Trust your cape.

All but the tiniest triple-negative breast cancers merit (neo)adjuvant chemo. We know that those who don’t respond completely to neoadjuvant treatment benefit from additional maintenance capecitabine, but how do we know who needs it after upfront surgery? The Chinese phase 3 SYSUCC-001 trial suggests maybe all of them. Granted, all 443 enrollees received upfront surgery regardless of initial stage as long as there was no evidence of infra/supraclavicular or internal mammary nodes. About two-thirds were cT2+ and one-third cN+, so most of these would receive neoadjuvant chemo in the US. Everyone received adjuvant chemo and were then randomized to +/- the addition of one-year of “low-dose” (650 mg bid) capecitabine maintenance. At 5 years there was an absolute 10% advantage in disease-free and mets-free survival with the addition of capecitabine, and overall survival was numerically improved from 81.3 → 85.5%. Importantly, given the mixed bag of patients, the big advantage in DFS held across all subgroups and, in fact, was more pronounced for earlier-stage (e.g., cT1 and cN0), lower-grade disease. TBL: Without the biologic stress test of neoadjuvant chemo, all-comers who receive upfront surgery for triple-negative breast cancer may benefit from the addition of maintenance capecitabine. | Wang, JAMA 2020