Primary or Early Triple Negative Breast Cancer
This section is intended for those people diagnosed with TNBC with no sign that it has spread away from the breast and lymph glands nearby into other organs.
This is called primary or early stage breast cancer, and in many people it can be cured.
We hope this will help you to understand your treatment options, ask questions to your medical team and cope with the physical and emotional pressures.
What decides how my cancer will be treated?
There are similarities but also differences between TNBC and other types of breast cancer. That means that some, but not all, of your treatments and experiences will be different to those of people with other types of breast cancer.
When TNBC is caught early it can be successfully treated and often cured by a mixture of surgery, radiotherapy and drug treatment.
You will probably already have had a ‘biopsy’, where a small part of the breast lump was taken out using a needle, to see whether it was cancer, and if so, what sort of cancer. You may also have X-rays, scans and blood tests.
Your surgeon and oncologist (cancer doctor) will recommend the best treatment for you depending on the results of these tests and in particular:
The size of the cancer, usually ranked 1, 2 or 3
It’s grade, which is how nasty or “aggressive” the cancer cells look under the microscope; this is graded 1, 2 or 3 (with grade 3 the most aggressive)
Whether the cancer has spread to the lymph glands in the armpit (or axilla)
What are the main treatments for TNBC?
Treatment for TNBC that has not spread is usually a mix of surgery, with or without radiotherapy, and drug treatment. While surgery and radiotherapy, the ‘local’ treatments to treat the cancer in your breast are the same as for other types of breast cancer, the drug treatments are different for people with TNBC.
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Your surgeon will discuss whether they recommend an operation to remove the tumour alone, called a ‘lumpectomy’ or removal of the whole breast, a ‘mastectomy’. You may want to discuss breast reconstruction with your surgical team if a mastectomy is planned.
It is also usually necessary to remove one or more lymph glands or nodes in the armpit or axilla, to see whether the cancer has spread there. This is called a sentinel lymph node biopsy, and the surgeons choose which nodes to remove by injecting a dye, radioactive tracer, or both close to the tumour in the breast. In some cases more of the lymph nodes may be removed; this is called an axillary clearance.
Your breast care nurse will tell you more about your operation and convalescence.
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Most people who have had a lumpectomy then have a course of radiotherapy to the breast to reduce the risk of the cancer coming back in the breast. Some people who have had a mastectomy will be recommended to have radiotherapy to the chest wall to reduce the risk of the cancer coming back there.
Radiotherapy is given by a machine called a linear accelerator that produces radiation, which is aimed at where the tumour was removed from the breast or at the chest wall. It is usually administered daily, Monday to Friday, for 1 to 4 weeks.
Treatment is overseen by radiographers who will tell you much more about radiotherapy and its side effects, but they are largely limited to where the radiotherapy goes and usually not severe.
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If your cancer is larger, higher grade or has spread to the lymph nodes your doctors may suspect that the cancer has thrown off tiny seedlings of cancer cells that are too small to be seen. If so, they will often recommend treatment with drugs, based around chemotherapy but sometimes including other drugs, to reduce the chances of the cancer coming back or spreading in the future.
This drug treatment may be given before surgery, after surgery or both and your doctors will explain which they are recommending and why. This treatment is given to give you the best chance of being cured, but it can be complicated and have side-effects, so there will be a lot for you to think about and discuss with your medical team and those close to you. Finally, bBecause you have TNBC, you would not benefit from hormone therapies such as tamoxifen or letrozole or treatments targeted at HER2 such as trastuzumab, so these will not be discussed with you.
What chemotherapy will I be offered?
The chemotherapy drugs you will receive are used in people with a wide variety of cancers, including other types of breast cancer. These include paclitaxel often given with carboplatin, which may work better against TNBC, epirubicin and cyclophosphamide.
Most chemotherapy is given intravenously directly into a vein, usually in your hand, often every 3 weeks, but sometimes weekly. Treatment that would usually be given every 3 weeks is sometimes given every 2 weeks as “accelerated chemotherapy”. This is given with “growth factors”, drugs given as an injection under the skin on the days after chemotherapy that largely prevent the fall in the number of white blood cells, and associated increased risk of infection, that would otherwise happen.
Another chemotherapy drug, called capecitabine, is a tablet taken by mouth. Capecitabine is usually given to people with TNBC who had other chemotherapy before their operation but still had some cancer present in the breast or lymph gland after that chemotherapy.
Chemotherapy are strong drugs and do have side effects, but these are well known and can usually be controlled. Whether you get side effects, and how bad they are, differs from person to person. Your oncology team will provide you with detailed information about side effects of the particular chemotherapy drugs that you are to receive. You may want to keep notes of any side effects so you can discuss them with your medical team at your next appointment.
Will I be offered immunotherapy?
Recently, clinical trials have shown that some people with early TNBC benefit from the addition of immunotherapy, which stimulates the immune system.
Pembrolizumab (Keytruda) is a targeted therapy that helps the immune system “see” and attack cancer cels by blocking a chemical that cancer cells use to hide. It may be considered in people with early TNBC at higher risk of their cancer returning and spreading.
Pembrolizumab is given intravenously, with chemotherapy, before surgery and then for a year after surgery. It has side effects that result from the immune system also attacking normal parts of the body such as the gut, lungs or thyroid gland and you will be monitored closely while taking pembrolizumab.
What other drugs might I be offered?
Your oncologists may also discuss other, targeted drugs, which are not chemotherapy or immunotherapy, after surgery.
Bisphosphonates are drugs that strengthen the bones, but can also reduce the risk of breast cancer coming back in women who are postmenopausal. The bisphosphonate can be taken by mouth daily for 3 – 5 years but can cause irritation of the gullet or oesophagus. If taken intravenously, the bisphosphonate is typically given every 6 months. When you start the bisphosphonate, you will have your vitamin D levels checked and you may need to take supplements if youR vitamin D levels are low. Bisphosphonates can also cause problems with healing of the jaw after having a tooth removed, something called osteonecrosis of the jaw. For this reason you will be advised to have a dental check-up and, any treatment dental treatment completed, before starting the bisphosphonate. If you see your dentist when you are taking a bisphosphonate, you should tell them.
Finally, breast cancer in people with BRCA 1 or BRCA2 mutations (which can be inherited) is more commonly TNBC than other types of breast cancer. For people with BRCA mutated TNBC who are at higher risk of the cancer coming back, that risk can be reduced by taking the tablet olaparib (or Lynparza) for a year after completing chemotherapy. Again, this is a targeted therapy, and often referred to as a PARP inhibitor because of how it works. Although not chemotherapy, olaparib can have significant side effects.
Will I receive these drugs before or after surgery?
In the past, drug treatment always followed chemotherapy and was known as adjuvant treatment. These days, drug treatment is often given before chemotherapy and known as neo-adjuvant therapy. Your cancer team will discuss with you what is best for you and what you prefer.
Having neo-adjuvant treatment, before surgery, means the cancer can be monitored and measured to see whether treatment is working. This treatment can also affect the type of surgery that is then needed. Finally, if cancer cells can still be seen in the specimen removed at surgery, this can affect whether further drug treatment is discussed.
Neo-adjuvant chemotherapy usually lasts 12-24 weeks and in some people is given with immunotherapy.
Adjuvant chemotherapy is given to people who did not receive neo-adjuvant therapy; in this situation adjuvant chemotherapy is with the same or similar drugs that are used as neo-adjuvant treatment. Other adjuvant treatment can also be given in the form of:
Pembrolizumab given for a year after surgery and neo-adjuvant immunotherapy (and chemotherapy)
Capecitabine for 6 months offered to people in whom cancer can be seen in the tissue removed at surgery after neo-adjuvant treatment.
Olaparib for a year considered for people with BRCA1 or 2 mutations
New treatments are being developed for people with early or primary TNBC and you might want to ask your medical team about clinical trials. Please see the section Trials, Research and Donations for more details.
What can I do to help my recovery?
There is a lot of evidence that staying positive, fit and healthy can help with your recovery.
Ignore ‘myths’ on the internet and use only authoritative and reliable sources of information such as The UK Charity for TNBC, MacMillan Cancer Relief and Cancer Research UK.
Frequently asked questions about early stage/primary TNBC
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Many people when first diagnosed with triple negative breast cancer can be cured, if they have primary/early breast cancer that is found and treated early, when it is confined to the breast area.
There are many ways to treat primary/early TNBC, with the aim of cure.
It will usually be treated with surgery, to remove the lump or, if necessary, the breast itself (a mastectomy). One or more of the lymph nodes under the arm may also be removed.
It may also involve radiotherapy, given after surgery to kill any cancer cells left behind in the breast despite surgery. This involves a beam of radiation given from outside the body, usually daily over a few weeks.
Surgery, with or without radiotherapy, will usually deal with the cancer in the breast. However, cancers can sometimes throw off seedlings or metastases that are too small to be detected that can lead to the cancer coming elsewhere in the body in the future. This risk can be reduced by giving drug treatment, usually through a drip into a vein, which treats cancer cells wherever they may be. Even after such treatment, however, it cannot be guaranteed that the cancer will not come back.
This drug treatment can be given before surgery (called neo-adjuvant), after surgery (adjuvant) or both.
The drugs used are chemotherapy, either given alone or with immunotherapy. Various types of chemotherapy are used to treat breast cancer. TNBC is the only type of breast cancer where immunotherapy is used; it is used with chemotherapy but is not suitable for everyone with primary/early TNBC.
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The symptoms of triple negative breast cancer are no different to the other types of breast cancer. The chances of a successful outcome, i.e. cure, are significantly improved by early diagnosis, so treatment can begin before the cancer can grow or spread. This is particularly important for TNBC.
Until a biopsy has been analysed in a laboratory, it is not possible to know if it is TNBC or not.
Most people diagnosed with TNBC have early/primary disease, and if they have signs or symptoms they relate to the breast. Cancers can be detected by routine mammograms, which in the UK are offered to women between 50 and 70 years of age. In people with dense breast tissue, the tumor can sometimes be hard to detect on a mammogram.
Less often, the first diagnosis of TNBC can be with disease that is already advanced/metastatic. If so, people may have signs or symptoms affecting other parts of the body.
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Coming to the end of a successful course of treatment (often surgery, radiotherapy and drugs) can be both a huge relief and also a bit scary.
As there are no long term treatments that can rule out your cancer returning (often called recurrence) the emotional aspects of the disease can be at least as difficult to deal with as the physical effects.
There is some evidence that leading a healthy lifestyle by being active and having a healthy diet, may be of benefit. Joining a Group and talking to people who understand these concerns, can also help to reduce stress.
There is a good chance that TNBC will not come back or recur. Make sure you go for the annual mammograms you should be offered, and any appointments with your GP or the hospital. If you do feel anything different about your body, which lasts more than a couple of weeks, is out of the ordinary for you and not otherwise explained, contact your Oncology team or Breast Cancer Nurse Specialist.
If TNBC does recur, this tends to be in the first 3 to 5 years after the initial diagnosis. Local recurrence, where the cancer comes back close to where the original cancer was, may be treated by surgery or radiotherapy. Distant recurrence or metastasis, where the cancer spreads to other parts of the body is more serious and would usually need drug treatment.
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Chemotherapy can cause a range of side effects that usually start a few days or weeks after treatment begins. Most go away after a course of treatment finishes but some can last longer or only start after treatment has finished.
These side effects are no more better or worse for people with triple negative breast cancer. Rather, they depend on which chemotherapy drugs are being given; because the chemotherapy drugs used to treat TNBC can be different to other cancers, this can affect whether side effects occur more or less often.
Importantly, the chemotherapy drugs and the treatments that are used to prevent or treat side their effects have changed over the years so your experience may be different to that of friends or relatives in the past.
Also, because chemotherapy (and other) treatments can be “stronger” for people being treated for early TNBC (where the aim is to cure), side effects can be more severe for those being treated for advanced/metastatic TNBC (where the aim is to control the cancer and maintain quality of life for as long as possible). This means that if you are being treated for advanced/metastatic TNBC, the side effects of chemotherapy may be less severe than those you experienced previously when you were treated for early TNBC.
Finally, side effects do differ from person to person so, although it can be helpful to talk to other people having similar treatment, there is no guarantee that the side effects will be the same for any two people.
The list of side effects looks quite alarming and almost everyone gets some side effects from chemotherapy but you will probably not get them all. Your breast team will talk you through the likely side effects before each treatment begins.
The most common side effects are:
Tiredness
Hair loss, to a lesser or greater extent, which can affect hair on your head but also other parts of your body; the hair does grow back, slowly, after treatment has finished
Stomach upset, which can cause
Feeling sick (nausea) or being sick (vomiting)
Constipation or diarrhoea
Loss of appetite and/or altered taste
A low blood count, which can cause
Increased risk of infection (due to low white blood cells or “neutrophils”)
Bleeding or bruising more easily (due to low platelets)
Loss of energy, shortness of breath and rapid heartbeat (due to anaemia)
Sore mouth and throat
Numbness or tingling in the hands, and difficulty with fiddly movements, or in the feet
Difficulty with memory and concentration
If you have side effects that are troubling you, let your breast care team know, even if you were warned they may happen!
Most chemotherapy affects, to a greater or lesser extent, people’s blood count and the biggest concern is the increased risk of infections that can become serious or dangerous if your white blood cell or neutrophil count is low and your immune system is not working properly. If you get
Fevers
Shivers and shakes
Or just feel really poorly in yourself
You should contact your cancer team; they will probably have given you a number to call if you are worried. You may want to get a thermometer to check your temperature at home.
Medication can prevent or reduce some of these side-effects, especially nausea and vomiting, and you will usually be given treatment to keep such side-effects to a minimum. Why not keep a record of what side effects you have, and when they happen. If you tell your breast care team they may be able to give you something extra to ease those side effects next time.
Sometimes chemotherapy treatment may need to be delayed (put back) until side effects have settled down, or the dose of chemotherapy may need to be changed; treatment may be stopped if the side effects cannot be controlled, but this would be unusual.
The Macmillan Cancer Support or Cancer Research UK websites have more detailed, reliable information. Your breast team will talk you through the likely side effects before each treatment begins. If they give you a list of your chemotherapy drugs you can check which side effects are more or less likely to affect you.
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There are 3 main types of treatment for triple negative breast cancer (TNBC), and other types of cancer. These are
Surgery
Radiotherapy
Drugs
There are different types of cancer drug therapy, and chemotherapy is one of them.
Chemotherapy drugs are powerful chemicals that “poison” fast growing cancer cells. Unfortunately, they also affect normal parts of the body so they do have side effects. Most side effects are well known and can also often be treated to reduce their impact.
Sometimes chemotherapy is given as just one drug on its own; at other times chemotherapy drugs are given together, in combination. Some people with TNBC are suitable for chemotherapy in combination with immunotherapy.
Chemotherapy can be used to treat all types of breast cancer, but it has been particularly important in treating people with TNBC who do not benefit from hormonal or other “targeted” therapies. Increasingly, however, new drugs are being developed to treat people with TNBC.
Most chemotherapy drugs are given into a vein (intravenously) but some are given by mouth (orally). Intravenous chemotherapy can be given through a small needle in the back of the hand or into a thin, flexible tube that is placed, and remains, in a vein. You might want to discuss a central venous device, sometimes called a central venous catheter (CVC) or central venous access device (CVAD) with your oncology team.
Different chemotherapy treatments can be given weekly every two weeks or three weeks as “cycles” that continue over several weeks or months as a “course” of treatment. There is usually a break in treatment between cycles to let you recover before the next cycle.
Chemotherapy may be given to someone with TBNC for different reasons:
To hopefully cure early TNBC by preventing it from spreading and coming back
or
To control TNBC once it has visibly spread, prolonging someone’s life and maintaining their quality of life.
There are many different chemotherapy drugs that work in different ways and have different side effects; you may well receive a number of them during treatment. Your breast team will talk you through your treatment and the likely side effects. If they give you a list of the chemotherapy drugs, and what will happen when, you can understand better what to expect.
