Key points
- "Triple-negative" means the tumour has neither hormone receptors nor HER2; so hormone tablets do not work on it, and the main treatment is chemotherapy and, in many patients, immunotherapy [1, 18, 8].
- In most patients, treatment starts before surgery: chemotherapy with pembrolizumab made the tumour disappear completely by the time of surgery in about 2 in every 3 patients, and lengthened life [3, 4].
- If some tumour remains after that, treatment is completed after surgery: olaparib tablets in women with a BRCA mutation, or capecitabine tablets [6, 5, 8].
- A BRCA test is needed for most patients; its result can change treatment and also matters for the family [9].
- There are more options for disease that has spread, too: immunotherapy with chemotherapy, olaparib, and drugs that deliver chemotherapy straight to the cancer cell [10, 11, 12, 13].
The story of triple-negative breast cancer
About 1 to 2 in every 10 breast cancers are "triple-negative" [1, 2]. For years this was seen as the most worrying type of breast cancer. In a large study, these patients more often had the disease come back elsewhere in the body, and more often died, in the first 5 years; but the risk of relapse peaked about 3 years after diagnosis and fell quickly after that [1].
Chemotherapy was the only real weapon. But researchers noticed something important: when chemotherapy was given before surgery, triple-negative tumours disappeared completely more often than other types, and women whose tumour had disappeared completely by the time of surgery lived as well as other patients. By contrast, if some tumour remained, the risk was higher [2].
This observation shaped today's treatment: treatment before surgery both shrinks the tumour and shows who needs more treatment after surgery. Three major advances completed the picture: capecitabine tablets for remaining tumour [5], olaparib tablets for women with a BRCA mutation [6], and the immunotherapy drug pembrolizumab with chemotherapy, which lengthened patients' lives in a large study [3, 4].
Treatment today at each stage
- 1
Small tumour without lymph node involvement
Chemotherapy with pembrolizumab before surgery is for larger tumours or those with lymph node involvement [3, 8]. For smaller tumours without node involvement, the doctor decides on surgery first and the need for chemotherapy based on the size of the tumour.
- 2
Tumour larger than 2 cm or lymph nodes involved: treatment before surgery
- 3
If tumour remains after surgery
- 4
Disease that has spread
The drug is chosen according to tests on the tumour. If the tumour has a lot of the PD-L1 protein, chemotherapy with pembrolizumab, which lengthened life in these patients [10]. With a BRCA mutation, olaparib tablets [11]. If the tumour is "HER2-low", trastuzumab deruxtecan (Enhertu) [12]. Sacituzumab govitecan, which delivers a powerful chemotherapy straight to the cancer cell, almost doubled survival after earlier treatments [13] and is now also used as a first treatment [14, 15].
BRCA testing and other important tests
American guidelines recommend offering BRCA genetic testing to all newly diagnosed patients aged 65 or younger, and to older patients when the result could change treatment, for example for olaparib [9]. The result also matters for your relatives; if you have a mutation, they too can assess their own risk after genetic counselling [9]. Read more: Is cancer hereditary?
If the disease has spread, two other tests on the tumour also matter: the amount of the PD-L1 protein (the CPS number), which shows how much immunotherapy will help [10], and whether the tumour's HER2 is exactly "zero" or "low" [12].
When should I call my doctor?
During chemotherapy: report a temperature of 38 °C or higher, chills or any sign of infection straight away; infection during this time can be dangerous [19]. With pembrolizumab: report a new cough or breathlessness, diarrhoea or stomach pain, yellowing of the skin or eyes, a severe headache or a racing heart straight away; these side effects can appear even after treatment has ended [16]. With sacituzumab govitecan: report the first episode of diarrhoea and any fever or chills straight away [17]. With capecitabine: redness, pain or blistering of the palms and soles is common; tell your doctor about it [5]. See: Low blood counts and preventing infection
Frequently asked questions
Is triple-negative breast cancer curable?
Yes. At early stages most patients are cured: in a large study, with today's treatment nearly 9 in every 10 patients with stage 2 or 3 disease were alive five years later [4]. The risk of relapse is highest in the first few years and falls quickly after that [1]. See: Is breast cancer curable?
Why is chemotherapy given before surgery? Does it mean my disease is worse?
If my tumour disappeared completely, do I still need pembrolizumab after surgery?
In the main study, pembrolizumab was continued after surgery for everyone, and the European guideline also recommends continuing it whether or not the tumour has disappeared [3, 8].
What are the side effects of pembrolizumab?
Most side effects can be managed, but sometimes the immune system attacks healthy organs such as the thyroid, bowel, lungs or liver [16]. Most patients who developed an underactive thyroid needed thyroid hormone tablets long term [16]. See: Pembrolizumab
If the disease has spread, what hope is there?
The aim is long-term control of the disease and a good life. New drugs have lengthened the lives of these patients in recent years; for example, in patients whose tumour has a lot of PD-L1, adding pembrolizumab to chemotherapy typically added about 7 months of life [10].
For physicians
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Background: Dent 2007 (1601 patients, 11.2% TNBC): HR for distant recurrence 2.6 and for death 3.2 within the first 5 years, but not thereafter; distant recurrence peaked at about year 3 [1]. Liedtke 2008 (1118 neoadjuvant patients): pCR 22% in TNBC versus 11%; with pCR, survival was similar in TNBC and non-TNBC, while with residual disease OS was worse in TNBC [2].
Early disease: KEYNOTE-522 (1174 patients, stage II–III, regardless of PD-L1; 4 cycles of pembrolizumab 200 mg every 3 weeks + paclitaxel and carboplatin, then 4 cycles of pembrolizumab + AC or EC, and after surgery up to 9 cycles of pembrolizumab): pCR 64.8% versus 51.2%; treatment-related grade ≥3 adverse events 78.0% versus 73.0% [3]; 5-year OS 86.6% versus 81.7% (P=0.002; median follow-up 75.1 months) [4]. CREATE-X (910 patients, HER2-negative with residual invasive disease after neoadjuvant therapy; before the immunotherapy era): 5-year DFS 74.1% versus 67.6% (HR 0.70) and OS 89.2% versus 83.6% (HR 0.59); in TNBC, DFS 69.8% versus 56.1% (HR 0.58) and OS 78.8% versus 70.3% (HR 0.52); hand-foot syndrome 73.4% [5]. OlympiA (1836 patients, gBRCA, high-risk HER2-negative): 3-year iDFS 85.9% versus 77.1% (HR 0.58) [6]; at a median follow-up of 6.1 years, HR for OS 0.72 and 6-year OS 87.5% versus 83.2%; MDS/AML 0.4% versus 0.7% [7]. ESMO Pan-Asian 2024: neoadjuvant chemotherapy with pembrolizumab for cT2–4 N0 or any node-positive disease [I, A]; adjuvant pembrolizumab for 9 cycles regardless of pCR [I, A]; one year of olaparib in gBRCA carriers with high-risk TNBC (no pCR or pathological stage II–III) [I, A]; capecitabine for 6 to 8 cycles for residual disease in patients who have not received an immune checkpoint inhibitor [I, A] [8]. ASCO-SSO 2024: BRCA1/2 testing for all newly diagnosed patients aged 65 or younger and selected patients over 65, including PARPi candidates [9]. Doses: KEYNOTE-522 regimen · adjuvant capecitabine (CREATE-X) · adjuvant olaparib (OlympiA).
Metastatic disease: KEYNOTE-355 (CPS ≥10): median OS 23.0 versus 16.1 months (HR 0.73); not significant at CPS ≥1 (HR 0.86) [10]. OlympiAD (gBRCA, HER2-negative): median PFS 7.0 versus 4.2 months (HR 0.58) [11]. DESTINY-Breast04 (HER2-low, 1 to 2 prior lines of chemotherapy): overall OS 23.4 versus 16.8 months (HR 0.64); in the hormone receptor-negative cohort (exploratory), PFS 8.5 versus 2.9 months (HR 0.46) and OS 18.2 versus 8.3 months (HR 0.48); drug-related ILD 12.1% [12]. ASCENT (at least 2 prior lines): median OS 12.1 versus 6.7 months (HR 0.48); grade ≥3 neutropenia 51% and grade ≥3 diarrhoea 10% [13]. ASCENT-04/KEYNOTE-D19 (first line, CPS ≥10): sacituzumab govitecan + pembrolizumab versus chemotherapy + pembrolizumab, median PFS 11.2 versus 7.8 months (HR 0.65); OS still immature [14]. NCCN version 4.2026: for CPS below 10 without gBRCA, first-line sacituzumab govitecan (category 1, preferred), datopotamab deruxtecan (category 2A, preferred) or chemotherapy [15]. Sacituzumab: boxed warning for neutropenia and diarrhoea; withhold for ANC below 1500 or neutropenic fever, and primary G-CSF prophylaxis is recommended in patients at increased risk [17]. Doses: KEYNOTE-355 · sacituzumab govitecan · trastuzumab deruxtecan.
Scientific evidence
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Scientific evidence
12 itemsOverall Survival with Pembrolizumab in Early-Stage Triple-Negative Breast Cancer
Adjuvant Capecitabine for Breast Cancer after Preoperative Chemotherapy
Sustained benefit of adjuvant olaparib in women with germline BRCA1- and BRCA2-associated high-risk HER2-negative early breast cancer: updated results from the OlympiA phase III trial
Pembrolizumab plus Chemotherapy in Advanced Triple-Negative Breast Cancer
Olaparib for Metastatic Breast Cancer in Patients with a Germline BRCA Mutation
Trastuzumab Deruxtecan in Previously Treated HER2-Low Advanced Breast Cancer
Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with early breast cancer
Breast Cancer, Version 4.2026, NCCN Clinical Practice Guidelines In Oncology
Sacituzumab Govitecan in Metastatic Triple-Negative Breast Cancer
Sacituzumab Govitecan plus Pembrolizumab for Advanced Triple-Negative Breast Cancer
Pembrolizumab for Early Triple-Negative Breast Cancer
Adjuvant Olaparib for Patients with BRCA1- or BRCA2-Mutated Breast Cancer
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Related cancer types
Treatment guides
References
19 referencesShow all references, 13 with a study cardClose the reference list
Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.
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- 7Sustained benefit of adjuvant olaparib in women with germline BRCA1- and BRCA2-associated high-risk HER2-negative early breast cancer: updated results from the OlympiA phase III trial
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- 14Sacituzumab Govitecan plus Pembrolizumab for Advanced Triple-Negative Breast Cancer
- 15Breast Cancer, Version 4.2026, NCCN Clinical Practice Guidelines In Oncology
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- 18Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials
- 19Infection and Neutropenia during Cancer Treatment
This page is based on reputable scientific sources and was last updated on 28 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.
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