Triple-negative breast cancer (TNBC)

Diagnosis

Triple-negative breast cancer (TNBC) is usually diagnosed in steps, not with a single test. If symptoms or a screening test such as a mammogram suggest breast cancer, the workup starts with a physical exam with a healthcare professional. Other tests typically include imaging, biopsy, testing cells in the lab and tests for biomarkers.

Breast exam

During a breast exam, a healthcare professional looks at the breasts for anything that's not typical. This might include changes in the skin or to the nipple. Then the health professional feels the breasts for lumps. The health professional also feels along the collarbones and around the armpits for lumps.

Mammogram

A mammogram is an X-ray of the breast tissue. Mammograms are commonly used to screen for breast cancer. If a screening mammogram finds something concerning, you might have another mammogram to look at the area more closely. This more-detailed mammogram is called a diagnostic mammogram. It's often used to look closely at both breasts.

Breast ultrasound

Ultrasound uses sound waves to make pictures of structures inside the body. A breast ultrasound may give your healthcare team more information about a breast lump. For example, an ultrasound might show whether the lump is a solid mass or a fluid-filled cyst. The healthcare team uses this information to decide what tests you might need next.

Breast MRI

MRI machines use a magnetic field and radio waves to create pictures of the inside of the body. A breast MRI can make more-detailed pictures of the breast. Sometimes this method is used to look closely for any other areas of cancer in the affected breast. It also might be used to look for cancer in the other breast. Before a breast MRI, you usually receive an injection of dye. The dye helps the tissue show up better in the images.

Biopsy

A biopsy is a procedure to remove a sample of tissue for testing in a lab. To get the sample, a healthcare professional puts a needle through the skin and into the breast tissue. The health professional guides the needle using images created with X-rays, ultrasound or another type of imaging. Once the needle reaches the right place, the health professional uses the needle to draw out tissue from the breast. Often, a marker is placed in the spot where the tissue sample was removed. The small metal marker shows up on imaging tests. The marker helps your healthcare team monitor the area of concern.

Lab testing

The tissue sample from a biopsy goes to a lab for testing. Tests can show whether the cells in the sample are cancerous. Other tests give more details about the cells. Pathologists do the testing. Pathologists are doctors who look for disease in cells, fluids and tissue removed from the body.

Results are often given in a pathology report. The results may show:

• Cell type. The results show whether the cancer cells are ductal cells, lobular cells or other kinds of cells.
• Cell grade. The grade of the breast cancer cells is based on how the cells look under a microscope. The grade tells the healthcare team whether the cancer is likely to grow slowly or quickly.
• Hormone receptor status. Cancer cells that use hormones to help them grow have receptors that help them catch the hormones in the bloodstream. If testing finds receptors for hormones, the cancer is hormone receptor positive. If testing doesn't find receptors, then the cancer is hormone receptor negative. TNBC is hormone receptor negative.
• PD-L1 status. Programmed cell death ligand 1 (PD-L1) is a protein that some breast cancer cells make to help them hide from the immune system. Results of this test can tell your healthcare team whether immunotherapy treatments are likely to work against your cancer cells. This test is used for TNBC that spreads or comes back after treatment.
• The presence of TILs. Tumor infiltrating lymphocytes (TILs) are immune system cells found around the cancer. TILs may be a sign that the immune system is actively fighting the cancer. The healthcare team may test for TILs to better understand your prognosis.
• HER2 status. Some breast cancer cells use a protein called human epidermal growth factor receptor 2 (HER2) to help them grow. Healthy breast cells make some HER2, but the cancer cells can make a lot more. If tests show the cancer cells have extra copies of the HER2 gene or increased levels of the HER2 protein, the cancer is HER2 positive. If testing doesn't find these, the cancer is HER2 negative. TNBC is HER2 negative.
• Ki-67 score. Ki-67 is a protein that marks how fast the cancer cells divide, also called the proliferation rate. The Ki-67 score goes from 0% to 100%. A higher score suggests a higher rate of dividing cells and faster growth.

The healthcare team uses the results from lab tests to decide on the cancer's stage, understand the prognosis and make a treatment plan.

Treatment

Treatment for triple-negative breast cancer (TNBC) often involves several steps. Treatments typically include surgery and medicines, such as chemotherapy and immunotherapy. Other treatments might include radiation therapy, targeted therapy and antibody-drug conjugates.

If the cancer in the breast is small enough in stages 1 through 3, treatment may start with a lumpectomy or mastectomy.

Sometimes treatment starts with medicine. Healthcare professionals may use chemotherapy and, sometimes, immunotherapy before surgery. The medicines help shrink the cancer and make it easier to remove. Using medicines first also helps the healthcare team see how well the treatment works. This helps the care team make decisions about what treatments to do after the surgery. Treatment before surgery is called neoadjuvant therapy.

After surgery, treatment depends on what is found. Some people may get more chemotherapy, more immunotherapy or radiation therapy.

Breast cancer surgery

Breast cancer surgery typically involves a procedure to remove the breast cancer and a procedure to remove some nearby lymph nodes. Operations used to treat breast cancer include:

• Removing the breast cancer. A lumpectomy is surgery to remove the breast cancer and some of the healthy tissue around it. The rest of the breast tissue isn't removed.

• Removing all of the breast tissue. A mastectomy is surgery to remove all breast tissue from a breast. The most common mastectomy procedure is total mastectomy, also called simple mastectomy. This procedure removes all of the breast, including the lobules, ducts, fatty tissue and some skin, including the nipple and areola.

  Some newer types of mastectomy procedures might not remove the skin or nipple. For instance, a skin-sparing mastectomy leaves some skin. A nipple-sparing mastectomy leaves the nipple and the skin around it, called the areola. These newer operations may not be for everyone.

• Removing a few lymph nodes. A sentinel node biopsy is an operation to take some lymph nodes for testing. When breast cancer spreads, it often goes to the nearby lymph nodes first. To see if the cancer has spread, a surgeon removes some of the lymph nodes near the cancer. If no cancer is found in those lymph nodes, the chance of finding cancer in any of the other lymph nodes is small. No other lymph nodes need to be removed.
• Removing several lymph nodes. Axillary lymph node dissection is an operation to remove many lymph nodes from the armpit. Your breast cancer surgery might include this operation if imaging tests show the cancer has spread to the lymph nodes. It also might be used if cancer is found in a sentinel node biopsy.
• Removing both breasts. Some people who have cancer in one breast may choose to have the other breast removed, even if it doesn't have cancer. This procedure is called a contralateral prophylactic mastectomy. It might be an option if you have a high risk of getting cancer in the other breast. The risk might be high if you have a strong family history of cancer or have DNA changes that increase the risk of cancer.

You may choose to have breast reconstruction after mastectomy surgery. Breast reconstruction is surgery to restore shape to the breast. Options might include reconstruction with a breast implant or reconstruction using your own tissue. Consider asking your healthcare team for a referral to a plastic surgeon before your breast cancer surgery.

Chemotherapy

Chemotherapy treats cancer with strong medicines that kill cancer cells. It can shrink TNBC to make it easier to remove with surgery. There are many types of chemotherapy medicines that damage the cancer cells in different ways. Most chemotherapy medicines are given through a vein. Some come in pill form.

Immunotherapy

Immunotherapy for cancer is a treatment with medicine that helps the body's immune system fight cancer cells. Typically, the immune system fights off diseases by attacking germs and other cells that shouldn't be in the body. Cancer cells survive by hiding from the immune system. Immunotherapy helps the immune system cells recognize and kill the cancer cells.

For TNBC, immunotherapy may be used before surgery to shrink the cancer and make it easier to remove. It also may be used after surgery or when surgery isn't an option.

To see if this treatment is likely to help, your healthcare team may test your cancer cells for a protein called programmed cell death ligand 1 (PD-L1). Immunotherapy medicines only work in cells that have this protein.

Radiation therapy

Radiation therapy treats TNBC with powerful energy beams. The energy can come from X-rays, protons or other sources. During radiation therapy, you lie on a table while a machine moves around you. The machine directs radiation to precise points in your body.

For TNBC, radiation therapy is sometimes used after surgery to kill any cancer cells that might remain.

Targeted therapy

Targeted therapy for cancer is a treatment that uses medicines that attack specific chemicals in the cancer cells. By blocking these chemicals, targeted treatments can cause cancer cells to die.

One example of targeted therapy is medicines called poly (ADP-ribose) polymerase (PARP) inhibitors. PARP inhibitors target cells with BRCA1 or BRCA2 gene variations. Your healthcare team may do tests to see if these medicines might help fight your cancer.

Many other targeted therapy medicines exist. Some are used only when the cancer comes back or spreads to other parts of the body.

Antibody-drug conjugates

Antibody-drug conjugates are medicines that combine targeted therapy with chemotherapy. These medicines use targeted therapy to target the cancer cells and deliver chemotherapy directly to the cells. Antibody-drug conjugates are typically used alone or with other medicines to treat breast cancer that spreads.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Alternative medicine

No alternative medicine treatments have been found to cure breast cancer. But complementary and alternative medicine therapies may help you cope with side effects of treatment.

Alternative medicine for fatigue

Many people with breast cancer have fatigue during and after treatment. This feeling of being very tired and worn down can continue for years. When combined with care from your healthcare team, complementary and alternative medicine therapies may help relieve fatigue.

If you are interested in ways to reduce fatigue, talk with your healthcare team about:

• Expressing your feelings. Find an activity that allows you to write about or discuss your emotions. Examples include writing in a journal, participating in a support group or talking to a counselor.
• Doing gentle exercise. If you get the OK from your healthcare team, start with gentle exercise a few times a week. Add more exercise, as you feel up to it. Consider walking, swimming, yoga and tai chi.
• Managing stress. Take control of the stress in your daily life. Try stress-reduction techniques such as muscle relaxation, visualization, and spending time with friends and family.

Coping and support

Some breast cancer survivors say their diagnosis felt overwhelming at first. It can be stressful to feel overwhelmed at the same time that you need to make important decisions about your treatment. In time, you may find ways to cope with your feelings. Until you find what works for you, it might help to:

Learn enough about your TNBC to make decisions about your care

If you'd like to know more about your TNBC, ask your healthcare team for the details of your cancer. Write down the type, stage and hormone receptor status. Ask for reliable sources of information where you can learn more about your treatment options.

Knowing more about your cancer and your options may help you feel more confident when making treatment decisions. Still, some people don't want to know the details of their cancer. If this is how you feel, let your care team know that too.

Talk with breast cancer survivors

You may find it helpful and encouraging to talk with others who have been diagnosed with breast cancer. For support groups, contact the American Cancer Society or ask your healthcare team about local or online groups. Find support online through Mayo Clinic Connect, a community where you can connect with others for support, practical information and answers to everyday questions.

Find someone to talk with

Find a person who has experience helping people with serious illnesses. Ask your healthcare team to suggest a counselor, clergy member or medical social worker you can talk with.

Keep your friends and family close

Your friends and family can provide a crucial support network for you during your cancer treatment.

As you begin telling people about your breast cancer diagnosis, you'll likely get many offers for help. Think ahead about things you may want help with. Examples include listening when you want to talk, helping you with preparing meals, cleaning your home or caring for your pets.

Preparing for your appointment

Make an appointment with a doctor or other healthcare professional if you have any symptoms that worry you or are not going away. If an exam or imaging test shows you might have breast cancer, your healthcare team will likely refer you to a specialist.

Specialists who care for people with breast cancer include:

• Breast health specialists.
• Breast surgeons.
• Doctors who specialize in diagnostic tests, such as mammograms, called radiologists.
• Doctors who specialize in treating cancer, called oncologists.
• Doctors who treat cancer with radiation, called radiation oncologists.
• Genetic counselors.
• Plastic surgeons.

What you can do to prepare

• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Write down your family history of cancer. Note any family members who have had cancer. Note how each member is related to you, the type of cancer, the age at diagnosis and whether each person survived.
• Make a list of all medicines, vitamins or supplements that you're taking and the doses.
• Keep all your records that relate to your cancer diagnosis and treatment. Organize your records in a binder or folder that you can take to your appointments.
• Consider taking a family member or friend along. Sometimes it can be hard to absorb all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your healthcare professional.

Questions to ask your doctor

Your time with your healthcare professional is limited. Prepare a list of questions so that you can make the most of your time together. List your questions from most important to least important in case time runs out. For breast cancer, some basic questions to ask include:

• What type of TNBC do I have?
• What is the stage of my cancer?
• Can you explain my pathology report to me? Can I have a copy for my records?
• Do I need any more tests?
• What treatment options are available for me?
• What are the benefits from each treatment you recommend?
• What are the side effects of each treatment option?

Other questions to ask may include:

• Will treatment cause menopause?
• Will treatment affect my being able to become pregnant in the future?
• How might each treatment affect my daily life? Can I continue working?
• Is there one treatment you recommend over the others?
• How do you know that these treatments will benefit me?
• What would you recommend to a friend or family member in my situation?

More questions to ask:

• How quickly do I need to make a decision about cancer treatment?
• What happens if I don't want cancer treatment?
• What will cancer treatment cost?
• Does my insurance plan cover the tests and treatment you're recommending?
• Are there any brochures or other printed material that I can take with me? What websites or books do you recommend?
• Are there any clinical trials or newer treatments that I should consider?

In addition to the questions that you've prepared, don't hesitate to ask other questions you think of during your appointment.

What to expect from your doctor

Be prepared to answer some questions about your symptoms and your health, such as:

• When did you first begin having symptoms?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?