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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.
The 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.
Metastatic triple-negative disease spreads early to lung, liver and brain and grows fast, so the first line matters more than in other breast cancers. At relapse the tumour is retested, because receptors can change, and three results steer treatment: PD-L1 by combined positive score (10 or more in roughly four in ten patients), germline BRCA status and the HER2 immunohistochemistry score that identifies HER2-low disease. Until 2018 the options were taxanes, anthracyclines, platinum, capecitabine and eribulin, with platinum favoured in BRCA carriers after the TNT trial.
Immunotherapy came first. IMpassion130 showed atezolizumab with nab-paclitaxel delays progression in PD-L1-positive disease and won an accelerated approval that was withdrawn in 2021 when IMpassion131 with paclitaxel failed. KEYNOTE-355 (847 patients) showed pembrolizumab with chemotherapy extends survival in tumours with a combined positive score of 10 or more (hazard ratio 0.73) and became the first-line standard for that group. The TROP2 antibody-drug conjugates then moved into the first line: ASCENT-04 showed sacituzumab govitecan with pembrolizumab beats chemotherapy with pembrolizumab in PD-L1-positive disease, ASCENT-03 showed sacituzumab govitecan beats chemotherapy in PD-L1-negative disease, and TROPION-Breast02 (644 patients) showed datopotamab deruxtecan extends overall survival from 18.7 to 23.7 months in patients who cannot have immunotherapy, the first first-line antibody-drug conjugate to do so; all three were approved in 2026.
| Setting | Approach | Guideline |
|---|---|---|
| First line, combined positive score 10 or more | Pembrolizumab with chemotherapy (KEYNOTE-355) or with sacituzumab govitecan (ASCENT-04). | not mapped |
| 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. | not mapped |
| Germline BRCA carriers | Olaparib (OlympiAD) or talazoparib (EMBRACA) after or instead of first-line chemotherapy; platinum chemotherapy is also more active. | not mapped |
| 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. | not mapped |
| Brain metastases | Stereotactic radiosurgery or whole-brain radiotherapy with continued systemic therapy; antibody-drug conjugates have early evidence of intracranial activity. | not mapped |