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10 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
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.
| Setting | Approach | Guideline |
|---|---|---|
| Stage I, tumours 2 cm or less without node involvement | 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. | not mapped |
| Stage II to III, before surgery | Pembrolizumab with carboplatin and paclitaxel, then with doxorubicin or epirubicin and cyclophosphamide, followed by surgery (KEYNOTE-522). | not mapped |
| After surgery, pathological complete response | Pembrolizumab to complete a year and radiotherapy by stage; omission of adjuvant pembrolizumab is under test (OptimICE-pCR). | not mapped |
| After surgery, residual disease | 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). | not mapped |
| Local therapy | Breast conservation with whole-breast radiotherapy or mastectomy, sentinel node biopsy after neoadjuvant therapy, and post-mastectomy radiotherapy for node-positive disease. | not mapped |