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Enter what the pathology report at surgery showed, your germline BRCA result and whether pembrolizumab was part of the treatment before surgery, and read the statements that apply, quoted word for word from NICE, the trials and the residual cancer burden studies. An educational aid to prepare for the conversation with your oncologist, not advice. Nothing you enter leaves this page.
Answer the 3 questions and the statement that applies to that combination appears here, quoted word for word from NICE TA886: olaparib for adjuvant treatment of BRCA mutation-positive HER2-negative high-risk early breast cancer after chemotherapy, recommendation 1.1 (May 2023) and the sources listed below, with a plain line on what it means and the questions to take to your surgeon.
Without JavaScript, every statement the aid can show is listed further down the page. This is an educational aid, not advice.
The aid picks from these 11 cards; each quotes its source word for word. Read them all here, with or without the questions above.
“Estimates of 10-year relapse-free survival rates in the four RCB classes (pathologic complete response, RCB-I, RCB-II, and RCB-III) were 86%, 81%, 55%, and 23% for triple receptor-negative”
“Whether the addition of pembrolizumab to neoadjuvant chemotherapy would significantly increase the percentage of patients with early triple-negative breast cancer who have a pathological complete response (defined as no invasive cancer in the breast and negative nodes) at definitive surgery is unclear.”
What this means: A complete response means the chemotherapy did its work: in the long-running Symmans series 86 of 100 people with triple-negative disease and a complete response were free of relapse at 10 years. Nothing extra is added to treatment on the strength of this result; radiotherapy is decided on the stage before treatment and the operation done, and follow-up is annual mammography.
“Estimates of 10-year relapse-free survival rates in the four RCB classes (pathologic complete response, RCB-I, RCB-II, and RCB-III) were 86%, 81%, 55%, and 23% for triple receptor-negative”
“RCB score was prognostic within each breast cancer subtype, with higher RCB score significantly associated with worse event-free survival.”
What this means: Residual cancer burden grades what was left after chemotherapy from I (a little) to III (a lot). For triple-negative disease the 10-year relapse-free figures were 81 in 100 for RCB-I, 55 for RCB-II and 23 for RCB-III in the Symmans series, and the pooled analysis of 5,161 patients confirmed the class is prognostic in every subtype. It is the reason the treatments on the cards below are offered.
“the association we observed between RCB and a patient's residual risk suggests that prospective evaluation of RCB could be considered to become part of standard pathology reporting after neoadjuvant therapy.”
What this means: The pooled analysis asked pathologists to report the residual cancer burden after chemotherapy. If your report gives only a tumour size or a yp-stage, the class can usually be calculated from the measurements already recorded; ask the team to state it, because it is the clearest guide to the risk the treatments below are meant to lower.
“Olaparib (alone or with endocrine therapy) is recommended, within its marketing authorisation, as an option for the adjuvant treatment of HER2‑negative high-risk early breast cancer that has been treated with neoadjuvant or adjuvant chemotherapy in adults with germline BRCA1 or 2 mutations.”
“Among patients with high-risk, HER2-negative early breast cancer and germline BRCA1 or BRCA2 pathogenic or likely pathogenic variants, adjuvant olaparib after completion of local treatment and neoadjuvant or adjuvant chemotherapy was associated with significantly longer survival free of invasive or distant disease than was placebo.”
“Four-year OS was 89.8% in the olaparib group and 86.4% in the placebo group”
“Stage II-III: Neoadjuvant pembrolizumab + carboplatin/paclitaxel → AC/EC, surgery, adjuvant pembrolizumab (KEYNOTE-522). Germline BRCA + residual disease: olaparib 1 year (OlympiA). Residual disease without BRCA: capecitabine (CREATE-X). Radiation per stage.”
What this means: For people who carry an inherited BRCA1 or BRCA2 variant and still had invasive cancer at surgery, a year of olaparib tablets after surgery and radiotherapy is funded on the NHS. In OlympiA it reduced invasive recurrence (82.7% against 75.4% free of invasive disease at 4 years) and improved survival. It starts after radiotherapy, and pembrolizumab, where given, continues alongside; olaparib and capecitabine were not tested together, so ask which the team proposes and why.
“Among patients with triple-negative disease, the rate of disease-free survival was 69.8% in the capecitabine group versus 56.1% in the control group (hazard ratio for recurrence, second cancer, or death, 0.58; 95% CI, 0.39 to 0.87), and the overall survival rate was 78.8% versus 70.3% (hazard ratio for death, 0.52; 95% CI, 0.30 to 0.90).”
“The hand-foot syndrome, the most common adverse reaction to capecitabine, occurred in 73.4% of the patients in the capecitabine group.”
“Stage II-III: Neoadjuvant pembrolizumab + carboplatin/paclitaxel → AC/EC, surgery, adjuvant pembrolizumab (KEYNOTE-522). Germline BRCA + residual disease: olaparib 1 year (OlympiA). Residual disease without BRCA: capecitabine (CREATE-X). Radiation per stage.”
What this means: CREATE-X gave capecitabine tablets for six to eight cycles after surgery to people with HER2-negative residual disease, and the gain was clearest in triple-negative disease: 79 rather than 70 of 100 alive at 5 years. It is the OnCo record's standard for residual disease without a BRCA variant. CREATE-X predates pembrolizumab, so how the two fit together is a matter of judgement; sore, red or peeling palms and soles are common and the dose is adjusted for them.
“Offer genetic testing for BRCA1 and BRCA2 mutations to women under 50 years with triple-negative breast cancer , including those with no family history of breast or ovarian cancer”
“If you were diagnosed with triple negative breast cancer under the age of 60, you should be offered a referral to a specialist family history clinic or a regional genetics clinic to discuss genetic testing , regardless of your family history of breast cancer.”
“Olaparib (alone or with endocrine therapy) is recommended, within its marketing authorisation, as an option for the adjuvant treatment of HER2‑negative high-risk early breast cancer that has been treated with neoadjuvant or adjuvant chemotherapy in adults with germline BRCA1 or 2 mutations.”
What this means: Testing is offered to everyone with triple-negative breast cancer under 60 in the UK, and the result changes what is offered after surgery: olaparib is funded only for carriers. It also tells relatives whether predictive testing is open to them. If the result is not back, ask for it to be chased before the treatment after surgery is fixed; Breast Cancer Now says results usually take 1 to 3 months.
“We conducted a phase 3, double-blind, randomized trial involving patients with human epidermal growth factor receptor 2 (HER2)-negative early breast cancer with BRCA1 or BRCA2 germline pathogenic or likely pathogenic variants and high-risk clinicopathological factors who had received local treatment and neoadjuvant or adjuvant chemotherapy.”
“Olaparib (alone or with endocrine therapy) is recommended, within its marketing authorisation, as an option for the adjuvant treatment of HER2‑negative high-risk early breast cancer that has been treated with neoadjuvant or adjuvant chemotherapy in adults with germline BRCA1 or 2 mutations.”
What this means: OlympiA recruited people with high-risk features; for those treated with chemotherapy before surgery, residual disease was the high-risk feature, so a complete response after neoadjuvant treatment was not the population studied and the NICE recommendation speaks of high-risk disease. A complete response is good news; the BRCA result still matters for the other breast, the ovaries and your relatives, which is a conversation with the genetics team rather than a treatment decision.
“If an altered gene is found (a positive result), this confirms your chances of developing breast cancer are higher than the general population. You may also have a higher chance of developing other types of cancer.”
“Your genetics team will know which altered gene runs in your family. They can then search for the alteration more easily in other family members, who can be tested to see if they also carry it (predictive genetic testing).”
What this means: Each child of a carrier has a 1 in 2 chance of inheriting the variant, and brothers and sisters may carry it too. The genetics team explains who can be offered predictive testing and how to tell them; nobody is tested without their own consent.
“Pembrolizumab is recommended, within its marketing authorisation, as an option with chemotherapy for neoadjuvant treatment and then continued alone as adjuvant treatment after surgery for adults with triple-negative: early breast cancer at high risk of recurrence or locally advanced breast cancer.”
“After definitive surgery, patients received adjuvant pembrolizumab (pembrolizumab-chemotherapy group) or placebo (placebo-chemotherapy group) every 3 weeks for up to nine cycles.”
“The estimated overall survival at 60 months was 86.6% (95% confidence interval [CI], 84.0 to 88.8) in the pembrolizumab-chemotherapy group, as compared with 81.7% (95% CI, 77.5 to 85.2) in the placebo-chemotherapy group”
What this means: In KEYNOTE-522 everyone who had pembrolizumab before surgery went on to up to nine more doses afterwards, whether or not the response was complete, and that is how NICE recommends it. Whether people with a complete response can safely stop is the question the OptimICE-pCR trial is asking; ask whether it is open to you. Immune-related side effects can still begin during this phase.
“Pembrolizumab is recommended, within its marketing authorisation, as an option with chemotherapy for neoadjuvant treatment and then continued alone as adjuvant treatment after surgery for adults with triple-negative: early breast cancer at high risk of recurrence or locally advanced breast cancer.”
What this means: The NHS recommendation is for pembrolizumab started with chemotherapy before surgery and continued afterwards; the trial did not test starting it only after surgery. If you did not have it, there was usually a reason (a smaller tumour, surgery first, an autoimmune condition, or treatment before December 2022). Worth asking what the reason was and whether it changes anything now.
“Offer annual mammography for 5 years to all people who have had or are being treated for breast cancer, including DCIS.”
“Ensure all people who have had treatment for breast cancer have an agreed, written care plan, recorded in their notes by a named healthcare professional (or professionals) from the multidisciplinary team. Give a copy to the person and to their GP.”
What this means: NICE asks for a written plan that names your professionals, gives the dates for reviewing any treatment after surgery, the mammography schedule, the signs to look out for and the numbers to ring. Ask for your copy. Triple-negative relapses cluster in the first three years, so knowing what to report matters more than extra scans, which NICE does not recommend routinely.
Each combination of answers maps to a fixed set of cards, and every card quotes the statement it implements with the page it was read from; nothing is scored or inferred. Where the sources disagree, both are quoted. The mapping is data in the OnCo repository and is tested against every combination of answers. Checked 2026-09-24.
This is an educational aid to prepare for a conversation with your surgical team. It is not medical advice, and it cannot see your scans or your history. OnCo is orientation, not medical advice.