Whether you’ve just been diagnosed or worry you could have breast cancer, you’re probably nervous, confused, and definitely scared. That’s normal, and everyone featured on HealthCentral with a serious illness felt just like you do now. But we—and they—are here for you. On this page alone, you’ll discover not only the realities and challenges of the condition, but also the best treatments, helpful lifestyle changes, wisdom from people who have been where you are now, and all the critical information you need to help you not just manage—but thrive. We’re sure you’ve got a lot of questions...and we’re here to answer them.
We went to some of the nation’s top experts in breast cancer to bring you the most up-to-date information possible.
P. Hank Schmidt, M.D.Breast Surgical Oncologist
Jonathan Stegall, M.D.Medical Director
Zahi Mitri, M.D.Breast Cancer Oncologist
What Is Breast Cancer, Exactly?
If you have boobs or know someone who does, you likely know some of the breast-cancer basics because there’s a darn good chance there’s a person in your life who’s had it. Breast cancer is the most common malignancy in women—about 270,000 cases are diagnosed each year—accounting for approximately 30% of all cancer cases, according to the American Cancer Society. Although it happens much less often, men can also develop breast cancer. In fact, Beyonce’s dad recently became one of the 2,670 men diagnosed annually.
In each of these people, their breast cancer began the same way: A rogue cell began to multiply in ways it’s not supposed to, eventually forming a tumor. To really understand the different types and stages of breast cancer, it helps to have an image in your mind of where it starts and how it grows. The main structures of the breast are milk glands (called lobules), the ducts that carry milk, and fatty and fibrous tissue that make up most of the breast. Most breast cancers start in the glands or ducts.
Once breast cancer is found, doctors will give it a stage—from 0 to IV—depending on the extent of the disease, what the prognosis is, and which treatments will work best. Within each stage, there are further classifications depending on things like tumor size and lymph-node involvement, usually indicated by doctors with the letters a, b, and c. For now, we’re sticking with the main categories:
Stage 0: Also called ductal carcinoma in situ (DCIS), stage 0 tumors are abnormal cells that form inside the duct (“in situ” means remaining in place), and current research suggests that in many cases, these cells will not grow any further or cause problems for the patient. Some even consider this non-invasive form of DCIS precancer.
The catch? About 20% to 30% of the time, these cells continue their out-of-control ways and push into tissues outside of the duct (this is called “invasive” cancer). Unfortunately, there is no sure way to know which type of DCIS you have, which is why even stage 0 breast cancers are treated (more on this below).
Stage I: This is the earliest possible stage of invasive breast cancer. At this point, the tumor isn’t bigger than 20 millimeters (2 cm) and and hasn’t spread more than microscopically to underarm lymph nodes. Cancers caught at this stage are curable and treatable: The five-year survival rate—meaning, the number of women who are alive five years after diagnosis—is an incredible 99%.
Stage II: These tumors are really trying to stake their claim. They’re generally larger than 20 mm and may have spread into a few lymph nodes under the arm. But deep breath. The five-year survival rate for stage II cancer is a still a reassuring 85%.
Stage III: At this point, the tumor is likely pretty big (larger than 50 mm) and/or cancer cells have made their way into several lymph nodes, either under the arms or as far away as the collarbone. This stage also includes cancers that have directly invaded the chest wall or have formed skin nodules or ulceration.
Stage IV: This most advanced form of breast cancer, known as metastatic, has spread to the bones and/or organs, such as lungs, liver, or brain. The most difficult part about this diagnosis is that it’s not considered curable. However, in some people, progression of the disease can be slowed or even stopped by a series of medications and other treatment, and the disease becomes more of a chronic illness. The five-year for this stage is 27%, which we know isn’t easy to see, but here’s what you must remember about these stats: Yes, they are scary, but you are not a number. There are women alive today who have been living with metastatic breast cancer for decades.
Less Common Cancers and Other Breast Diseases
Worth noting: The above describes the most common breast cancers, but there are a few less-common types you should know about, and some other breast diseases that are sometimes confused with breast cancer.
Paget Disease: This rare breast cancer starts in the milk ducts and then spreads to the skin of the nipple and areola. It can look like an eczema rash.
Inflammatory Breast Cancer: In these cases, the cancer is typically more advanced, according to the National Cancer Institute, and has spread to the skin of the breast, making it red, swollen, and sometimes dimpled like the skin of an orange. With IBC, you may not always feel a lump, and it tends to be more common in younger women and those who are African-American.
Lobular carcinoma in situ: Despite the word “carcinoma” in the name, lobular carcinoma in situ (LCIS) is not cancer. In LCIS, cells do grow abnormally in the milk glands of the breast, but they do not invade other tissues. Although this condition isn’t cancer, it is a sign that a person is at increased risk for developing cancer in either breast in the future, and you’ll most likely need more frequent screenings.
Dionna Koval shares her story with metastatic breast cancer and the search for a cure. Click to learn more.
What Causes Breast Cancer in the First Place?
Exactly what triggers breast cells to grow out of control isn’t well understood, but scientists do know that certain factors and habits can interfere with a cell’s instruction manual, aka its genes, according to the American Cancer Society. If something blocks its signal to stop dividing or messes with its ability to repair DNA damage, those abnormal cells will just keep on going.
Every person's risk is different and depends on factors such as genetics, family history, lifestyle, and other issues. But the average woman has about a 12% chance of developing breast cancer at some point in her life. The average age of diagnosis is 62.
Here are some of the most common risk factors for breast cancer:
Family history: Having a close relative (mother, father, or sister) or several more-distant relatives who’ve had the disease can make your risk higher. Women with a BRCA1 or 2 mutation have a 50% to 85% risk of developing breast cancer in their lifetime. Normally, these genes help prevent that abnormal growth; but when they’re damaged, it’s harder for the body to short-circuit tumor development.
Not everyone needs to be tested for these mutations, but those with certain types of family history (such as having two first-degree relatives with breast cancer or one if you have Ashkenazi-Jewish heritage) should. So ask your doctor at your next check up if you should consider genetic screening to get better handle on your breast cancer odds. If it turns out that you do have one of the mutations, you'll be able to work with your doctor on a plan to get those risk numbers down.
Age: Simply getting older increases the risk of developing breast cancer, and most cases of this illness happen in people 50 years or older. Sometimes it takes decades of little gene mutations to accumulate before one finally tips the balance and triggers a tumor.
Hormones: Most breast cancers are fueled by estrogen and progesterone, so the longer a woman is exposed to reproductive hormones, the higher her risk of breast cancer. Women who started their periods before age 12 have about a 20% higher chance of developing breast cancer than someone who started after age 14. Hitting menopause after age 55 increases the odds by about 30% versus going through the change 10 years earlier. Taking combined estrogen and progesterone hormone therapy for menopause symptoms also increases risk (how much depends on how old you are and how long you took the medications). A history of using certain oral contraceptives for birth control is also linked to a very small (7%) increase in risk.
Body fat: Here's a little-know fact about fat: It produces estrogen. So the more you have, the higher your hormone levels tend to be. A study in JAMA Oncology found that in post-menopausal women, the risk of an estrogen-sensitive tumor was about twice as high in those with the highest percentage of body fat compared to the lowest. This was true even for women who had a “healthy” body-mass index.
Alcohol: Look, you can still enjoy a cocktail now and then, but even moderate drinking (one to two drinks a day) may increase the risk of breast cancer by about a third to a half, according to a study in Current Breast Cancer Reports.
Family planning: Whether you have kids or not and at what age can affect your breast cancer risk by changing your levels of and exposure to hormones. A study in the International Journal of Cancer found that women who never had children were were 1.3-times more likely to develop the disease… Women who had their first baby after age 35 were 1.4-times more likely to get breast cancer than those who had a kid before age 20. Try not to get too hung up on these numbers though: Is anyone recommending teen pregnancy to prevent breast cancer? Nope. The right time to have a baby is whenever you say it is—which may be never.
Do I Have the Symptoms of Breast Cancer?
Some breast cancers cause no obvious symptoms at all—which is why regular mammography screening is so important. (The American Cancer Society says women need yearly mammograms starting at age 45 but should have the option of beginning annual screening at 40.) Sometimes though, these tumors do make themselves known to you, so it helps to have a sense of what to look for. Having any of the following symptoms does not necessarily mean you have cancer. Instead, consider them a signal to call your doctor:
Lumps and swelling: Many women have naturally lumpy breasts. You should take note of any lumps you feel or see in your breasts—but if both boobs have similar lumps in similar places, or they come and go with your menstrual cycle and are smooth and rubbery, they’re likely just cysts or other normal clumps of tissue. The lump to pay most attention to is one that’s new, only on one side, and doesn’t go away.
Another thing to know: Although tumors can feel squishy and smooth to the touch, cancerous lumps often have irregular edges and feel hard and immovable, like a pebble. Unexplained swelling of part or all of one breast should also be checked out. Sometimes more advanced breast cancers that have spread to the lymph nodes can also cause swelling, tenderness, or a mass in the armpit or by the collar bone.
Pain: Many women experience breast tenderness that comes and goes during certain times of the menstrual cycle, but new pain that doesn’t go away with your period should be checked out.
Nipple changes: A newly retracted (or, sunken in) nipple is a symptom in some cancers. A tumor can cause inflammation and scarring that tugs that tissue inward. Same goes for sudden nipple discharge, especially fluid that’s bloody, in someone who isn’t breastfeeding or had a baby in the last year. And an eczema-like rash around the nipple can be a sign of Paget disease.
Skin changes: Redness, warmth, swelling, or dimpling could point to inflammatory breast cancer.
A doctor diagnoses breast cancer using a few different tools, usually starting with imaging tests like a mammogram.
Mammogram: Most women should start getting regular screening mammograms in their 40s, although high-risk women may need to start earlier. These x-ray imaging tests look for masses or small white dots known as calcifications. If a doctor suspects breast cancer, they will order a diagnostic mammogram to further explore any changes in the breast. During a diagnostic mammogram, a radiologist will often look at the images immediately while you wait, in case they want to take additional pictures, or they'll use especially “magnified” views to really zero in on an area.
Ultrasound: Sometimes the doctor will want to get a different or more-detailed picture of your breast and will order an ultrasound or magnetic resonance imaging (MRI) to get more information about a suspicious lump or spot. Ultrasound is a great option for following up on a suspicious lump because the sound waves bounce back differently off a fluid-filled cyst versus a solid lump that’s more likely to be cancer.
Magnetic Resonance Imaging (MRI): Women who are at high risk for breast cancer sometimes need an MRI along with their regular mammograms. That’s because an MRI can “see” some cancers that a mammogram will miss. That said, skipping a mammo and just having an MRI isn’t a good idea, because MRI can miss other cancers that will show up on a mammogram!
During a biopsy, the doctor will take a bit of fluid or tissue from the breast and test it for abnormalities. There are a couple different types of biopsies:
Fine-needle aspiration: In this least-invasive option, a doctor inserts a skinny, hollow needle into the lump to remove some cells. (If the lump is hard to feel or find, a surgeon will sometimes use ultrasound imaging to help her know where to aim.)
Excisional biopsy: Just like is sounds, this one is more like surgery. A doctor will cut out the suspicious lump entirely and test it—this is the most accurate way to diagnose, or rule out, cancer.
If a biopsy shows that a tumor is cancerous, doctors will run other tests to figure out what type of breast cancer it is. Many different tumor characteristics affect prognosis and treatment, including:
Hormone status: Breast cancers that depend on estrogen or progesterone to grow are called hormone receptor-positive tumors. These cancers can be treated with hormone-therapy drugs and often have a better prognosis than other tumors, according to the American Cancer Society. A majority of breast cancers are hormone-receptor positive.
HER2 status: HER2-positive breast cancers overproduce the HER/neu protein, which can speed tumor growth. Those who test positive receive certain targeted medications that can block those signals.
If both hormone receptor and HER2 tests are negative, the breast cancer is classified as triple-negative. They tend to be more aggressive than other types of breast cancer, though experts aren't exactly sure why, and there are fewer targeted treatments.
What Is the Best Treatment for Breast Cancer?
Most breast-cancer treatment includes surgical removal of the tumor. But many people will need more care after that. The best combination of treatments for your breast cancer depends on the type and stage, and your own preferences. A lot of people consult with a team of different types of doctors including oncologists and breast surgeons before deciding what to do.
Lumpectomy: Just the tumor and some of the tissue around it is taken out. This can be a good option for people with cancers that are small, relative to the breast and are not multiple within the breast. Many patients with spread to nodes may also be candidates.
Mastectomy: All the breast tissue (and sometimes the nipple and/or skin of the breast) is removed. It’s often recommended when there are several areas of cancer in the breast, or when the tumor is very large compared to the amount of healthy breast tissue.
Lymphadenectomy: Removal of some or all of the lymph nodes under the arm. This may be required if the tumor has spread beyond the breast itself.
Chemotherapy medications are used to kill or shrink cancer cells. Some tumors respond better to chemo than others—tests done on your specific cancer cells will help you and your doctor decide whether these drugs should be part of your treatment plan. Chemo is usually given as an IV infusion or injection at a clinic or doctor’s office. Doses are given in bursts—or cycles—of a few weeks at a time so that patients are able to rest and recover from each treatment before having another. The length of time a person will need chemotherapy treatments can vary, but it often lasts anywhere from three to six months.
Hormonal therapies are often used to treat hormone-positive cancers in order to cut off the supply of hormones the tumors need to grow and spread. These medications are usually taken for a long time—between five and 10 years.
Other medications may be used to encourage a person’s own immune system to kill cancer cells or to target specific proteins in some cancers (such as HER2-positive tumors). Rather than killing cancer cells the way that chemotherapy does, targeted therapies typically don’t damage healthy cells as much. Targeted therapies can be given as injections, IV infusions, or in pill form and some may be given for up to a year.
Very high-energy x-rays are delivered to the breast in order to wipe out cancer cells, shrink tumors, and/or help prevent breast cancer from growing back after surgery. Whether you need radiation depends on a lot of factors. If you have a lumpectomy instead of a mastectomy, for example, you will likely need radiation to zap any malignant cells that may have been left behind, lowering the chances that tumor will grow back. Some women will need radiation after mastectomy, as well.
Radiation is either done on your entire breast, or just the part where the tumor was located. If your doctors decide that you need whole-breast radiation, you’ll get a treatment five days a week for three to six weeks. If only part of your breast needs radiation, you’ll typically need one or two treatments a day for three to five days.
Other Types of Therapy That Can Help
There’s a reason people talk about the war against cancer: Because treatment turns your body into battleground. So when you’re going through it, do whatever you need to feel comforted, supported, and less stressed out. Massage, yoga, acupuncture, and/or plain old therapy can be the balm that protects you from any collateral damage.
It can. Different treatments have different risks and side effects, but these are some of the most common ones, according to the CDC:
Loss of sensation in the chest or remaining breast tissue
A type of swelling called lymphedema. After having radiation therapy—or lymph nodes removed during surgery—lymph fluid can start building up in the arms, hands, breasts, or torso.
Higher risk of infections
Reduced appetite and/or weight loss
Brain fog or trouble with concentration and memory (often called “chemo brain”)
Increased risk of blood clots
Increased cholesterol or blood sugars
Increased risk of infection
Side effects of breast-cancer treatment can be pretty unpleasant, but these days, doctors have a lot of ways to help ease, from anti-nausea medications to ones that boost your immunity. Don't worry about putting up a brave front. If you're struggling with symptoms, let your doctors know so they can help you find some relief.
What’s Life Like for People With Breast Cancer?
Living day-to-day after being diagnosed with breast cancer can be full of fear and anxiety, plus pain or other really-not-fun side effects from treatment. You may also have to deal with people who don't understand the condition and can't fully grasp what you're going through. But here’s the good news: Because breast cancer is a relatively common illness and because there are so many excellent treatments, there are a lot of people who understand your situation and can help.
Take things one step at a time: Educate yourself about breast cancer, never be afraid to ask your medical team questions, and enlist the help of a friend or loved one to go to appointments with you. Breast-cancer treatment can be complex and the terminology confusing. It can be hard to keep everything straight when you are feeling unwell or are scared—your appointment buddy can take detailed notes and write down questions for you to ask next time.
This diagnosis can turn your life upside down. But you’re going to be making some of the most important decisions of your life over the next few months, and stress and depression can interfere with your healing process. Here’s how to fight back.
Work stress-relief into your daily life. Negative emotions can impact your ability to make thoughtful decisions, as well as lead to stress that can suppress your immune system. So be sure to incorporate activities that help you quiet your mind such as meditation, deep breathing, exercise, journaling, or any other method that works for you.
Speak up! Talking with friends and family about what you're going through can help you feel less alone. It’ll also give them a chance to offer support. And when they do, take it. If you’re too tired to cook, let them bring you dinner. If you want company at a chemotherapy treatment, let them drive you to the clinic and stay and chat during your infusion.
Consider attending a support group or talking to a therapist. Being diagnosed with breast cancer is frightening—even if yours is caught early and you have a sunny prognosis. No one can understand exactly what you’re going through quite like someone who’s experienced it. Many larger hospitals and cancer centers have free support groups for patients. Try one out.
Cancer involves you in the fight of your life, and it’s often difficult to think about anything else, including sex. Plus, the way you feel about your body and how it looks can change a lot after lumpectomy or mastectomy surgery. Treatments like chemotherapy or hormone therapy can also interfere with sexual desire or function. But you don’t have to just sit back and take it. A good first step is to talk to your doctor. Most women deal with some sex-life changes and interruptions during or after breast-cancer treatment. Your doctor will not be surprised or embarrassed when you bring it up! And she can help: There are medications and other fixes she can recommend to help ease sexual side effects of medications; plus she can refer you to a support group for other breast-cancer survivors or to a counselor who is skilled at helping survivors ease back into their normal lives—orgasms included.
Where Can I Find Breast Cancer Communities?
There’s a lot of talk about breast cancer but finding and talking to people who know exactly what you’re going through can be just as important as finding a treatment plan that works. Here are some places to start to make connections, find resources, and meet friends.
Follow because: Breast cancer does not rule her life—she continues to live life to the fullest, with just “a touch of metastatic breast cancer.” One day she’s at chemo, the next day she’s basically a mermaid who lives at the beach.
Follow because: She went from the big stage as a ballerina with the Joffrey Concert Group in NYC, to chemo chairs with stage IV metastatic breast cancer. With a double mastectomy behind her, she’s fighting and clawing her way back to the spotlight, one plie at a time.
Follow because: There’s actually a bra for that—and she’s the one to thank for it. She’s the founder and designer of AnaOno—a bra made specifically for women who have had breast-cancer reconstruction, breast surgery, mastectomy, or are living with other conditions that just don’t mix well with other bras.
Follow because: Dancer, yogi, mom of three, and breast cancer warrior — these are just a few of her titles. But when we scroll her feed, we see: poet. Her words of gratitude and encourage are like mini-mantras to live your life by — and a lot of them stem from her survivorship.
Follow because: She’s fearless and fighting stage IV breast cancer. Her campaigns for breast-cancer awareness are fresh and spread like wildfire, and we totally encourage you to blaze that trail with her.
Follow because: Motivational YouTuber Nalie Agustin was diagnosed with stage IV breast cancer at just 24 years old. She vlogged all the way through her treatments on her channel and then started The Nalie Show there, where she talks to fellow cancer survivors, celebrities, and other inspiring folks.
Follow because: We might be biased since she’s a HealthCentral columnist, but we’re thinking — no, we know — you’re going to adore her just as much as we do. Not that long ago she was a 30-something mom of two boys, following her husband across the country for his dream job, and celebrating a milestone birthday. That all changed overnight when she found a lump in her breast. Now she’s a beautifully mixed bag of mom-chemo-wig-wife-radiation-recovery-life. Her posts, like mini columns, will leave your heart either broken, fulfilled, or both, all at once. Oh, and she shares breast-cancer-friendly recipes, too! Told you she’s worth the follow.
Follow because: Her Insta bio says it all: she’s “one tough mother, fighting breast cancer and raising a baby.” Without even reading her words (which will also suck you in), the pictures you’ll find while scrolling her feed are so powerful and will draw you in (like the one of her with a full head of hair looking over at herself, now bald #chills). You see the tough parts of chemo, but also how she fights to bounce back in life — like hopping on her cycle bike the day after her first chemo treatment.
Follow because: Just because she’s a few years out from her final round of chemo, doesn’t mean she stops fighting the hardest fight of her life against cancer returning. Especially when she has another reason to fight — for her miracle baby, conceived three years after finishing cancer treatments. Join her on the first of every month for a self-breast check (don’t worry, she’ll remind you), and on her fitness journey to stay strong so she can fend of metastatic breast cancer.
Top Breast Cancer Podcasts
The Cancer Game Plan. The hosts of this weekly show talk to a new inspiring cancer warrior every week about their journey plus their “funniest” cancer moment and top tips for living with cancer.
Investigating Breast Cancer. This show, from the Breast Cancer Research Foundation, discusses the latest breast-cancer news with top doctors in the field.
Stripped Down & Straight Up with Nikki Austman. Two-time breast cancer survivor and certified life coach helps you juggle a Jekyll-and-Hyde life of depression and laughter—because the balance is real when you’re living with breast cancer.
Cancer, Casually. The Fullest’s Managing Editor and breast-cancer survivor Lindsay DeLong brings on some notable and courageous guests to help thrivers keep thriving through other’s gut-wrenching or inspiring journeys. Walk away with a new perspective on the ‘Big C.’
The Good Glow. After her breast cancer diagnosis, Georgie Crawford’s perspective on life completely changed. She needed a new outlook—one that brought her back to the basics of self-care and surrounding yourself with positivity. This listen will give you all the good vibes.
The Cancer Dietitian Podcast. Nothing says cancer care like good nutrition—they basically shove it down your throat (almost literally) during treatment. Julie Lanford, R.D., tells you exactly what you need to fuel your body, whether you’re in treatment, a survivor trying to avoid a recurrence, or you have a family history of breast cancer and are trying to stay ahead of the odds.
Top Breast Cancer Support Groups and Non-Profits
Living Beyond Breast Cancer. Trustworthy information, community, and support for people with breast cancer and their friends and families—plus ongoing educational programs such as conferences and webinars. There’s also a free online/telephone helpline that will match patients with volunteers for one-on-one support and education.
Young Survival Coalition. The YSC focuses especially on people age 40 and under affected by breast cancer with free educational programs and guidebooks plus active discussion boards, a private Facebook group, and in-person meet-ups.
Susan G. Komen Breast Cancer Foundation. One of the best-known breast-cancer advocacy organizations, Komen is a powerhouse fundraiser for breast-cancer research, and offers wide-ranging free services from an online treatment navigation tool to a breast care helpline and information on financial assistance.
Metastatic Breast Cancer Network. A patient-led advocacy organization focusing on the unique needs and concerns of people living with metastatic (or Stage IV) breast cancer. The MBCN offers info on clinical trials and treatments for advanced breast cancer, peer support groups and message boards, and even funds scientific research.
The Breasties. They make breast cancer look cool. “Free retreats, events, and community for women affected by breast and reproductive cancers.”
Stupid Dumb Breast Cancer on Facebook. A community of women going throuhg breast cancer at all different stages. You will get an answer and support on anything you post. Sweet, genuine women wanting to pay it forward and support others.
Frequently Asked QuestionsBreast Cancer
How do I check myself for breast cancer?
The best way is to get to know your breasts—how they feel, what they look like, and how they change during your menstrual cycle—and to let your doctor know about any concerning changes. The most common symptom of breast cancer is a lump. Other signs can include dimpled skin, pain or swelling in one breast that's not related to your period, skin inflammation, and unexpected nipple discharge.
What are the chances that I could develop breast cancer?
Every person's risk is different and depends on factors such as genetics, family history, lifestyle, and other issues. But the average woman has about a 12% chance of developing breast cancer at some point in her life. The median age of diagnosis is 62; only about 5% of women with breast cancer are diagnosed under age 40.
What is the breast-cancer survival rate?
Prognosis depends on several things including the stage of cancer, type of tumor, and what treatments are available. But on average, the five-year survival rate for invasive breast cancer is 90%. The 10-year survival rate is 83 percent. The 5-year survival rate for metastatic breast cancer (the type that has spread to other parts of the body) is 27%. But remember, the survival rate for the earliest forms of breast cancer is 99%.
Can men get breast cancer?
Yes. Any person of any gender can get breast cancer, although women are 70 to 100 times more likely to develop the disease than men, according to the American Cancer Society. About 2,600 men are diagnosed each year.
Who should be tested for BRCA mutations: UpToDate. (2019). “Recommendations from the United States Preventive Services Task Force on who should be offered genetic testing for BRCA mutations.” uptodate.com/contents/image?imageKey=ONC%2F57434
Body fat and risk:JAMA Oncology. (2018). “Body Fat and Risk of Breast Cancer in Postmenopausal Women with Normal Body Mass Index; A Secondary Analysis of the Women’s Health Initiative Randomized Clinical Trials and Observational Study.” ncbi.nlm.nih.gov/pmc/articles/PMC6439554/
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