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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.

03691 yrMonths from diagnosis · solid bar = shortest typical duration, hatched = up to the longest · arrow = continues for yearsPhaseDiagnosis and stagingDiagnosis and tests · 2-4 wkPembrolizumab + carboplatin/paclitaxelBefore surgery · 12 wkPembrolizumab + anthracycline/cycloph…Before surgery · 12 wkSurgerySurgery and recovery · 3-6 wkAdjuvant pembrolizumabAfter surgery · 27 wkRadiotherapyRadiotherapy · 3-6 wk · alongsideSurveillanceSurveillance · yearsDid the pathology show a complete response (pCR)?decision 1Diagnosis and testsBefore surgerySurgery and recoveryAfter surgeryRadiotherapySurveillance
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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. 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.

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  2. 2. Pembrolizumab + carboplatin/paclitaxel
    weeks 2-14

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

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  3. 3. Pembrolizumab + anthracycline/cyclophosphamide
    weeks 14-26

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

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  4. 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).

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    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. 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).

    Source
  6. 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.

    Source
  7. 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

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