KEYNOTE-522 schedule).
PembrolizumabCarboplatinPaclitaxel / nab-paclitaxelImmune checkpoint inhibitors Cytotoxic chemotherapy
Source
3. Pembrolizumab + anthracycline/cyclophosphamide
weeks 14-26
Four further 3-week cycles with doxorubicin or epirubicin plus cyclophosphamide.
PembrolizumabDoxorubicinCyclophosphamide
Source
4. Surgery
weeks 26-32
Lumpectomy or mastectomy with sentinel node biopsy 3-6 weeks after the last chemotherapy; the pathology report shows whether all invasive cancer has gone (pCR).
Sentinel lymph node biopsy
Source
Decision: Did the pathology show a complete response (pCR)?
- pCR: continue adjuvant pembrolizumab; surveillance afterwards
- Residual disease: adjuvant pembrolizumab, and capecitabine (CREATE-X) or olaparib for a germline BRCA mutation (OlympiA) are added
5. Adjuvant pembrolizumab
weeks 29-56
Nine 3-week cycles after surgery, as in KEYNOTE-522. Whether patients with pCR need it is being tested (OptimICE-pCR).
Pembrolizumab
Source
6. Radiotherapy
weeks 29-35 (alongside the previous phase)
After lumpectomy, or after mastectomy with node-positive disease; 15-16 fractions over 3 weeks is standard in the UK, 5-6 weeks elsewhere; given alongside adjuvant pembrolizumab.
IMRT / IGRT (modern external beam)
Source
7. Surveillance
from week 56, continues for years
History and examination every 3-6 months for 3 years, every 6-12 months in years 4-5, then yearly; annual mammography. No routine scans or blood tests without symptoms.
Source

Sources

Phase by phase

1. Diagnosis and staging

weeks 0-4

Core biopsy with receptor testing (ER, PR, HER2), breast imaging, and staging scans for stage II-III; germline BRCA testing.

Histopathology & immunohistochemistry Mammography & tomosynthesis MRI Germline (hereditary) testing

Source

2. Pembrolizumab + carboplatin/paclitaxel

weeks 2-14

Four 3-week cycles of pembrolizumab with weekly paclitaxel and carboplatin (KEYNOTE-522 schedule).

PembrolizumabCarboplatinPaclitaxel / nab-paclitaxelImmune checkpoint inhibitors Cytotoxic chemotherapy

Source

3. Pembrolizumab + anthracycline/cyclophosphamide

weeks 14-26

Four further 3-week cycles with doxorubicin or epirubicin plus cyclophosphamide.

PembrolizumabDoxorubicinCyclophosphamide

Source

4. Surgery

weeks 26-32

Lumpectomy or mastectomy with sentinel node biopsy 3-6 weeks after the last chemotherapy; the pathology report shows whether all invasive cancer has gone (pCR).

Sentinel lymph node biopsy

Source

Decision: Did the pathology show a complete response (pCR)?

pCR: continue adjuvant pembrolizumab; surveillance afterwards
Residual disease: adjuvant pembrolizumab, and capecitabine (CREATE-X) or olaparib for a germline BRCA mutation (OlympiA) are added

5. Adjuvant pembrolizumab

weeks 29-56

Nine 3-week cycles after surgery, as in KEYNOTE-522. Whether patients with pCR need it is being tested (OptimICE-pCR).

Pembrolizumab

Source

6. Radiotherapy

weeks 29-35 (alongside the previous phase)

After lumpectomy, or after mastectomy with node-positive disease; 15-16 fractions over 3 weeks is standard in the UK, 5-6 weeks elsewhere; given alongside adjuvant pembrolizumab.

IMRT / IGRT (modern external beam)

Source

7. Surveillance

from week 56, continues for years

History and examination every 3-6 months for 3 years, every 6-12 months in years 4-5, then yearly; annual mammography. No routine scans or blood tests without symptoms.

Source