Breast Cancer A Resource Guide For Minority Women October 2015

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Breast CancerA Resource Guide for Minority Women October 2015Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource CenterOMHRESOURCECENTER 1

ContentsOverview of Breast CancerAbout This GuideRisk FactorsStatisticsMammogram InformationFederal Agencies and ProgramsNational Organizations/ProgramsState ProgramsTribal ProgramsCommunity-Based ProgramsResourcesReferencesBreast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center34579131927293034372

Overview of Breast CancerBreast cancer is the most common cancer among women in the U.S. and the second leading cause of cancer death among women. Every year, about 200,000 newcases of breast cancer are reported nationwide and more than 40,000 women diefrom the disease. Getting mammograms regularly can help prevent breast cancer.Minority women aremost likely to haveadvanced breast cancer when the canceris first discovered.Minority women are most likely to have advanced breast cancer when the canceris first discovered. Although white women are more likely to get breast cancer,African American women are the most likely to die from it. Women of other ethnicbackgrounds (Asian, Hispanic and Native American) have a lower risk of developingand dying from breast cancer than white women and African American women.It is thought that social determinants such as access to care, living conditions andpoverty, as well as cancer risk and genetic factors, all contribute to this disparity.Early detection, diagnosis and treatment is a vital tool in reducing breast cancerdeaths in minority women.Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center3

About This GuideThe goal of this guide is to provide information that informs and provides a sourcefor needed services that can be accessed by women of color.The lists of organizations, documents,programs and otherresources are relevantto people withbreast cancer,students, healthcare professionalsand researchers.The Office of Minority Health Resource Center (OMHRC) has compiled the followingResource Guide for those interested in breast cancer resources. The lists of organizations, documents, programs and other resources are relevant to people with breastcancer, students, health care professionals and researchers.While OMHRC has taken great care in the preparation of this publication, it is notintended to be used as a substitute for the expertise of a qualified health care professional. It is the responsibility of the reader to review the information to determinetheir appropriateness for the intended audience.Inclusion does not imply endorsement by the OMHRC, the Office of Minority Healthor the U.S. Department of Health and Human Services. Organizations included inthis listing should be contacted directly to determine the cost and availability ofservices and information.Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center4

Risk FactorsArisk factor is anything that increases your chance of getting a disease. Differentdiseases have different risk factors. Some risk factors like gender or geneticmakeup can’t be changed. Other risk factors such as smoking, diet and physical activity can be controlled via behavioral choices.Most women havesome risk factors andmost women do notget breast cancer.However, it is possible to have breastcancer without having any of the knownrisk factors.The risk of breast cancer is not the same for all women. Having a risk factor does notmean you will get the disease, and not all risk factors affect your risk to the same extent. Most women have some risk factors and most women do not get breast cancer.However, be advised it is possible to have breast cancer without having any of theknown risk factors.The infographic found in the following link and on the next page illustrates the risksfor breast cancer: http://www.cdc.gov/cancer/breast/basic info/infographic.htmRisk Factors continued on next page.Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center5

Breast Cancer: Know the RisksMany things can increase the chance that you’ll get breast cancer. They’re called risk factors.Some things you can change. Others you can’t.LifestyleGet at least4 hours ofexerciseeach week.Keep ahealthy weight,especially aftermenopause.MenstruationStartingmenopause(the “changeof life”) afterage 55.Startingyour periodbeforeage 12.Limit alcoholicdrinks toone per THWETUMOSUSAFRTHWETUMOSUSAFRHaving childrenafter age 35 ornever havingchildren.Notbreastfeedingyour babies.If you’re takinghormone replacementtherapy (HRT), ask yourdoctor if you need it.Other Risk FactorsFamily History & GeneticsRelatives withbreast cancer orovarian cancerat a young age.Changes in theBRCA1 or BRCA2genes related tobreast cancer.Some types of HRT increase your riskfor breast cancer and can cause “dense breasts”(more breast tissue than fat tissue). Densebreasts increase your risk forbreast cancer and make it harder for amammogram to find cancer.Gettingolder.Radiationtreatment tothe chest area.Breast canceror certain otherbreast problemsin the past.Having one or more of these risks doesn’t mean you’ll get breast cancer. Also, some women have breast cancereven when they don’t have any of these risks. So, talk to your doctor about what you can do to lower your risk,and the right screening for you.No insurance? You may be able to get free or low-cost screening through CDC's National Breast and Cervical Cancer EarlyDetection Program. Call (800) CDC-INFO or scan this QR code.National Center for Chronic Disease Prevention and Health PromotionDivision of Cancer Prevention and ControlBreast Cancer Resource Guide for Minority Women Office of Minority Health Resource CenterMore information about breast cancer: www.cdc.gov/cancer/breast/6

StatisticsAfrican Americans A frican American females have the highest age-adjusted breast cancer incidencerates among all minority groups—a rate of 127.3 new cases per 100,000.1 A frican American females have the highest breast cancer death rate among allwomen—28.3 per 100,000 population.2 A frican American females experience higher death rates from breast cancer thanany other racial or ethnic group, even though whites experience higher incidencerates.3127.3 new casesper 100,000Death rate of 28.3per 100,000 C ancer is the second leading cause of death for African American females , whoare more likely than other females to die from breast and cervical cancers. Thisis usually because abnormal cells or tumors are found at a later, more advancedstage.4 A frican Americans females are more likely to die of cancer than are whites andmore than two times more likely to die of cancer than are Asians, Pacific Islanders,American Indians/Alaska Natives and Hispanics.5 T he overall five-year survival rate for breast cancer among African Americanfemales has improved from approximately 27 percent since the 1960s. However,African Americans continue to have a lower five-year survival rate than whitesoverall (60 percent vs. 69 percent).6American Indians or Alaska Natives A merican Indian and Alaska Native females have the third highest age-adjustedbreast cancer incidence rates among minority groups—a rate of 104.0 new casesper 100,000.7104 new casesper 100,000 6 2.6 percent of American Indian and Alaska Native females (age adjusted, aged 40years and over) report receiving a mammogram within a two-year period.8Death rate of 10.1per 100,000 A merican Indian and Alaska Native females have a lower breast cancer deathrate— 10.1 per 100,000 population – than white and African American females.9Asian Americans or Pacific Islanders A sian and Pacific Islander females have an age-adjusted breast cancer incidencerate of 100.8 new cases per 100,000.10 O nly 56 percent of Asian females 40 years and older report having a mammogramwithin a two-year period.11 A sian American and Pacific Islander females have lower breast cancer mortalityrates—11.1 per 100,000— than white, Hispanic, African American, American Indianand Alaska Native females.12100.8 new casesper 100,000Death rate of 11.1 per100,000 N ative Hawaiians have the highest death rate from breast cancer than any groupin the U.S.13See page 36 for references.Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource CenterStatistics continued on next page.7

StatisticsHispanics H ispanic/Latina females have a breast cancer incidence rate of 95.0 per 100,000—fourth among minority females. 14 H ispanic/Latina females have a breast cancer death rate of 14.6 per 100,000—thirdhighest behind African American and white females. 15 F ive-year cause-specific survival rates for local, regional and distant-stage breastcancer diagnosed in Hispanic females are 96 percent, 83 percent and 26 percent,respectively. 1695.5 new casesper 100,000Death rate of 14.6per 100,000See page 36 for references.To see additional statistics on breast cancer in minority populations, visit the Office of MinorityHealth website at www.minorityhealth.hhs.gov. African Americans: http://minorityhealth.hhs.gov/omh/browse.aspx?lvl 4&lvlid 16 American Indians/Alaska Natives: http://minorityhealth.hhs.gov/omh/browse.aspx?lvl 4&lvlid 31 Asian Americans: http://minorityhealth.hhs.gov/omh/browse.aspx?lvl 3&lvlid 63 Hispanic Americans: http://minorityhealth.hhs.gov/omh/browse.aspx?lvl 4&lvlid 61 N ative Hawaiians and Other Pacific Islanders: http://minorityhealth.hhs.gov/omh/browse.aspx?lvl 4&lvlid 76Breast cancer may occur in males.Males at any age may develop breast cancer, but it is usually detected (found) in males between60 and 70 years of age. Males make up less than 1 percent of all cases of breast cancer.(Source: east-treatment-pdq).For more information on breast cancer in males please review the following links:American Cancer org/symptoms/types/male bcHis Breast Cancer Awareness:http://www.hisbreastcancer.org/Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center8

Mammogram InformationGetting a MammogramA mammogram is an X-ray picture of the breast. Doctors use a mammogram to look for early signs of breastcancer.Regular mammograms are the best tests doctors haveto find breast cancer early, sometimes up to three yearsbefore it can be felt. When breast cancer is found early,many women go on to live long and healthy lives.plate. Another plate will firmly press your breast fromabove.The plates will flatten the breast, holding it still whilethe X-ray is being taken. You will feel some pressure.The other breast will be X-rayed in the same way.The steps are then repeated to make a side view ofeach breast. You will then wait while the technologistchecks the four X-rays to make sure the pictures do notneed to be re-done. Keep in mind that the technologistcannot tell you the results of your mammogram.What does having a mammogram feel like?Having a mammogram is uncomfortable for mostwomen. Some women find it painful.A mammogram takes only a few moments, though,and the discomfort is over soon. What you feel dependson the skill of the technologist, the size of your breastsand how much they need to be pressed. Your breastsmay be more sensitive if you are about to get or haveyour period.A doctor with special training, called a radiologist, willread the mammogram. He or she will look at the X-rayfor early signs of breast cancer or other problems.Mammograms for women over age 40 are coveredunder the Affordable Care Act. Depending on your insurance plan, you may be able to get mammograms atno cost to you. Talk to your insurance provider, or learnmore at: www.Healthcare.gov T ry not to have your mammogram the week beforeyou get your period or during your period. Yourbreasts may be tender or swollen then. O n the day of your mammogram, don’t wear deodorant, perfume or powder. These products can show upas white spots on the X-ray. S ome women prefer to wear a top with a skirt orpants, instead of a dress. You will need to undressfrom your waist up for the mammogram.How is a mammogram done?When will I get the results of my mammogram?You will usually get the results within a few weeks,although it depends on the facility. A radiologist readsyour mammogram and then reports the results to youor your doctor.If there is a concern, you will hear from the mammography facility earlier. Contact your health professionalor the mammography facility if you do not receive areport of your results within 30 days.What happens if my mammogram is normal?Continue to get regular mammograms.Mammograms work best when they can be comparedwith previous ones. This allows your doctor to comparethem to look for changes in your breasts over time.You will stand in front of a special X-ray machine. Atechnologist will place your breast on a clear plasticMammografy Information continued on next page.Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center9

Mammogram InformationWhat happens if my mammogram is abnormal?If it is abnormal, do not panic.An abnormal mammogram does not always mean thatthere is cancer. But you will need to have additionalmammograms, tests or exams before the doctor cantell for sure.You may also be referred to a breast specialist or asurgeon. These doctors are experts in diagnosingbreast problems. It does not necessarily mean you havecancer or need surgery.Where can I get a mammogram and who can I talk to ifI have questions?An example of anormal mammogram. Each woman’smammogram maylook a little differentbecause all breastsare a little different. If you have a regular doctor, talk to him or her. C all the National Cancer Institute’s Cancer Information Service (CIS) at 1-800-4-CANCER (1-800-4226237). TTY: 1-800-332-8615. F or Medicare information, you can call 1-800 MEDICARE (1-800-633-4227) or visithttps://www.medicare.gov/ C DC’s National Breast and Cervical Cancer Early Detection Program works with health departments andother groups to provide low-cost or free mammograms to women who qualify. Find out if you qualify.Source CDC: ams.htmMammografy Information continued on next page.Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center10

Percent of women having a mammogram withinthe past 2 years as of 2013. 40 years and over, crude:198719931994200020032005200820102013White only29.660.060.671.470.170.167.967.466.8Black or AfricanAmerican only24.059.164.367.870.470.468.067.967.1American Indian orAlaska Native only*49.865.847.463.163.162.771.262.6Asian 1.265.065.061.264.261.4Native Hawaiian orOther PacificIslander only———******2 or more ina* Estimates are considered unreliable. Data precededby an asterisk have a relative standard error (RSE) of20 percent–30 percent. Data not shown have an RSEgreater than 30%.Source: Health US 2014, Table 76 (page 1 of 3). Use ofmammography among women aged 40 and over, byselected characteristics: United States, selected s14.pdf— Data not availableMammografy Information continued on next page.Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center11

Additional Source for Native Hawaiian or Other PacificIslander only: Native Hawaiian Data Book 2013Mammograms among Women by Race-Ethnicity and AgeGroup in Hawai’i: 2012 Table 7.80a UpdatedRaceAged 18 ever had amammogramLastmammogramwithin 2 yrsAged 40 ever had amammogramMost recentmammogramwithin 2 ce: Hawai’i State Department of Health. Behavior Risk Factor Surveillance ore information on American women and mammogram utilization can befound at this interactive site: http://www.healthypeople.gov/Data 2020, the Healthy People 2020 interactive tool, allows users to exploredata and technical information related to Health People 2020 objectives. Screening such as mammography is effective as a preventive tool in early detection ofbreast cancer.Chart source: Women receiving a mammogram within past 2 years (ageadjusted, percent, 50–74 years) By ata/Chart/4055?category 3&by Race/Ethnicity&fips -1&years%5b2%5d 2013Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center12

Federal Agencies and ProgramsThere are several agencies within the U. S. Department of Health and HumanServices (HHS) that have programs targeting all aspects of breast cancer,including education, mammography, outreach, prevention, research and treatment.Below are descriptions of several programs.Inclusion does not imply endorsement by the OMHRC, the Office of Minority Healthor the U.S. Department of Health and Human Services. Organizations included inthis listing should be contacted directly to determine the cost and availability ofservices and information.For more information on federal breast cancer programs,contact the Office of Minority Resource Center at 800-444-6472 or email info@minorityhealth.hhs.gov.Agency for Healthcare Research and Quality (AHRQ)Office of Communications and Knowledge Transfer540 Gaither RoadRockville, MD 20850301-427-1364http://www.ahrq.govCenters for Disease Control and Prevention (CDC)1600 Clifton RoadAtlanta, GA 30333800-CDC-INFO (800-232-4636)404-639-3311http://www.cdc.govAHRQ is the lead agency charged with supportingresearch designed to improve the quality of health care,reduce its cost, improve patient safety, decrease medical errors and broaden access to essential services.CDC, recognized as the lead federal agency for protecting the health and safety of people at home andabroad, provides credible information to enhancehealth decisions and promotes health through strongpartnerships. The CDC serves as the national focus fordeveloping and applying disease prevention and control, environmental health, and health promotion andeducation activities designed to improve the health ofthe people of the United States.AHRQ sponsors and conducts research that providesevidence-based information on health care outcomes,quality, cost, use and access. The information helpshealth care decision makers— including patients, clinicians, health system leaders and policymakers—makemore informed decisions and improve the quality ofhealth care services.Federal Agencies and Programs continued on next page.Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center13

Federal Agencies and ProgramsCDC resources continued. Division of Cancer Prevention and ControlNational Center for Chronic Disease Prevention andHealth PromotionCenters for Disease Control and Prevention3719 N Peachtree RoadBldg. 100MS F-76Chamblee, GA 30341888-842-6355http://www.cdc.gov/cancer/The Division of Cancer Prevention and Control(DCPC) conducts, supports and promotes effortsto prevent cancer and to increase early detectionof cancer. DCPC works with its partners—includingstates, tribes/tribal organizations, territorial healthagencies, other federal agencies, voluntary andprofessional organizations, academia and businesses—to carry out the following activities: monitoring,conducting research and evaluation, building capacity and partnerships, education, training and information services. Health Disparities: Minority Cancer sDCPC works to eliminate barriers to screening andearly detection of cancer among minorities byimplementing community-based education programs targeting minorities, tracking cancer amongminorities, implementing community-based education programs targeting minorities, tracking cancerrates among minority populations, and conducting,supporting and encouraging research that includesminority populations. A ppropriate referrals, and when necessary, appropriate diagnostic follow-up, case management andassurances for medical treatment P ublic information and education to increase theuse of screening services E ducation to health professionals to improve thescreening process M echanisms to monitor the quality of the screening process A ppropriate surveillance and epidemiologicalsystems Linkages with key partnershipsNIHSeniorHealth.gov, the websitefor older adults developed by theNational Institute on Aging (NIA)and the National Library of Medicine (NLM), makes aging-relatedhealth information easily accessiblefor family members and friendsseeking reliable, easy to understandonline health information.For breast cancer information helpful to older women, go l National Breast and Cervical Cancer Early DetectionProgram tmNBCCEDP builds the infrastructure for breast andcervical cancer early detection by supporting publicand provider education, quality assurance, surveillance and evaluation activities critical to achievingmaximum utilization of screening, diagnostic andcase management services. The program provides: F ree mammograms as well as breast and cervicalcancer screening services to women who are lowincome and to racial/ethnic minoritiesFederal Agencies and Programs continued on next page.Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center14

Federal Agencies and ProgramsFood and Drug Administration (FDA)10903 New Hampshire AvenueSilver Spring, MD 20993888-INFO-FDA (1-888-463-6332)http://www.fda.govFDA is the federal agency responsible for protectingthe public’s health by assuring the safety, effectiveness,quality and security of human and veterinary drugs,vaccines and other biological products, and medicaldevices. The FDA is also responsible for the safety andsecurity of most of our nation’s food supply, all cosmetics, dietary supplements and products that give offradiation. FDA-Approved pprovedDrugs/ucm279174.htmThis webpage contains information about approvedHematology/Oncology (Cancer) Approvals & SafetyNotifications. The site also includes advice on how toobtain access to unapproved drugs via clinical trials. Pink Ribbon Sunday MammographyAwareness .pdfThe FDA Office of Women’s Health launched the PinkRibbon Sunday Mammography Awareness Programto educate African American and Hispanic womenabout early detection of breast cancer through mammography.The program strives to reduce breast cancer healthdisparities by providing community leaders with freeresources to develop mammography awareness programs tailored to the needs of their region.Health Resources and Services Administration (HRSA)5600 Fishers Lane, Room 14-45Rockville, MD 20857http://www.hrsa.govHRSA’s mission is to improve and expand access toquality health care for all. HRSA’s key program areasinclude HIV/AIDS services, the Ryan White CARE Act,primary health care, maternal and child health, healthprofessions, special programs and rural health policy. HRSA Community Health Center (CHC) Programhttp://findahealthcenter.hrsa.gov/This program, run through HRSA’s Bureau of PrimaryHealth Care, provides primary and preventive care,including mammography and clinical breast exams,in underserved areas of the country. A large numberof users are underserved women.National Institutes of Health (NIH)9000 Rockville PikeBethesda, MD 20892301-496-4000http://www.nih.govComprised of 27 separate components, mainly Institutes and Centers, the National Institutes of Health(NIH) are one of the world’s foremost biomedical research centers, and the federal focal point for biomedical research in the United States.NIH conducts research in its own laboratories; supportsthe research of non-federal scientists in universities,medical schools, hospitals and research institutionsthroughout the country and abroad; helps in the training of research investigators; and fosters communication of medical information. FDA Mammography cfdocs/cfMQSA/mqsa.cfmFDA regulates the standards for mammographymachines and training for the people who givemammograms. FDA also certifies the places that givemammograms in the U.S., under the MammographyQuality Standards Act (MQSA). FDA keeps a list of allcertified places where you can get a mammogram.Federal Agencies and Programs continued on next page.Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center15

Federal Agencies and ProgramsNIH resources continued. National Cancer Institute (NCI)9000 Rockville PikeBethesda, MD 20892-2580800-4-CANCER (800-422-6237)http://cancer.govThe National Cancer Institute (NCI) is the nation’sprimary agency for conducting and coordinatingfederally sponsored research on the diagnosis, treatment and prevention of cancer. NCI has establisheda cancer control effort that emphasizes smokingprevention and cessation, dietary modification toprevent cancer, early detection of cancer through effective screening and widespread application of thelatest achievements in treatment research.The NCI web site contains reliable information aboutcancer for patients, health professionals and peopleat-risk for cancer. The site offers information on specific types of cancer with information on prevention,detection, treatment, statistics, coping and clinicaltrials. Cancer.gov also provides fact sheets and clinical trial information. NCI Cancer Genetics Services prevention/genetics/directory/descriptionThis is a directory of individuals who provideservices related to cancer genetics.These services include: Cancer genetics risk assessment Genetic counseling Genetic susceptibility testing NCI Contact Center-Cancer Information Service800 4 The NCI Contact Center (also known as NCI’s CancerInformation Service) is a federally funded cancereducation program that was established in 1975 asan essential part of NCI’s mission and informationefforts. The CIS also responds to calls in English andSpanish, Monday through Friday 8:00 a.m. to 8:00p.m. ET. They also respond to email (http://www.cancer.gov/contact/email-us) and live chat (http://www.cancer.gov/contact) is available in English only8:00 a.m. to 11:00 p.m. ET. University of Hawai’i Cancer Center701 Ilalo Street, Suite 600Honolulu, HI 96813808-586-3010808-586-3052 Faxhttp://www.uhcancercenter.org/The University of Hawai’i Cancer Center is the onlyNCI-designated center in Hawai’i and the Pacific. Thecenter’s mission is to reduce the burden of cancerthrough research, education and patient care with anemphasis on the unique ethnic, cultural and environmental characteristics of Hawai’i and the Pacific. Thecenter is a research organization affiliated with theUniversity of Hawai’i at Manoa with facilities locatedin downtown Honolulu and Kaka‘ako. NCI Center to Reduce Cancer HealthDisparities (CRCHD)National Cancer Institute9609 Medical Center DriveMSC 97466th Floor, West TowerBethesda, MD 20892240-276-6170240-276-7862 chdThe Center to Reduce Cancer Health Disparities(CRCHD) is central to NCI’s efforts to reduce theunequal burden of cancer in our society via basicand community research, as well as networks, and totrain the next generation of competitive researchersfrom diverse populations in cancer and cancer healthdisparities research. Division of Cancer Control and Population Sciences9609 Medical Center DriveMSC 9769Bethesda, MD 20892http://cancercontrol.cancer.gov/The Division of Cancer Control and Population Sciences (DCCPS) aims to reduce risk, incidence anddeaths from cancer as well as enhance the quality oflife for cancer survivors. The division conducts andsupports an integrated program of the highest quality genetic, epidemiologic, behavioral, social, appliedand surveillance cancer research.Federal Agencies and Programs continued on next page.Breast Cancer Resource Guide for Minority Women Office of Minority Health Resource Center16

Federal Agencies and ProgramsNIH resources continued. State Cancer Profileshttp://statecancerprofiles.cancer.gov/The State Cancer Profiles website is a comprehensive system of interactive maps and graphs enablingthe investigation of cancer trends at the national,state and county level. The goal of the site is toprovide statistics to help guide and prioritize cancercontrol activities at the state and local levels. It is acollaboration between the NCI and the Centers forDisease Control & Prevention (CDC). National Institute of Environmental HealthSciences (NIEHS)11 T.W. Alexander DriveResearch Triangle Park, NC 27709919-541-3345http://www.niehs.nih.govThe mission of the National Institute of Environmental Health Sciences (NIEHS) is to discover howthe environment affects people in order to promotehealthier lives. Breast Cancer and the EnvironmentResearch Programhttp://www.bcerc.orgThe Breast Cancer and the Environment ResearchCenters (BCERC) study the impact of prenatal-to-adult environmental exposures that maypredispose a woman to breast cancer. Functioningas a consortium of basic scientists, epidemiologists,research translational units and community advocates within and across centers, BCERC investigatesenvironmental agents that may influence breastcancer development in adulthood. National Lib

Breast Cancer Resource Guide for Minority Women OfThce of Minority Health Resource Center Breast cancer is the most common cancer among women in the U.S. and the sec-ond leading cause of cancer death among women. Every year, about 200,000 new cases of breast cancer are reported nationwide and more than 40,000 women die from the disease.

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