Guidelines recommend atezolizumab plus nab-paclitaxel (A + nP) for first-line treatment of unresectable, locally advanced, or metastatic triple-negative breast cancer expressing programmed death-ligand 1 (PD-L1) on tumor-infiltrating immune cells (IC), based on IMpassion130. We report the final overall survival (OS) and safety of that study as per the prespecified analysis plan. Patients were randomized to nP 100 mg/m2 (days 1, 8, and 15 of a 28-day cycle) with atezolizumab 840 mg (A + nP) or placebo (P + nP; days 1 and 15), until progression or unacceptable toxicity. Coprimary endpoints were progression-free survival intention-to-treat (ITT) and PD-L1 IC-positive populations and OS (tested hierarchically in the ITT population and, if significant, in the PD-L1 IC-positive population). Each arm comprised 451 patients; 666 (73.8%) had died by the final OS analysis cut-off (median follow-up, 18.8 months; interquartile range, 8.9-34.7 months). Median OS in the ITT population was 21.0 months 95% confidence interval (CI), 19.0-23.4 months with A + nP, and 18.7 months (95% CI, 16.9-20.8 months) with P + nP stratified hazard ratio (HR), 0.87; 95% CI, 0.75-1.02; P = 0.077. Exploratory analysis in the PD-L1 IC-positive population showed a median OS of 25.4 months (95% CI, 19.6-30.7 months) with A + nP (n = 185) and 17.9 months (95% CI, 13.6-20.3 months) with P + nP (n = 184; stratified HR, 0.67; 95% CI, 0.53-0.86). Safety outcomes were consistent with previous analyses and the known toxicity profiles of each agent. Immune-mediated adverse events of special interest were reported in 58.7% and 41.6% of patients treated with A + nP and P + nP, respectively. Although the OS benefit in the ITT population was not statistically significant, precluding formal testing, clinically meaningful OS benefit was observed with A + nP in PD-L1 IC-positive patients, consistent with prior interim analyses. This combination remained safe and tolerable with longer follow-up. •Final OS data from IMpassion130 (A + nP in metastatic triple-negative breast cancer) agree with prior interim analyses.•OS benefit with A + nP versus P + nP in the ITT population was not statistically significant, precluding further testing.•Exploratory data not formally tested showed clinically meaningful OS benefit for A + nP in the PD-L1 IC-positive population.•Three-year OS rates in the PD-L1 IC-positive population were 35.8% with A + nP versus 22.2% with P + nP.•No new safety signals were seen with longer follow-up; adverse events were consistent with those known for each drug.