What are the treatment options for triple-negative (TN) metastatic breast cancer?

From the Guidelines

Triple-negative metastatic breast cancer should be treated with systemic chemotherapy as the primary approach, with first-line treatment usually involving taxane-based chemotherapy, such as paclitaxel or docetaxel, or anthracycline-based regimens, like doxorubicin, often given in combination with other agents such as cyclophosphamide, and for patients with PD-L1 positive tumors, immunotherapy with pembrolizumab combined with chemotherapy is now recommended. The treatment options for triple-negative metastatic breast cancer are diverse and depend on various factors, including previous therapies, pre-existing comorbidities, nature of the disease, toxicity profiles, patient preferences, and access to agents. Some key points to consider in the treatment of triple-negative metastatic breast cancer include:

• The use of taxane-based chemotherapy, such as paclitaxel or docetaxel, as a first-line treatment option, with paclitaxel being administered weekly (80 mg/m2) or every 3 weeks (175 mg/m2) 1.
• The use of anthracycline-based regimens, like doxorubicin, as a first-line treatment option, with doxorubicin being administered at a dose of 60-75 mg/m2 every 3 weeks or 20 mg/m2 weekly 1.
• The use of combination chemotherapy regimens, such as doxorubicin/cyclophosphamide (AC) or epirubicin/cyclophosphamide (EC), as a first-line treatment option, with the choice of regimen depending on the individual patient's characteristics and preferences 1.
• The use of immunotherapy with pembrolizumab combined with chemotherapy for patients with PD-L1 positive tumors, as recommended by the ASCO guideline update 1.
• The use of sacituzumab govitecan, an antibody-drug conjugate, as a treatment option for patients who have received at least two prior therapies for metastatic breast cancer, as recommended by the ASCO guideline update 1.
• The importance of supportive care, including pain management, bone-strengthening medications, and palliative radiation, in the comprehensive care of patients with triple-negative metastatic breast cancer. In terms of specific treatment regimens, some options include:
• Paclitaxel plus carboplatin, which has been shown to be an effective therapeutic option in the first-line setting for patients with metastatic triple-negative breast cancer, with a median PFS of 8.3 months and a median OS of 16.8 months 1.
• Gemcitabine plus carboplatin, which has been shown to be an effective therapeutic option in the first-line setting for patients with metastatic triple-negative breast cancer, with a median PFS of 6.0 months and a median OS of 12.6 months 1.
• Albumin-bound paclitaxel plus carboplatin, which has been shown to be an effective therapeutic option in the first-line setting for patients with metastatic triple-negative breast cancer, with a median PFS of 8.3 months and a median OS of 16.8 months 1. Overall, the treatment of triple-negative metastatic breast cancer requires a comprehensive and individualized approach, taking into account the patient's unique characteristics, preferences, and needs.

From the FDA Drug Label

KEYTRUDA, in combination with chemotherapy, is indicated for the treatment of patients with locally recurrent unresectable or metastatic TNBC whose tumors express PD-L1 (CPS ≥10) as determined by an FDA-approved test The treatment options for triple-negative (TN) metastatic breast cancer are:

• KEYTRUDA in combination with chemotherapy for patients with locally recurrent unresectable or metastatic TNBC whose tumors express PD-L1 (CPS ≥10) as determined by an FDA-approved test 2

From the Research

Treatment Options for Triple-Negative Metastatic Breast Cancer

The treatment options for triple-negative metastatic breast cancer include:

• Chemotherapy, which has been the main treatment option for a long time 3, 4, 5, 6
• Polyadenosine diphosphate-ribose polymerase inhibitors (PARPis) for patients with a BRCA mutation 3, 5
• Immunotherapy with checkpoint inhibitors such as atezolizumab and pembrolizumab for patients with PD-L1-positive tumors 3, 4, 5, 6
• Antibody-drug conjugates such as sacituzumab govitecan, which has demonstrated superior progression-free survival and overall survival compared to chemotherapy 5
• Targeted therapies such as tyrosine kinase inhibitors, anti-androgens, and histone deacetylase inhibitors, which are being explored in clinical trials 7, 6

First-Line Treatment Options

First-line treatment options for metastatic triple-negative breast cancer include:

• Platins (carboplatin/cisplatin) for patients with a BRCA mutation 3
• Nab-paclitaxel and atezolizumab for patients with PD-L1-positive tumors 3
• Single-agent chemotherapy with taxanes (paclitaxel or docetaxel) for patients without a BRCA mutation and with PD-L1-negative tumors 3
• Combinations such as anthracyclines plus cyclophosphamide or platins with taxanes for patients with a high disease burden or who are very symptomatic 3

Subsequent Treatment Options

Subsequent treatment options for metastatic triple-negative breast cancer include:

• Anthracyclines for patients who received taxanes and vice versa 3
• Fluorouracil/capecitabine, eribulin, gemcitabine, cisplatin/carboplatin, vinorelbine, and ixabepilone for patients who progressed to taxanes and anthracyclines, or who present contraindications to these agents 3
• Immunotherapy with checkpoint inhibitors such as atezolizumab and pembrolizumab for patients with PD-L1-positive tumors 4, 5, 6
• PARP inhibitors such as talazoparib and olaparib for patients with a germline BRCA mutation 5