Early triple-negative breast cancer: the decisions you may face
5 treatment settings, 4 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.
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.
Removing just the first lymph node a tumour drains to, instead of all of them, to check for spread.
- Avoids lymphoedema from full dissection
Fewer, larger daily doses instead of the classic five to seven weeks of small ones. Large trials in breast and prostate cancer showed the same control with the same or fewer late effects and far less time in hospital.
- One to three weeks instead of five to seven
- Same cancer control in randomised trials
- Frees machine capacity
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- False negatives in ~5-10%
- Long-term follow-up still accruing for the shortest schedules
- Not suitable where large volumes of normal tissue are treated
- Requires precise setup
- Between Sentinel lymph node biopsy and Hypofractionated radiotherapy, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (stage i, tumours 2 cm or less without node involvement), which of the standard options do you recommend and why?Why: Guideline options include: 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.
Add these to your appointment list, or take the full question set for this cancer.
Stage II to III, before surgery
Pembrolizumab with carboplatin and paclitaxel, then with doxorubicin or epirubicin and cyclophosphamide, followed by surgery (KEYNOTE-522).
Pembrolizumab is a PD-1 blocking antibody approved in more than 40 settings, from melanoma and lung cancer to the first tumour-agnostic approval for mismatch-repair-deficient tumours in 2017, and before and after surgery in triple-negative breast cancer. A subcutaneous form arrived in 2025, and it is the backbone partner for ADCs and personalised neoantigen vaccines.
Carboplatin is a platinum chemotherapy that crosslinks DNA; it is part of the standard pre-surgery regimen for triple-negative breast cancer.
A microtubule poison discovered in the Pacific yew tree, among the most used chemotherapies in breast, lung, and ovarian cancer.
The red chemotherapy drug from a soil bacterium that is still the backbone of treatment for sarcoma, lymphoma and breast cancer, limited by cumulative heart damage.
Epirubicin (Ellence) is a close relative of doxorubicin used mainly after breast cancer surgery when lymph nodes are involved, and in stomach cancer regimens; it is a little kinder to the heart.
Cyclophosphamide is an alkylating chemotherapy that damages DNA in dividing cells. It is part of CHOP for lymphoma, AC for breast cancer and VAC for childhood sarcomas, clears lymphocytes before CAR-T and prevents graft-versus-host disease after transplant; bladder bleeding, infertility and secondary leukaemia are its harms.
Immune checkpoint inhibitors are antibodies against CTLA-4, PD-1 or PD-L1 that release the brakes on T cells so they attack the cancer. They are approved in more than 20 tumour types and produce lasting, sometimes curative responses that chemotherapy rarely does, but most patients do not respond and autoimmune side effects are the cost.
- Durable, sometimes curative responses
- Broad applicability
- Early-stage (II-III) TNBC: pembrolizumab + chemotherapy before surgery, pembrolizumab after
Show survival figures (1)
Averages across everyone diagnosed, often years ago. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.
- EFS HR 0.63; OS HR 0.66 (5-year); 7-year OS 85.1% vs 77.2%.
Pathologic complete response (ypT0/Tis ypN0) (%): Pembrolizumab + chemotherapy 64.8 (n=401) vs Placebo + chemotherapy 51.2 (n=201) · source
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Hypothyroidism (immune-mediated) · Pooled monotherapy data, >2,800 patients | 8% | - |
| Pneumonitis (immune-mediated) · Pooled monotherapy data, >2,800 patients | 3.4% | - |
| Colitis (immune-mediated) · Pooled monotherapy data, >2,800 patients | 1.7% | - |
| Hepatitis (immune-mediated) · Pooled monotherapy data, >2,800 patients | 0.7% | - |
- No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
- Dose by Calvert formula using GFR (see the calculators).
- Cumulative dose: risk rises steeply above 400-550 mg/m² (see the anthracycline calculator).
- Reduce by 50% for bilirubin 20-50 µmol/L and 75% for 50-85 µmol/L.
- Most patients do not respond
- Autoimmune toxicity
- Biomarkers are imperfect
- Between Pembrolizumab, Carboplatin, Paclitaxel / nab-paclitaxel and the other options, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in KEYNOTE-522, and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- Which side effects of Pembrolizumab are most likely for me, which are reversible, and which would make us stop?Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (stage ii to iii, before surgery), which of the standard options do you recommend and why?Why: Guideline options include: Pembrolizumab with carboplatin and paclitaxel, then with doxorubicin or epirubicin and cyclophosphamide, followed by surgery (KEYNOTE-522).
- Am I a candidate for Pembrolizumab, Carboplatin, Paclitaxel / nab-paclitaxel or related drugs, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of KEYNOTE-522 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
After surgery, pathological complete response
Pembrolizumab to complete a year and radiotherapy by stage; omission of adjuvant pembrolizumab is under test (OptimICE-pCR).
Pembrolizumab is a PD-1 blocking antibody approved in more than 40 settings, from melanoma and lung cancer to the first tumour-agnostic approval for mismatch-repair-deficient tumours in 2017, and before and after surgery in triple-negative breast cancer. A subcutaneous form arrived in 2025, and it is the backbone partner for ADCs and personalised neoantigen vaccines.
- Tests PembrolizumabStage II-III TNBC with pathologic complete response after KEYNOTE-522 regimen: adjuvant pembrolizumab vs observation
No headline result recorded yet.
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Hypothyroidism (immune-mediated) · Pooled monotherapy data, >2,800 patients | 8% | - |
| Pneumonitis (immune-mediated) · Pooled monotherapy data, >2,800 patients | 3.4% | - |
| Colitis (immune-mediated) · Pooled monotherapy data, >2,800 patients | 1.7% | - |
| Hepatitis (immune-mediated) · Pooled monotherapy data, >2,800 patients | 0.7% | - |
- No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
- Is Pembrolizumab the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?Why: A single standard does not mean a single choice; timing and trials are decisions too.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in OptimICE-pCR (A012103), and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- Which side effects of Pembrolizumab are most likely for me, which are reversible, and which would make us stop?Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (after surgery, pathological complete response), which of the standard options do you recommend and why?Why: Guideline options include: Pembrolizumab to complete a year and radiotherapy by stage; omission of adjuvant pembrolizumab is under test (OptimICE-pCR).
- Am I a candidate for Pembrolizumab, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of OptimICE-pCR (A012103) apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
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).
Pembrolizumab is a PD-1 blocking antibody approved in more than 40 settings, from melanoma and lung cancer to the first tumour-agnostic approval for mismatch-repair-deficient tumours in 2017, and before and after surgery in triple-negative breast cancer. A subcutaneous form arrived in 2025, and it is the backbone partner for ADCs and personalised neoantigen vaccines.
Olaparib was the first PARP inhibitor, and turned an inherited BRCA mutation from a risk factor into a drug target, including after surgery in breast cancer.
Capecitabine (Xeloda) is a tablet form of the chemotherapy fluorouracil. It is a backbone of treatment for bowel cancer and a standard option in advanced breast cancer.
A test of the DNA you were born with, to find inherited risk genes such as BRCA or Lynch syndrome.
- Actionable for patient and relatives
- Cheap
- Tests OlaparibAdjuvant olaparib for one year in germline BRCA-mutated, HER2-negative, high-risk early breast cancer
iDFS HR 0.58; OS HR 0.72.
Invasive disease-free survival at 3 years (%): Olaparib 85.9 (n=921) vs Placebo 77.1 (n=915) · HR 0.58 · source - Tests PembrolizumabStage II to III TNBC with residual invasive disease after neoadjuvant therapy and surgery: adjuvant sacituzumab govitecan + pembrolizumab vs pembrolizumab ± capecitabine
No headline result recorded yet.
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Hypothyroidism (immune-mediated) · Pooled monotherapy data, >2,800 patients | 8% | - |
| Pneumonitis (immune-mediated) · Pooled monotherapy data, >2,800 patients | 3.4% | - |
| Colitis (immune-mediated) · Pooled monotherapy data, >2,800 patients | 1.7% | - |
| Hepatitis (immune-mediated) · Pooled monotherapy data, >2,800 patients | 0.7% | - |
- No pharmacokinetic interactions expected (antibody). See the irAE guide for toxicity management.
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Anaemia · OlympiA adjuvant, n=911 | 24% | 9% |
| Neutropenia · OlympiA adjuvant, n=911 | 16% | 5% |
| Leukopenia · OlympiA adjuvant, n=911 | 17% | 3% |
| Fatigue · OlympiA adjuvant, n=911 | 42% | 1.8% |
- Avoid grapefruit and Seville oranges.
- 200 mg twice daily for CrCl 31-50.
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
- VUS burden
- Uptake and counselling capacity
- Between Pembrolizumab, Olaparib, Capecitabine and the other options, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- How closely do I match the people in OlympiA and ASCENT-05 / OptimICE-RD (AFT-65, GBG 119, NSABP B-63), and does that change what the results mean for me?Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
- Which side effects of Pembrolizumab or Olaparib are most likely for me, which are reversible, and which would make us stop?Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (after surgery, residual disease), which of the standard options do you recommend and why?Why: Guideline options include: 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).
- Am I a candidate for Pembrolizumab, Olaparib, Capecitabine, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of OlympiA and ASCENT-05 / OptimICE-RD (AFT-65, GBG 119, NSABP B-63) apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Add these to your appointment list, or take the full question set for this cancer.
Local therapy
Breast conservation with whole-breast radiotherapy or mastectomy, sentinel node biopsy after neoadjuvant therapy, and post-mastectomy radiotherapy for node-positive disease.
Removing just the first lymph node a tumour drains to, instead of all of them, to check for spread.
- Avoids lymphoedema from full dissection
IMRT and IGRT shape the radiation beam to the tumour's outline from multiple angles and check the patient's position with a scan before every session, so surrounding organs receive less dose. Fewer, larger doses are now standard in breast and prostate cancer, but a low-dose bath still spreads across normal tissue.
- Conformal dose, fewer side effects
- Hypofractionation saves visits
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- False negatives in ~5-10%
- Low-dose bath to normal tissue
- Motion management
- Between Sentinel lymph node biopsy and IMRT / IGRT (modern external beam), which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- For my situation (local therapy), which of the standard options do you recommend and why?Why: Guideline options include: Breast conservation with whole-breast radiotherapy or mastectomy, sentinel node biopsy after neoadjuvant therapy, and post-mastectomy radiotherapy for node-positive disease.
Add these to your appointment list, or take the full question set for this cancer.