Early and Advanced Triple Negative Breast Cancer (TNBC)

Authored by Ilana Schlam, published on 2026-04-12 17:07:47.0

Post ASCO, ESMO and SABCS 2025 TNBC algorithm. Radiation is indicated for some with early stage disease. Add Zometa for postmenopausal patients, q6 months for 2-3 years (Early stage).*Keynote522 studied adjuvant pembro irrespective of RD vs pCR, no clear data about combination of pembro + capecitabine. Olaparib showed improvements in outcomes in BRCA carriers with RD. **No data about ADC sequencing, ~60 of patients in DESTINY-breast04 had HER2 low, HR- disease.

  1. Early stage TNBC
    • <2 cm and node negative (obtain axillary US)
      • < 1 cm
        • Surgery
          • Observation (T1a) vs chemotherapy
      • 1-2 cm
        • Surgery
          • Chemotherapy (neoadjuvant chemotherapy can be considered in a case-by-case basis)
    • ≥2 cm or node positive
      • TC-AC + pembro
        Keynote 522 Preferred for high risk Can consider carbo/docetaxel/pembro per NeoPACT if not eligible for anthracyclines
        • Surgery
          • pCR
            • Pembro
              Keynote 522
          • RD
            • Pembro + ?Capecitabine (BRCAwt)
              Keynote 522, CreateX
            • Pembro + ?Olaparib g(BRCA)
              Keynote 522, OLYMPIA
  2. Advanced TNBC
    • PDL1 + (22C3 CPS >10)
      *ASCENT 04: Saci+pembro vs chemo+pemrbo improved PFS (PDL1+) +crossover
      • Pembro + chemotherapy (consider SG)
        Keynote 355 ASCENT-04
        • gBRCA 1/2 mutation
          • PARPi (ola, tala)
            OLYMPIAD, EMBRACA
            • HER2 1-2+
              • Chemotherapy
              • T-DXd
                DESTINY-Breast04 (After 1+ line)
              • Sacituzumab-govitecan (if not used 1L)
                Ascent (After 2+ lines)
            • HER2 low
              • Sacituzumab-govitecan (if not used 1L)
                Ascent (After 2+ lines)
              • T-DXd
                DESTINY-Breast04 (After 1+ line)
              • Chemotherapy
            • HER2 0
              • Sacituzumab-govitecan (if not used 1L)
                Ascent (After 2+ lines)
                • Chemotherapy
    • PDL1 -
      *ASCENT 03: Saci+ vs chemo+ improved PFS (PDL1-). +crossover *TROPION Breast 02: dato+ vs chemo+ improved PFS and OS (PDL1-). -crossover
      • Chemotherapy (consider ADC: SG or dato-DXd)
        ASCENT 03 TROPION-Breast02
        • gBRCA 1/2 mutation
          • PARPi (ola, tala)
            OLYMPIAD, EMBRACA
            • HER2 1-2+
              • Chemotherapy
              • T-DXd
                DESTINY-Breast04 (After 1+ line)
              • Sacituzumab-govitecan (if not used 1L)
                Ascent (After 2+ lines)
            • HER2 low
              • Sacituzumab-govitecan (if not used 1L)
                Ascent (After 2+ lines)
              • T-DXd
                DESTINY-Breast04 (After 1+ line)
              • Chemotherapy
            • HER2 0
              • Sacituzumab-govitecan (if not used 1L)
                Ascent (After 2+ lines)
                • Chemotherapy
        • No gBRCA 1/2mutation
          • Chemotherapy
            • HER2 1-2+
              • Chemotherapy
              • T-DXd
                DESTINY-Breast04 (After 1+ line)
              • Sacituzumab-govitecan (if not used 1L)
                Ascent (After 2+ lines)
            • HER2 low
              • Sacituzumab-govitecan (if not used 1L)
                Ascent (After 2+ lines)
              • T-DXd
                DESTINY-Breast04 (After 1+ line)
              • Chemotherapy
            • HER2 0
              • Sacituzumab-govitecan (if not used 1L)
                Ascent (After 2+ lines)
                • Chemotherapy
tosprivacyOverall Survival with Pembrolizumab in Early-Stage Triple-Negative Breast CancerClinical and Biomarker Findings of Neoadjuvant Pembrolizumab and Carboplatin Plus Docetaxel in Triple-Negative Breast Cancer NeoPACT Phase 2 Clinical TrialAdjuvant Capecitabine for Breast Cancer after Preoperative ChemotherapyOverall survival in the OlympiA phase III trial of adjuvant olaparib in patients with germline pathogenic variants in BRCA1/2 and high-risk, early breast cancerSacituzumab Govitecan plus Pembrolizumab for Advanced Triple-Negative Breast CancerPembrolizumab plus Chemotherapy in Advanced Triple-Negative Breast CancerStudy of Sacituzumab Govitecan-hziy Versus Treatment of Physician's Choice in Patients With Previously Untreated Locally Advanced Inoperable or Metastatic Triple-Negative Breast Cancer (ASCENT-03)A Study of Dato-DXd Versus Investigator's Choice Chemotherapy in Patients With Locally Recurrent Inoperable or Metastatic Triple-negative Breast Cancer, Who Are Not Candidates for PD-1/​PD-L1 Inhibitor Therapy (TROPION-Breast02)OlympiAD extended follow-up for overall survival and safety: Olaparib versus chemotherapy treatment of physician's choice in patients with a germline BRCA mutation and HER2-negative metastatic breast cancerTalazoparib versus chemotherapy in patients with germline BRCA1/2-mutated HER2-negative advanced breast cancer: final overall survival results from the EMBRACA trialTrastuzumab Deruxtecan in Previously Treated HER2-Low Advanced Breast CancerFinal Results From the Randomized Phase III ASCENT Clinical Trial in Metastatic Triple-Negative Breast Cancer and Association of Outcomes by Human Epidermal Growth Factor Receptor 2 and Trophoblast Cell Surface Antigen 2 Expression