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Initial studies investigating single-agent activity of immune checkpoint inhibitors (ICIs) serve as proof of principle that harnessing the immune system can have anticancer activity in a variety of human malignancies. Although breast cancer was historically believed to be immunogenically silent, early studies indicate overall response rates with ICIs are similar to those observed with many other solid malignancies. Overall response rates in advanced breast cancer are low, but the responses are remarkably durable. A deeper understanding of the biology of the interaction between cancer and immune cells is required to both develop biomarkers that more accurately predict response to therapy and identify effective immunotherapy-based combination strategies that can enhance the immunogenicity of biologically “cold” tumors. Breast cancer encompasses a variety of diseases defined by the presence or absence of central oncogenic drivers, and early data suggest that the distinct subtypes may have unique immune phenotypes. Breast cancer represents an ideal disease in which to investigate immunotherapeutic strategies given the prevalence of the disease, unique clinical trial design opportunities, and immunophenotypic diversity.

The KEYNOTE-522 study is a practice-changing phase III randomized study that demonstrated that the addition of pembrolizumab to polychemotherapy improves outcomes in patients with high-risk early-stage triple-negative breast cancer (TNBC). This regimen is highly efficacious with unprecedented pathologic complete response (pCR) rates, and clinically meaningful improvements in event-free survival (EFS). However, the combination is also associated with significant high-grade treatment-related toxicity. The backbone regimen deviated from common practice, including the addition of carboplatin, lack of dose dense anthracyclines, and adjuvant capecitabine for residual disease, thus brining important questions regarding real-world translation of these results. This brief report practically addresses some of the most relevant questions physicians and patients face in optimizing care using the best available evidence.

Breast cancer is treated with a multidisciplinary approach involving surgical oncology, radiation oncology, and medical oncology. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Breast Cancer include recommendations for clinical management of patients with carcinoma in situ, invasive breast cancer, Paget’s disease, Phyllodes tumor, inflammatory breast cancer, and management of breast cancer during pregnancy. The content featured in this issue focuses on the recommendations for overall management of systemic therapy (preoperative and adjuvant) options for nonmetastatic breast cancer. For the full version of the NCCN Guidelines for Breast Cancer, visit NCCN.org.