Severe breathing difficulty, collapse, seizure or severe chest pain: call emergency services. Do not wait for an online answer.
Contact your oncology service immediately
Temperature 37.5°C or higher, 36°C or lower, shivering or suddenly feeling unwell — even with a normal temperature. Report new breathlessness, chest symptoms, severe diarrhoea, inability to drink, jaundice, a painful swollen leg or a severe rash promptly. You do not need to identify which medicine caused the symptom.
Follow the urgent contact instructions from your treating hospital. If you cannot reach the team, seek urgent medical assessment. Outside clinic hours, use your instructed out-of-hours pathway or the emergency department.
This page does not diagnose symptoms or decide whether it is safe to stay at home. You do not need to know which medicine caused a symptom before calling.
Treat the cancer before surgery as part of a plan intended to reduce the risk of it returning.
Immunotherapy
Pembrolizumab
Keytruda
Releases an immune brake
PD-1 is a control switch on T cells, a type of immune cell. When it connects with PD-L1 or PD-L2, the T cell receives a signal to reduce its activity. Some cancers use this pathway to escape immune attack. Pembrolizumab is an antibody that blocks PD-1, helping T cells recognise and attack the cancer. It does not directly poison cancer cells like chemotherapy. Releasing this brake can also allow immune cells to attack healthy organs, which explains the different side-effect pattern and why symptoms can appear after treatment stops.
Immune cell↓Brake blocked↓Cancer cell
What to watch for The immune system can also inflame healthy organs. New cough, diarrhoea, unusual weakness, severe headache, thirst or a spreading rash need prompt advice. Effects can start during treatment or after it finishes.
Carboplatin creates links in DNA, making it harder for cells to copy and repair their genetic instructions. Its dose depends on kidney function as well as the intended regimen.
Platinum enters cell↓DNA links form↓Copying is disrupted
What to watch for Keep blood-test appointments. Fever, unusual bleeding, repeated vomiting or infusion symptoms need prompt advice.
Cells use tiny structures called microtubules to separate their chromosomes when dividing. Paclitaxel stabilises these structures so they cannot rearrange normally, interrupting cell division. It can also affect nerves and other healthy tissues.
Microtubules form↓Structures remain locked↓Division is interrupted
What to watch for Report tingling or numbness before the next weekly dose, especially if it affects walking or hand use. Tell the nurse immediately about flushing, chest or throat tightness, itching, dizziness or breathing changes during infusion.
Doxorubicin interferes with enzymes and DNA processes needed for cell division. It can also affect heart muscle, so the team considers previous exposure and cardiac risk.
DNA handling disrupted↓Cell damage↓Division reduced
What to watch for Report pain or burning at the infusion site immediately. New breathlessness or chest symptoms need prompt review. Red urine for a short time can be a drug-colour effect; pain, clots or persistent bleeding still need advice.
Cyclophosphamide is activated in the body and damages DNA. This helps stop dividing cancer cells but can also affect blood-cell production and reproductive tissues.
Drug activated↓DNA damage↓Cell division affected
What to watch for Use the prescribed anti-sickness and hydration plan. Report fever, painful urination or blood in the urine.
Four 21-day cycles: paclitaxel on Days 1, 8 and 15; carboplatin AUC 5 on Day 1. Pembrolizumab 200 mg on Day 1 of each cycle (every three weeks).
About 12 weeks
Phase 2 · AC
Four 21-day cycles
Four further cycles (cycles 5–8): doxorubicin and cyclophosphamide on Day 1 every 21 days. Pembrolizumab 200 mg on Day 1 of each AC cycle.
After recovery
Surgery and pathology
Individual timing
The operation is planned after recovery; the pathology result helps decide the next treatment.
Separate phase
After surgery · pembrolizumab alone
Confirm the prescribed schedule
After surgery: pembrolizumab 200 mg every 21 days for nine doses OR 400 mg every 42 days for five doses. These are alternative schedules, not consecutive courses. Progression preventing definitive surgery or unacceptable pembrolizumab toxicity changes this plan; postoperative treatment is not automatic.
The phases run in order. The columns show sequence, not equal time intervals. No dates or other information need to be entered.
Relative sequence, not booked dates or equal time intervals. Baseline ECG is distinct from risk-based echo. No routine three-monthly CT or echo is implied. The team books and reviews results.
Check
Before starting
Phase 1 · weeks 1–12
Before / during AC
Surgery / postoperative
After treatment
Blood tests
FBC, renal and liver; verify GFR
Weekly before planned doses
Before each 21-day AC cycle
Before each pembrolizumab cycle
Symptoms or abnormalities determine follow-up
ECG / echo
ECG and cardiac risk review; echo if indicated
Symptoms prompt earlier assessment
Review before first doxorubicin; further echo by risk / symptoms
Review any cardiac symptoms or previous abnormalities
Risk-based cardiac follow-up
Cancer imaging
Breast/nodal imaging; staging as indicated
Clinical response review; image for concern
Assess response and plan surgery
Pathology review; agree next steps
Breast surveillance; no routine CT/markers when asymptomatic
Triple-negative breast cancer · neoadjuvant and adjuvant immunotherapy
Phase 1: four 21-day cycles; paclitaxel on Days 1, 8 and 15, carboplatin on Day 1. Phase 2: four AC cycles every 21 days. Pembrolizumab 200 mg every 21 days during chemotherapy; after surgery, nine 21-day doses or five 42-day doses (400 mg). See the whole-treatment map for monitoring and sequencing.
Read from left to right. Columns show stages, not equal lengths of time. This is a general plan: no dates or personal information are needed. Your team confirms which steps apply and arranges appointments.
On a small screen, swipe the map sideways. The checks below give the same timing in words.
1Blood testsFBC, renal and liver tests weekly during the carboplatin/paclitaxel phase, then before every AC cycle. Continue the required blood tests before each postoperative pembrolizumab cycle.
Check safety before the planned dose.
Ask / act: Agree the booking owner, result reviewer and plan if delayed.
2ECG / cardiac reviewBaseline ECG and cardiac history/risk assessment. NCCP lists baseline echo/MUGA for age over 65 or when clinically indicated. Recheck the cardiac assessment before starting doxorubicin; echo/MUGA during treatment is driven by symptoms, risk or the agreed cardio-oncology plan. There is no automatic three-monthly echo schedule for every person on this pathway.
Check risk before and during anthracycline exposure.
Ask / act: Agree the booking owner, result reviewer and plan if delayed.
3Cancer imagingRecord baseline breast/nodal findings and stage with imaging appropriate to the presentation. Assess clinical response during neoadjuvant treatment and use the appropriate breast imaging before surgery or sooner for concern. There is no universal three-monthly CT schedule for this early-breast pathway. After local treatment, arrange the agreed breast surveillance; routine CT/PET and tumour markers are not asymptomatic recurrence screening.
Assess response and plan local treatment.
Ask / act: Agree the booking owner, result reviewer and plan if delayed.
Which treatment phase am I in, and what happens next?
Which test is expected next, who arranges it, and who explains the result?
Who should I contact if an expected appointment has not arrived?
This map does not show whether a test has been ordered, booked or completed. Do not wait for a scheduled test if you develop new symptoms.
Phase 1 · four 21-day cycles
Day 1 → Day 21: a general pattern
This is a visual orientation, not a prediction of your personal cycle. It shows when some effects often emerge and which effects are not tied to a particular day.
Four 21-day cycles: paclitaxel on Days 1, 8 and 15; carboplatin AUC 5 on Day 1. Pembrolizumab 200 mg on Day 1 of each cycle (every three weeks).
Day of cycle123456789101112131415161718192021
Carboplatin + paclitaxel · Day 1IV treatment
Paclitaxel · Day 8IV treatment
Paclitaxel · Day 15IV treatment
Pembrolizumab · each cycle Day 1Separate immune schedule
Blood counts / infectionFever or sudden illness: call
Nerves / nailsReport before each weekly visit
Immune symptomsCan occur on any day or after treatment
The first phase: Four 21-day cycles: paclitaxel on Days 1, 8 and 15; carboplatin AUC 5 on Day 1. Pembrolizumab 200 mg on Day 1 of each cycle (every three weeks).
Changing to AC: Four further cycles (cycles 5–8): doxorubicin and cyclophosphamide on Day 1 every 21 days. Pembrolizumab 200 mg on Day 1 of each AC cycle.
Surgery and afterwards: After surgery: pembrolizumab 200 mg every 21 days for nine doses OR 400 mg every 42 days for five doses. These are alternative schedules, not consecutive courses. Progression preventing definitive surgery or unacceptable pembrolizumab toxicity changes this plan; postoperative treatment is not automatic.
Why these bands stay broad: Treatment markers show the planned days. Symptom bands are broad possibilities, not measured risk curves; serious symptoms can occur at any time. Band length does not show likelihood or severity, and the chart cannot tell you whether it is safe to receive treatment. NCCP 00857 v3 · official regimen ↗
There are no guaranteed “safe days”. Fever, shivers or suddenly feeling unwell require immediate contact. Serious symptoms override the timeline or diary.
Phase 2 · four 21-day cycles
Day 1 → Day 21: a general pattern
This is a visual orientation, not a prediction of your personal cycle. It shows when some effects often emerge and which effects are not tied to a particular day.
Four further cycles (cycles 5–8): doxorubicin and cyclophosphamide on Day 1 every 21 days. Pembrolizumab 200 mg on Day 1 of each AC cycle.
Day of cycle123456789101112131415161718192021
AC · Day 1IV treatment
Nausea / appetiteEarly or delayed effects
Blood counts / infectionFever or sudden illness: call
Pembrolizumab · each cycle Day 1Separate immune schedule
Immune symptomsCan occur on any day or after treatment
The first phase: Four 21-day cycles: paclitaxel on Days 1, 8 and 15; carboplatin AUC 5 on Day 1. Pembrolizumab 200 mg on Day 1 of each cycle (every three weeks).
Changing to AC: Four further cycles (cycles 5–8): doxorubicin and cyclophosphamide on Day 1 every 21 days. Pembrolizumab 200 mg on Day 1 of each AC cycle.
Surgery and afterwards: After surgery: pembrolizumab 200 mg every 21 days for nine doses OR 400 mg every 42 days for five doses. These are alternative schedules, not consecutive courses. Progression preventing definitive surgery or unacceptable pembrolizumab toxicity changes this plan; postoperative treatment is not automatic.
Why these bands stay broad: Treatment markers show the planned days. Symptom bands are broad possibilities, not measured risk curves; serious symptoms can occur at any time. Band length does not show likelihood or severity, and the chart cannot tell you whether it is safe to receive treatment. NCCP 00857 v3 · official regimen ↗
There are no guaranteed “safe days”. Fever, shivers or suddenly feeling unwell require immediate contact. Serious symptoms override the timeline or diary.
Postoperative · 21-day option
Day 1 → Day 21: a general pattern
This is a visual orientation, not a prediction of your personal cycle. It shows when some effects often emerge and which effects are not tied to a particular day.
After surgery: pembrolizumab 200 mg every 21 days for nine doses OR 400 mg every 42 days for five doses. These are alternative schedules, not consecutive courses. Progression preventing definitive surgery or unacceptable pembrolizumab toxicity changes this plan; postoperative treatment is not automatic.
Day of cycle123456789101112131415161718192021
Pembrolizumab · Day 1IV treatment
Immune symptomsReport during and after treatment
The first phase: Four 21-day cycles: paclitaxel on Days 1, 8 and 15; carboplatin AUC 5 on Day 1. Pembrolizumab 200 mg on Day 1 of each cycle (every three weeks).
Changing to AC: Four further cycles (cycles 5–8): doxorubicin and cyclophosphamide on Day 1 every 21 days. Pembrolizumab 200 mg on Day 1 of each AC cycle.
Surgery and afterwards: After surgery: pembrolizumab 200 mg every 21 days for nine doses OR 400 mg every 42 days for five doses. These are alternative schedules, not consecutive courses. Progression preventing definitive surgery or unacceptable pembrolizumab toxicity changes this plan; postoperative treatment is not automatic.
Why these bands stay broad: Treatment markers show the planned days. Symptom bands are broad possibilities, not measured risk curves; serious symptoms can occur at any time. Band length does not show likelihood or severity, and the chart cannot tell you whether it is safe to receive treatment. NCCP 00857 v3 · official regimen ↗
There are no guaranteed “safe days”. Fever, shivers or suddenly feeling unwell require immediate contact. Serious symptoms override the timeline or diary.
Postoperative · 42-day option
Day 1 → Day 42: a general pattern
This is a visual orientation, not a prediction of your personal cycle. It shows when some effects often emerge and which effects are not tied to a particular day.
After surgery: pembrolizumab 200 mg every 21 days for nine doses OR 400 mg every 42 days for five doses. These are alternative schedules, not consecutive courses. Progression preventing definitive surgery or unacceptable pembrolizumab toxicity changes this plan; postoperative treatment is not automatic.
Day of cycle123456789101112131415161718192021222324252627282930313233343536373839404142
Pembrolizumab · Day 1IV treatment
Immune symptomsReport during and after treatment
The first phase: Four 21-day cycles: paclitaxel on Days 1, 8 and 15; carboplatin AUC 5 on Day 1. Pembrolizumab 200 mg on Day 1 of each cycle (every three weeks).
Changing to AC: Four further cycles (cycles 5–8): doxorubicin and cyclophosphamide on Day 1 every 21 days. Pembrolizumab 200 mg on Day 1 of each AC cycle.
Surgery and afterwards: After surgery: pembrolizumab 200 mg every 21 days for nine doses OR 400 mg every 42 days for five doses. These are alternative schedules, not consecutive courses. Progression preventing definitive surgery or unacceptable pembrolizumab toxicity changes this plan; postoperative treatment is not automatic.
Why these bands stay broad: Treatment markers show the planned days. Symptom bands are broad possibilities, not measured risk curves; serious symptoms can occur at any time. Band length does not show likelihood or severity, and the chart cannot tell you whether it is safe to receive treatment. NCCP 00857 v3 · official regimen ↗
There are no guaranteed “safe days”. Fever, shivers or suddenly feeling unwell require immediate contact. Serious symptoms override the timeline or diary.
Read the whole cycle as text
Day 1–21: Follow the current phase
Four 21-day cycles: paclitaxel on Days 1, 8 and 15; carboplatin AUC 5 on Day 1. Pembrolizumab 200 mg on Day 1 of each cycle (every three weeks). Your team books actual appointments and reviews results. Call about urgent symptoms on any day.
Practical treatment guide
Your practical treatment plan
Four 21-day cycles: paclitaxel on Days 1, 8 and 15; carboplatin AUC 5 on Day 1. Pembrolizumab 200 mg on Day 1 of each cycle (every three weeks). Four further cycles (cycles 5–8): doxorubicin and cyclophosphamide on Day 1 every 21 days. Pembrolizumab 200 mg on Day 1 of each AC cycle. After surgery: pembrolizumab 200 mg every 21 days for nine doses OR 400 mg every 42 days for five doses. These are alternative schedules, not consecutive courses. Progression preventing definitive surgery or unacceptable pembrolizumab toxicity changes this plan; postoperative treatment is not automatic.
STEP 1
Before the first visit
Blood tests, ECG and cardiac review, medicines review, fertility discussion where relevant and the consent conversation come first. Include the prescribed immune baseline checks.
STEP 2
Plan venous access
A cannula, PICC or implanted port may be used. If a port is chosen, a trained team inserts it in a separate procedure with local anaesthetic and sometimes sedation; the team explains fasting, blood-thinner and wound instructions.
STEP 3
Infusion day
Trained staff check and access the line, give the prescribed premedicines and infusions, and monitor for reactions. Tell the nurse immediately about pain, burning, rash or breathlessness.
STEP 4
Home and next review
This regimen does not routinely need a take-home infusion pump. Staff disconnect the infusion; a port is de-accessed when appropriate. Keep line-care and next-visit instructions.
Port insertion and removal
The line team explains placement, dressing care and when normal activities can resume. A port is accessed with a special needle during treatment. Removal of the implanted device is a separate planned procedure when no longer needed; do not remove or adjust it yourself.
PICC care and urgent line symptoms
A PICC usually needs regular dressing and flushing appointments even between treatments. Fever, redness, swelling, pain, leakage or damage requires prompt advice. Your hospital supplies the exact care instructions.
Visit time and transport
Visits include assessment, pharmacy preparation, premedicines, infusions and observation. The first visit and a change in phase can take longer. Ask about transport and any escort needed after sedation or line insertion.
The platinum/taxane phase and AC need separate prescriptions. Carboplatin Day 1 uses a high-risk plan; paclitaxel-only Days 8 and 15 use a separate low-risk plan. AC uses its own high-risk plan.
Growth-factor support
The team decides whether growth-factor support is needed for this three-weekly AC regimen.
Checks before the next dose
FBC, renal and liver tests weekly during the carboplatin/paclitaxel phase, then before every AC cycle. Continue the required blood tests before each postoperative pembrolizumab cycle. Keep the thyroid and other immune-monitoring appointments.
After chemotherapy
After surgery: pembrolizumab 200 mg every 21 days for nine doses OR 400 mg every 42 days for five doses. These are alternative schedules, not consecutive courses. Progression preventing definitive surgery or unacceptable pembrolizumab toxicity changes this plan; postoperative treatment is not automatic.
This treatment is used for eligible high-risk triple-negative breast cancer before surgery, then continued with immunotherapy after surgery when appropriate. Chemotherapy damages cancer cells, while pembrolizumab helps immune cells recognise and attack them. The team considers cancer extent, fitness, heart health and whether immunotherapy is suitable.
Your treatment aim
Treat the cancer before surgery as part of a plan intended to reduce the risk of it returning.
Four 21-day cycles: paclitaxel on Days 1, 8 and 15; carboplatin AUC 5 on Day 1. Pembrolizumab 200 mg on Day 1 of each cycle (every three weeks). Four further cycles (cycles 5–8): doxorubicin and cyclophosphamide on Day 1 every 21 days. Pembrolizumab 200 mg on Day 1 of each AC cycle.
After surgery: pembrolizumab 200 mg every 21 days for nine doses OR 400 mg every 42 days for five doses. These are alternative schedules, not consecutive courses. Progression preventing definitive surgery or unacceptable pembrolizumab toxicity changes this plan; postoperative treatment is not automatic.
Ask who books each test, who reviews the result, and when you should hear the plan.
Blood tests
FBC, renal and liver tests weekly during the carboplatin/paclitaxel phase, then before every AC cycle. Continue the required blood tests before each postoperative pembrolizumab cycle.
Baseline ECG and cardiac history/risk assessment. NCCP lists baseline echo/MUGA for age over 65 or when clinically indicated. Recheck the cardiac assessment before starting doxorubicin; echo/MUGA during treatment is driven by symptoms, risk or the agreed cardio-oncology plan. There is no automatic three-monthly echo schedule for every person on this pathway.
Baseline thyroid tests; thyroid monitoring every 3–6 weeks during pembrolizumab. Cortisol is checked when clinically indicated; tell the team about recent steroid use when results are interpreted. Immune side effects may appear after treatment ends.
Record baseline breast/nodal findings and stage with imaging appropriate to the presentation. Assess clinical response during neoadjuvant treatment and use the appropriate breast imaging before surgery or sooner for concern. There is no universal three-monthly CT schedule for this early-breast pathway. After local treatment, arrange the agreed breast surveillance; routine CT/PET and tumour markers are not asymptomatic recurrence screening.
Other treatments depend on the complete diagnosis and pathology.
How the treatments fit
Chemotherapy comes before surgery. The surgeon discusses lumpectomy or mastectomy as alternatives according to your situation. Radiotherapy, if indicated, follows surgery and recovery; timing is agreed by both teams. It is not automatically given at the same time as these chemotherapy phases. Radiation may overlap postoperative pembrolizumab if both teams agree; this is not an automatic instruction.
This is a triple-negative pathway: endocrine therapy and endocrine-related DEXA are not automatically part of it. Bone-density testing may still be appropriate for other personal risk factors.
Call immediately for fever, shivers, sudden illness, new breathing difficulty or concerning symptoms. Do not wait for a scheduled blood test or appointment.
Why is my chemotherapy changing halfway through?
The planned course uses a platinum/taxane phase followed by AC, which works in a different way. The change is part of the pathway and does not by itself mean the first medicines failed.
Will I need to enter dates here?
No. The maps explain the sequence. Your clinical team provides actual appointment dates.
When are ECGs, echoes and blood tests done?
Baseline ECG and cardiac history/risk assessment. NCCP lists baseline echo/MUGA for age over 65 or when clinically indicated. Recheck the cardiac assessment before starting doxorubicin; echo/MUGA during treatment is driven by symptoms, risk or the agreed cardio-oncology plan. There is no automatic three-monthly echo schedule for every person on this pathway. FBC, renal and liver tests weekly during the carboplatin/paclitaxel phase, then before every AC cycle. Continue the required blood tests before each postoperative pembrolizumab cycle.
Where does radiotherapy fit?
Chemotherapy comes before surgery. The surgeon discusses lumpectomy or mastectomy as alternatives according to your situation. Radiotherapy, if indicated, follows surgery and recovery; timing is agreed by both teams. It is not automatically given at the same time as these chemotherapy phases.
Does pembrolizumab follow every chemotherapy visit?
No. Four 21-day cycles: paclitaxel on Days 1, 8 and 15; carboplatin AUC 5 on Day 1. Pembrolizumab 200 mg on Day 1 of each cycle (every three weeks). Four further cycles (cycles 5–8): doxorubicin and cyclophosphamide on Day 1 every 21 days. Pembrolizumab 200 mg on Day 1 of each AC cycle. After surgery: pembrolizumab 200 mg every 21 days for nine doses OR 400 mg every 42 days for five doses. These are alternative schedules, not consecutive courses. Progression preventing definitive surgery or unacceptable pembrolizumab toxicity changes this plan; postoperative treatment is not automatic.
Try explaining the plan back: Which phase are you in, which medicines are active, and what checks are due before the next phase?
Regimen schedule: NCCP 00857 v3. Medicine explanations and safety information: sources below. The timeline is an educational illustration, not a measured risk curve or an individual prediction.