Racial disparities in clinical outcomes of early-stage triple-negative breast cancer treated with neoadjuvant chemoimmunotherapy: Insights from the NCDB

Triple-negative breast cancer (TNBC) is an aggressive breast cancer subtype, and Black patients experience worse survival outcomes following neoadjuvant chemotherapy, likely reflecting a combination of biological, social, and structural factors. Neoadjuvant immune checkpoint inhibitors combined with chemotherapy (NACI) improve pathologic complete response (pCR) rates and overall survival (OS) in early-stage TNBC; however, racial disparities in outcomes with NACI remain poorly defined. We evaluated racial differences in pCR and survival among patients with early-stage TNBC treated with NACI.

Using the National Cancer Database, we identified patients with stage II–III TNBC treated with NACI between 2019 and 2022. Primary outcomes were pCR and OS. Associations between race and outcomes were assessed using univariate and multivariable logistic regression and Cox proportional hazards models, adjusting for age, stage, grade, Charlson-Deyo comorbidity score, insurance status, income, and rural versus urban residence. Statistical significance was defined as p ≤ 0.05.

Among 5,137 patients (median age 51 years), 69.9% were White, 20.5% Black, and 9.6% other races; 49.3% had stage II and 50.7% had stage III disease. Median follow-up was 26.6 months. Overall pCR rate was 76.5% and did not significantly differ by race (White 77%, Black 74%, Other 76%; p = 0.113). Patients achieving pCR had markedly improved survival, with 3-year OS of 92% versus 72% and 5-year OS of 84% versus 56% compared with those without pCR (p < 0.001). Despite similar pCR rates, Black patients experienced inferior survival, with 3-year OS of 84% and 5-year OS of 77%, compared with 88% and 83% among White patients (p < 0.05). On multivariable analysis, Black race remained independently associated with worse OS (HR 1.42, 95% CI 1.10–1.84; p = 0.007), while odds of achieving pCR were numerically lower but not statistically significant (OR 0.76, 95% CI 0.54–1.07). Additional factors associated with worse OS included rural residence, tumor size ≥10 cm, and stage III disease.

In this large national cohort, Black patients with early-stage TNBC treated with NACI experienced significantly worse overall survival despite comparable pCR rates, suggesting that response to therapy alone does not fully mitigate racial disparities. These findings highlight the urgent need for post-neoadjuvant, survivorship, and biomarker-driven strategies that address persistent structural, social, and biological determinants of inequity in TNBC outcomes.