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Dr. Aidah Abu Elsoud Alkaissi. An-Najah National University Faculty of Nursing. 2014-08-05. 1. Breast cancer is a growth of abnormal cells usually within the ducts (which carry the milk to the nipple) or lobules  (glands for milk production) of the breast.

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Dr. Aidah Abu Elsoud Alkaissi

An-Najah National University

Faculty of Nursing

2014-08-05

1

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Breast cancer is a growth of abnormal cells usually within the ducts (which carry the milk to the nipple) or lobules (glands for milk production) of the breast.
  • In more advanced stages of the disease, these out-of-control cells invade nearby tissues or travel throughout the body to other tissues or organs.

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How does breast cancer develop?

1. Normal ducts2.  Intraductal Hyperplasia3.  Atypical Ductal Hyperplasia4.  Ductal Carcinoma In Situ5.  Invasive Ductal Cancer

?:

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epidemiology incidence and prevalence
EpidemiologyIncidence and prevalence
  • Each year the disease is diagnosed in over one million women worldwide and is the cause of death in over 400,000 women.
  • Breast cancer can occur in men, although the incidence is much lower, amounting to around 1% of all breast cancers.
  • Breast cancer remains the leading cancer in black women in the USA, overall they have an incidence rate nearly 20% lower than that of American white women.

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epidemiology of breast cancer in palestine
Epidemiology of Breast Cancer in Palestine
  • Cancer incidence rate among Palestinian women is 15.1 per 100,000 women.
  • According to the statistics since 1998 up to now, the oncology center in Palestine reports approximately 280 women breast cancer yearly (57% out of them in West Bank and 43% in Gaza Strip).

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state of the evidence what is the connection between the environment and breast cancer
State of the EvidenceWhat Is the Connection Betweenthe Environment and Breast Cancer?
  • Breast cancer arises from a complicated mix of multiple factors, which may include inherited or acquired genetic mutations, altered gene expression and/or exposures to external agents that affect genes or the production of estrogen or other hormones.

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Age; Nearly 80% of all newly diagnosed invasive breast cancer cases occur in women aged 50 and older and is less common in premenopausal women.

Family history of breast cancer.

Paget´s disease accounts for 1% of all breast CA, is associated with an infiltrating, and intraductal carcinoma.

Risk Factors for Breast Cancer

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.Genetic factors; some cancers have a genetic component and can be inherited.

It is estimated that between 5 and 10% of breast cancer can be attributed to one of two predisposing genes:

BRCA1 on chromosome 17.

BRCA2 on chromosome 13.

Mutations in these genes are associated with a lifetime

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A mutation in the gene which causes a high risk of cancer does notnecessarily mean cancer will develop; nor does it predict at what age the cancer may appear.

The development of the disease may also be affected by the environment and interaction with other genes.

Risk Factors for Breast Cancer

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Risk Factors for Breast Cancer

  • Hormone factors:
    • Early menarche women who started their period before 12 years of age.
    • Late menopause women who go through menopause after age 55.

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Risk Factors for Breast Cancer

  • Pregnancy history: women who have their first child after the age of 30 or who have had fewer pregnancies or no pregnancies.
  • Breast density: women with less fatty, denser breasts, which are normally older women, have an increased chance of breast cancer.

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Risk Factors for Breast Cancer

  • Obesity after menopause women who were overweight based on a body mass index (BMI) greater than 25 are 1 to 2 times more likely to die from breast cancer than women with a normal BMI.

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Risk Factors for Breast Cancer

  • Ionizing radiation;In 2005, the National Toxicology Program classified X radiation and gamma radiation as known human carcinogens.
  • Compelling scientific evidence points to some of the 100,000 synthetic chemicalsin use today as contributing to the development of breast cancer, either by altering hormone function or gene expression.

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Risk Factors for Breast Cancer

  • There is broad agreement that exposure over time to estrogens in the body increases the risk of breast cancer.
  • Hormone replacement therapy (HRT)and hormones in oral contraceptivesincrease this risk.

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Volume 356:1670-1674Number 16, 2007The Decrease in Breast-Cancer Incidence in 2003 in the United States
  • In this study, it was concluded that:
  • The decrease in breast-cancerincidence seems to be related to drop in theuse of hormone-replacement therapy among postmenopausal women.

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Risk Factors for Breast Cancer

  • Early life exposure to high levels of polycyclic aromatic hydrocarbons (PAHs), present in tobacco smoke and other air pollution, increased the risk of premenopausal breast cancer in a case-control study of more than 3,200 women (Calabrese 2003).
  • A study of 21,000 Japanese women concluded that smoking, both active and passive, increases the risk of developing breast cancer in premenopausal women (Markey 2001).

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Risk Factors for Breast Cancer

  • Pesticides, fuels, household productsespecially cleaning agents, detergents, plastics (including food packaging, toys, credit cards and rainwear) are risk factors.
  • Solventsin the electronics, fabricated metal, printing chemical, textile and clothing industries are also risk factors.

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Risk Factors for Breast Cancer

  • Diesel exhaust, soot and fumes from combustion of diesel and other fuels, and from grilling meat and fish.
  • Chemical industries, in air and water pollution, and some cosmetics products.
  • “Chew toys” marketed for infants and also in some varieties of nail polish, perfumes, skin moisturizers, and flavorings.

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Risk Factors for Breast Cancer

  • Antibiotics used on poultry and hormones injected into cattle, sheep and hogs.
  • A growing body of evidence implicates non-ionizing radiation(electromagnetic fields and radio-frequency radiation as possible contributors to the development of breast cancer.
  • Microwaves, radio waves, radar are examples of nonionizing radiation.

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Mass, a puckering, thickening or subtle change in breast manifest as painless, firm, fixed lesion with poorly defined contour.

It can be found anywhere in the breast in most common in the upper outer quadrant.

Nipple retraction, or unusual discharge.

Signs & Symptoms

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Signs & Symptoms

  • Skin inflammation and thus is known as inflammatory breast cancer.
  • Changes in the appearance or shape of the breast can raise suspicions of breast cancer.

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Classifications

  • Tumors are classified histologically according to tissue Characteristics and staged clinically according to tumor size, nodal involvement, and presence of metastasis.
  • It is recommended that estrogen and progesteron receptor analysis be performed on surgical specimens

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Classifications

  • Information about the presence and abscence of estrogen and progesteron receptors can be used in predicting tumor responsiveness to hormonal manipulation
  • High levels of both receptors improve the prognosis and increase the likelihood of remission

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Diagnosis methods for

breast cancer

Screening & Diagnosis

Of breast cancer

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Strategies for increasing the participation of women in community breast cancer screening (Review)Bonll X et al. 2007 The Cochrane Collaboration.

  • Strategies for reducing breast cancer mortality in western countries have focused on screening, at least for women aged 50 to 69 years.
  • One of the requirements of any community screening program is to achieve a high participation rate, which is related to methods of invitation.

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The evidence favoured active strategies for inviting women into community breast cancer screening services:
    • letter of invitation
    • mailed educational material
    • letter of invitation plus phone call

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conventionell mammography screening
A mammogramis an x-ray of the breast, may find tumors that are too small to feel.

May find ductal carcinoma in situ, abnormal cells in the lining of a breast duct, which may become invasive cancer in some women.

Conventionell MammographyScreening

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Digital Mammography: The Promise of Improved Breast Cancer Detection

Kevin D. Evans, PhD, RT(R)(M)(BD), RDMS, RVS, FSDMS

    *Director/Assistant Professor, Radiologic Sciences and Therapy Division, The Ohio State University, Columbus, Ohio.    Address correspondence to: Kevin D. Evans, PhD, RT(R)(M)(BD), RDMS,RVS, FSDMS, Director/Assistant Professor, Radiologic Sciences and Therapy Division, The Ohio State University, 453 West 10th Avenue, 340 A. Atwell Hall, Columbus, OH 43210. E-mail: [email protected]

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evidenced based practice full field digital mammography screening
Advantages:

Accommodate most patients regardless of breast size.

Reduces the number of images required and decreases radiation exposure.

The higher resolution enables radiologists to see more detail within the soft tissue of the breast; this can lead to a more accurate diagnosis.

Evidenced-Based Practice: Full-Field Digital Mammography- Screening

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ultrasonography diagnosis
Ultrasonography is useful as a diagnostic adjunct to differentiate cystic from solid tissue in women with nonspecific thicheningUltrasonography- Diagnosis

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biopsy diagosis
If the clinical breast exam, mammogram or ultrasound shows an area of possible concern, a biopsy is usually the next step.

A biopsy is the removal of cells or tissues of concern so that they can be viewed under a microscope and further tested by a pathologist.

Biopsy- Diagosis

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Thin, hollow needle is inserted into the suspicious growth and cells are withdrawn for laboratory analysis.

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Invasive method of collecting large numbers of cells from the breast milk ducts, where the majority of breast cancers (95%) originate.

Wash saline through its natural opening in the nipple into a breast duct using indwelling hair-like single lumen catheters.

After the fluid was introduced into the duct, the fluid introduction catheters were removed.

Then, externally applied nipple aspiration techniques or external pressure applied to the breast were used to collect samples of the ductal fluid.

Finding atypical cells provides unique information about a woman’s personal risk for developing breast cancer.

Ductal lavage

Risk Assessment Tool

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at risk women may be eligible for participation of ductal lavage
At-risk women may be eligible for participation of Ductallavage
  • If they are between the ages of 35 to 70 years.
  • If they have a known BRCA1 or BRCA2 gene mutation.
  • Participants must have a family history of breast cancer (multiple family members) or other risk factors.
  • Mammograms and physical examinations must prove normal.

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A common place for breast cancer to spread is to the bones.

A bone scan is often done to assure there is no detectable metastasis to the bones.

Bone Scan

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positron emission mammography a pem scan
positron emission mammography (a PEM scan)

Advantages:

  • The PEM system’s camera and detectors are closer to the area affected with cancer, which produces a very sharp, detailed image of tumors and cancerous tissue.
  • With PEM, cancers can be seen as small as 1.5 – 2mm, about the width of a grain of rice

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MRI combines the use of powerful magnets and radio wave pulses.

Used to detect breast cancer in some women at higher risk

MRI can also be used before surgery to identify areas of the breast affected by the tumor.

Magnatic Resonance

Imaging Technology

(MRI) To Improve Breast Cancer Detection

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ct images faster than traditional scanners 2006 jian zhang
Researchers at the University of North Carolina developed a new method to create computed tomography (CT) images using carbon nanotube x-rays that works much faster than traditional scanners and uses less peak power.CT Images Faster Than Traditional Scanners 2006, Jian Zhang,

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ct images faster than traditional scanners 2006 jian zhang1
"The current Computerized axial tomography scanners take images sequentially, which is slow and inefficient.

Using the nanotube x-ray technology, the feasibility of multiplexing - taking multiple images at the same time,"

Carbon nanotubes, made of layers of carbon atoms, can be as small as one nanometer - one billionth of a meter - in diameter.

CT Images Faster Than Traditional Scanners 2006, Jian Zhang,

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treatment options for breast cancer
Treatment Options for Breast Cancer
  • The proper treatment protocol will depend on a number of factors, including:
    • Size of the tumor.
    • Stage of the disease.
    • Type of breast cancer.
    • Estrogen-receptor status and progesterone receptor levels.
    • Patient’s age, general health and menopausal status

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Progesterone Receptor Status Significantly Improves Outcome Prediction Over Estrogen Receptor Status Alone for Adjuvant Endocrine Therapy in Two Large Breast Cancer Databases . Journal of Clinical Oncology, Vol 21, Issue 10 (May), 2003: 1973-1979

  • womenwith Estrogen receptor (ER)-positive tumors derive significant benefit from 5 yearsof tamoxifen in reducing the odds of recurrence and death.
  • Whereaswomen with ER-negative tumors do not. This benefit is directlyproportional to the level of ER, with patients with higher tumorER levels deriving the greatest benefit from therapy.

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Women with systemicallyuntreated ER-positive/PgR-positive tumors have better clinicaloutcomes compared with women with ER-negative/PgR-negative tumors,

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P. V. Maynard. Estrogen Receptor Assay in Primary Breast Cancer and Early Recurrence of the Disease. CANCER RESEARCH 38. 4292-4295. 2006.

In this study:

  • It was found that poorly differentiated estrogen receptor-negative tumors recurred earlier than poorly differentiated receptor-positive tumors and had a very unfavorable prognosis.

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Treatment

  • Radical mastectomy (removal of the entire breast, underlying muscles and all axillary nodes) rarely is used today as a primary surgical therapy unless breast cancer is advanced at the time of DX

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Treatment

  • Modified surgical techniques (mastectomy plus axillary dissection or lumpectomy for breast conservation) accompanied by chemotherapy or radiation therapy have acheived outcomes comparable with those obtained with radical surgery methods

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tamoxifen nolvadex
Tamoxifen (Nolvadex®)
  • Tamoxifen is a nonsteroidal antiestrogen that binds to estrogen receptors and blocks the effects of estrogen on the growth of malignant cells in the breast.Tamoxifen blocks a tumor\'s ability to use estrogen
  • Studies shown decreased cancer recurrence, decreased mortality rates, increased 5-year survival rates in women with estrogen receptor positive tissue samples who have been treated with the drug

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aromatase inhibitors
Aromatase Inhibitors
  • Lower the amount of estrogen in post-menopausal women who have hormone-receptor-positive breast cancer.
  • The hormone estrogen delivers growth signals to the hormone receptors. With less estrogen in the body, the hormone receptors receive fewer growth signals, and cancer growth can be slowed down or stopped.

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aromatase inhibitors1
Aromatase Inhibitors
  • Before menopause, the ovaries produce most of a woman\'s estrogen, so reducing estrogen from other sources has little or no effect.
  • But in post-menopausal women, most of the body\'s estrogen is made from another hormone, androgen.
  • Aromatase inhibitors stop the enzyme called aromatase from turning androgen into estrogen, lowering the amount of estrogen produced OUTSIDE the ovaries. That means less estrogen in the bloodstream, less estrogen reaching estrogen receptors, and less cancer cell growth.

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The three aromatase inhibitors have some similar and some different indications for use:
    • Arimidex is approved by the FDA for women with early-stage disease right after surgery.
    • Aromasin is approved by the FDA for women with early-stage disease who have completed two to three years of tamoxifen.

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Femara is approved by the FDA for women with early-stage disease right after surgery. Femara is also approved by the FDA for women with early-stage disease who have completed five years of tamoxifen.
  • All three aromatase inhibitors are also approved for women with advanced (metastatic) disease.

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autologous bone marrow trasplantation and peripheral stem cell transplantation
Autologous Bone Marrow Trasplantation and Peripheral Stem Cell Transplantation
  • Are experimental therapies that may be used for the RX of advanced disease or in women at increased risk for recurrence

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Preventive Surgery

  • Women at extremely high risk for breast cancer, such as those with BRCA gene mutations and a strong family history of the disease, may consider preventive surgery.
  • This may include preventive mastectomy or oophorectomy (removal of the ovaries).

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targeting protein s14 in breast cancer treatment 2006
Targeting Protein S14 In Breast Cancer Treatment, 2006
  • Recently scientists from the University of Manchester have discovered a protein potentially involved in the spread or "metastatic progression" of tumors.
  • Their findings could lead to new approaches to treating breast cancer as blocking the protein\'s actions has the potential to stop malignant cells migrating. "What scientist have identified is a new role for a protein called LPP,".

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progress in understanding of breast cancer cell migration 2006
Progress In Understanding Of Breast-Cancer Cell Migration2006
  • "Until now, this protein was only thought to function at the cell periphery but it was shown that it works in conjunction with another protein - PEA3 - in the cell nucleus".
  • "PEA3 has already been implicated in the spread of breast cancer but scientists have found that the LPP molecule is essential for the correct function of PEA3".
  • "If scientists can target the LPP protein and stop it from working in malignant cells, we will have a possible new route to treatment

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new options in breast cancer
New Options In Breast Cancer
  • Lapatinib (Tykerb) is a new breast cancer drug currently undergoing for patients with breast cancer who have over expression of (human epidermal growth factor receptor-2 (HER2) gene, which promotes the growth of cancer cells.
  • HER2-positive breast cancers tend to be more aggressive than other types of breast cancer. They\'re also less responsive to hormone treatment.

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A new clinical study has demonstrated that Lapatinib is an effective treatment for breast cancer patients who may have HER2 gene over expression and are not controlled by Herceptin, which is the most common drug used in that setting.........

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nursing management
Nursing Management
  • Nursing Diagnosis:Fear and ineffective coping related to the diagnosis of breast cancer, its treatment, and prognosis.
  • Goal:Reduction of emotional stress, fear, and anxiety.

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nursing management1
Nursing Management
  • Nursing Diagnosis:Disturbed body image related to nature of surgery and side effects of radiation and/or chemotherapy.
  • Goal:Realistic adaptation to changes that will occur relative to treatment modalities.

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nursing management2
Nursing Management
  • Nursing Diagnosis:Acute pain related to tissue trauma from incision.
  • Goal:Absence of pain and discomfort.

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nursing management3
Nursing Management
  • Nursing Diagnosis:Dressing/grooming, bathing/hygiene self-care deficit related to partial immobility of upper extremity on side of breast surgery.
  • Goal:Avoidance of impaired mobility and achievement of self-care to the fullest possible level.

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nursing management4
Nursing Management
  • Nursing Diagnosis:Possible sexual dysfunction related to loss of body part and fear of partner’s reaction to this loss.
  • Goal:Identification of alternative satisfying/acceptable sexual experience.

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nursing management5
Nursing Management
  • Collaborative Problem:Infection, injury, lymphedema, neurovascular deficits.
  • Goal:Avoidance of complications.

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the following life styles may contribute to a decreased risk of disease development
The following life styles may contribute to a decreased risk of disease development:
  • Limiting alcohol consumption.
  • Maintaining a healthy weight.
  • Consulting a physician regarding alternatives to take estrogen or other hormones.
  • Incorporating physical activity into daily life.
  • Eating foods high in fiber and low in fat.
  • Eating plenty of fruits and vegetables.

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Breast cancer news, 2007

Addressing Problem of Breast Cancer

Prevention

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A new study in the "Journal of Clinical Oncology" reinforces current evidence showing that women with breast cancer can greatly reduce their risk of recurrence by:
    • eating a healthy plant-based diet rich in fruits and vegetables
    • making other healthy lifestyle choices

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"Women coping with breast cancer deserve to know that plant-based diets and regular exercise can spell the difference between life and death,"
  • "In the battle against breast cancer, fruits, vegetables, and other low-fat vegetarian foods may be our most powerful weapons.
  • Let women know that diet changes and exercise can help them beat this terrible disease".

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The new study, conducted by scientists with the University of California, tracked dietary patterns and exercise habits among about 1,500 women who were diagnosed with early-stage breast cancer
  • It observed that the death rate for women who consumed a high-fiber diet rich in fruits and vegetables and practiced good exercise habits was 44% lower than the rate for women who exercised little and ate few plant-based foods.

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