Finding Your Strength Through Knowledge: Proceedings from the San Antonio Breast Cancer Symposium

Cancer Risk Associated with Nitrates and Nitrites from Food Additives and the Consumption of Artificial Sweeteners: Results from the NutriNet-Santé Cohort

Nitrates and nitrites are found in nature in water and soil and are typically consumed through drinking water and eating.1 They’re also utilized in processed meats as a food additive to extend shelf life and prevent bacterial growth.1 These chemicals may have a role in processed meat’s carcinogenicity.1

The harmful effects of added sugars have been linked to several chronic diseases, prompting food manufacturers to utilize artificial sweeteners as a substitute in a variety of meals and beverages.2 Artificial sweeteners are found in more than 10,000 foods and beverage brands sold around the world. Their safety is debatable, and results from studies on their significance in causing numerous disorders are contradictory.2 Several studies have demonstrated that they are carcinogenic, although strong data are absent.2

The French NutriNet-Santé cohort study was carried out using more than 100,000 participants who were followed over a period of 12 years using extensive and current dietary assessments.1,2 The links between nitrate/nitrite and sweetener intakes and cancer risk were explored.1,2

Greater consumers of nitrates from food additives had a higher incidence of breast cancer than nonconsumers; this was especially true for potassium nitrate.1 Higher consumption of nitrites, specifically sodium nitrite, from food additives was linked to an increased risk of prostate cancer.1 Natural sources of nitrates and nitrites showed no significant correlation.1

Overall cancer risk was increased in higher users of total sweeteners (ie, above the average exposure among consumers) compared with nonconsumers.2 Aspartame and acesulfame-K were found to be linked to an increased risk of cancer.2 Similarly, breast cancer had a greater risk for total sweeteners, aspartame, and acesulfame-K.

Food additive nitrates and artificial sweeteners (particularly aspartame and acesulfame-K) were linked to a higher risk of breast cancer, while food additive nitrites were linked to a higher risk of prostate cancer in this large prospective cohort.1 Although these findings will need to be confirmed in future large-scale investigations, they provide new information in the midst of a heated debate over the use of nitrate additions in food.1 These findings on artificial sweeteners add to the ongoing re-evaluation of food additive sweeteners by the European Food Safety Authority and other health organizations throughout the world.2

African American Women May Have Distinctive Molecular Breast Cancer Features

Despite having a lower breast cancer incidence, African American women have disproportionately worse outcomes, including more aggressive malignancy, higher mortality rates, and a greater incidence of triple-negative breast cancer.3 The cause of these differences is unknown, but it could be due to differences in biologic and molecular characteristics.3 Targetable molecular profiles for breast cancer in African Americans are scarce, and may not be representative of racial minorities.3 To enhance therapy and outcomes for African American women with breast cancer, a greater understanding of actionable targets is required.3

Researchers used genetic data from 3 breast carcinoma investigations (Cell 2015, Firehose Legacy, and PanCancer Atlas).3 The most commonly affected genes, the most significantly altered genes across the 2 populations, and 35 actionable genes were identified after stratifying the data by Caucasian/white and African American/black.3 Genes were examined between racial subgroups (455 African American cases, 2103 Caucasian cases), and data were analyzed for differences.3

There were 2282 genes that were different between white and black subgroups. Only 3 of the most commonly altered genes (TP53, PIK3CA, and CSMD1) were significantly different between African Americans and Caucasians.3 Missense mutations in PIK3CA were found to be more prevalent in Caucasians.3 In African Americans, missense mutations in the TP53 gene were more common.3 A number of genes were found to be significantly different between African Americans and Caucasians in terms of actionable targets.3 In a survival analysis, African American women with PIK3CA alterations had significantly worse outcomes, whereas Caucasian women with PIK3CA alterations had significantly better outcomes.3

In breast cancer, there are significant and complex molecular variations between African American and Caucasian subgroups.3 Many of these molecular changes are associated with specific treatment options.3 The findings suggest that thorough molecular profiling could play a key role in evaluating treatments for breast cancer patients, and that African American women’s breast cancers may have distinct genetic traits that necessitate different treatment techniques.3

Subgroup Analyses Phase 3 Study of Patients with HER2-Positive Metastatic Breast Cancer Previously Treated with Trastuzumab and Taxane

Trastuzumab deruxtecan (T-DXd) is licensed for the treatment of patients with advanced HER2-positive metastatic breast cancer (mBC).4 DESTINY-Breast03 is a phase 3 trial comparing the efficacy and safety of T-DXd with that of trastuzumab emtansine (T-DM1) in patients with HER2-positive mBC or unresectable breast cancer, who have previously had trastuzumab and taxane treatment.4 The study included patients with clinically stable brain metastases as long as there had been ≥2 weeks between the end of their whole brain radiotherapy and study enrollment. T-DXd showed improvement in progression-free survival (PFS) compared with T-DM1.4

The primary outcome was PFS, but subgroups’ PFS and overall response rate (ORR) were also examined.4 Patients (N = 524) were randomly assigned to T-DXd or T-DM1. T-DXd had a better PFS than T-DM1.4 All T-DXd patients benefitted from treatment, regardless of hormone receptor status, prior pertuzumab treatment, presence or absence of visceral disease, number of prior lines of therapy, or brain metastases status (subgroups).4 T-DXd showed an ORR of 79.7% compared with 34.2% for T-DM1. ORR was significantly improved in all T-DXd subgroups compared with T-DM1. Patients with confirmed brain metastases had an ORR of 67.4% with T-DXd compared with an ORR of 20.5% in the T-DM1 group.4 Approximately one-third of T-DXd patients (32.2%) had progressive disease, compared with 58.9% T-DM1 patients.4 Overall, T-DXd’s safety profile was reasonable and equivalent to what was previously known.4

The primary goal of DESTINY-Breast03, the first-ever randomized phase 3 trial comparing T-DXd with standard of care, was met, with T-DXd displaying improved PFS compared with T-DM1.4 In this exploratory investigation, patients with HER2-positive mBC previously treated with trastuzumab and taxane showed a consistent PFS and ORR advantage with T-DXd compared with T-DM1.4 In patients with and without brain metastases, T-DXd treatment resulted in greater efficacy compared with T-DM1. T-DXd treatment is also associated with a substantial intracranial response and reduction in central nervous system disease, while maintaining a manageable safety profile.4

A Phase 3 Trial of Adjuvant Olaparib After (neo)-Adjuvant Chemotherapy: Quality-of-Life Results

After an interim analysis revealed statistically significant invasive disease-free survival (DFS) improvement from 1 year of olaparib compared with placebo after a median of 2.5 years of follow-up, the primary results from the OlympiA study were recently published.5 Despite the fact that olaparib had fewer deaths than placebo, overall survival (OS) did not meet the statistical significance level for interim analysis.5 The initial publication also included information on the adverse event profile, which was similar to that previously reported.5

The OlympiA phase 3 trial examined the impact of 1 year of adjuvant olaparib after completion of (neo)adjuvant chemotherapy and definitive local therapy on invasive DFS, distant DFS, and OS.5 Gastrointestinal symptoms (nausea, vomiting, and diarrhea) and several quality-of-life (QOL) outcomes were measured.5 It was suspected that patients treated with olaparib would have more severe fatigue at 6 and 12 months.5 It was also suspected that patients receiving olaparib may have more severe gastrointestinal symptoms at 6 and 12 months, but no difference by 24 months and no difference in fatigue severity post-treatment at 18 and 24 months, and no difference in QOL between olaparib and placebo over the course of the study.5

The study included 1751 patients.5 There were no differences in baseline QOL and symptom scores between olaparib and placebo.5 At 6 and 12 months, as suspected, fatigue severity was significantly higher in patients treated with olaparib than in those treated with placebo.5 At 18 and 24 months, there were no significant variations in fatigue severity.5 Nausea and vomiting were worse in patients treated with olaparib than in patients treated with placebo, with small differences at 6 and 12 months, and no differences at 18 and 24 months.5 In terms of other symptoms and QOL, there were no significant differences between olaparib and placebo.5 With olaparib, the increased treatment-emergent symptoms were minor and disappeared after treatment.5 During the first 24 months after (neo)adjuvant treatment, QOL scores were similar and gradually improved.5

First Real-World Data from the French Temporary Authorization for Use Program in Patients with HER2-Positive Breast Cancer Treated with T-DXd

Trastuzumab deruxtecan (T-DXd) has been shown to be effective and safe for HER2-positive metastatic and/or unresectable breast cancer in patients relapsing after ≥2 anti-HER2–based treatments.6 It was shown to improve overall survival and delay progression of disease.6 The French Health Agency grants fast access to novel pharmaceuticals outside of clinical trials and prior to usual drug registration for certain indications through what is called the cohort temporary authorization for use (cATU) program.6 The first real-world evidence data from the cATU program in patients with HER2-positive breast cancer treated with T-DXd are shown here.6

In patients with HER2-positive metastatic and/or unresectable breast cancer who had previously undergone ≥2 lines of anti-HER2 regimens in the metastatic context, T-DXd was given intravenously every 3 weeks as the only treatment.6 Patients had to meet certain criteria to be eligible for the study.6 Clinical, biological, and safety data, as well as treatment response, were recorded.6 On March 31, 2021, an analysis was carried out using the data that had been obtained.6

Between September 30, 2020, and March 31, 2021, 459 patients received T-DXd.6 Most (90.1%) of the patients were women, with an average age of 58 years.6 The majority (98.9%) had HER2-positive breast cancer, and 67% had hormone receptor–positive breast cancer.6 Common locations of cancer spread (metastases) were bones, lymph nodes, lungs, liver, and brain.6 The median period between primary breast cancer diagnosis and inclusion in the study was 6.6 years (range, 6.6 months-33.9 years).6 More than three-fourths (76.5%) of patients had undergone surgery and 81.7% had previously received radiation.6 In the metastatic context, the average number of previous cancer treatments was 4.6 Nearly one-fifth (21.1%) had 2 previous lines of metastatic treatment, 19.6% had 3, and 59.3% had ≥4.6 Prior trastuzumab emtansine was given to 94.8% of patients, while prior pertuzumab was given to 79.3%.6 Data on tumor assessment were provided for 160 patients during follow-up.6 A complete or partial response was observed in 56.7% of patients, while 12.1% progressed.6 Of the 459 patients treated, 21.1% had ≥1 adverse drug reactions (ADRs), with 8.9% having ≥1 significant ADRs.6 The most common ADRs involved gastrointestinal toxicity (35.4%).6 There were 13 fatal cases reported but none were drug-related deaths.6 Four patients had ADRs that resulted in T-DXd discontinuation (0.9%).6 Dose decreases were observed in 3.7% of patients and temporary suspensions in 4.6%.6

The enrollment of 468 patients in just 6 months demonstrated the population’s unmet medical needs.6 T-DXd demonstrated anticancer efficacy, with a response rate that was equivalent to that seen in earlier clinical trials.6 T-DXd was well-tolerated, with no additional safety concerns found.6

Gastrointestinal Toxicity Is Prevalent with Antibody–-Drug Conjugate (ADC) Treatment in Metastatic Breast Cancer

Antibody–drug conjugates (ADCs) are a new class of drugs, which are being developed to selectively target tumor cells and minimize adverse effects.7 Three ADCs, trastuzumab emtansine (T-DM1), sacituzumab govitecan, and trastuzumab deruxtecan, are currently approved for the treatment of metastatic breast cancer.7 Gastrointestinal adverse effects are relatively frequent with these agents.7 Researchers analyzed a collection of previous studies to evaluate gastrointestinal adverse events in patients with metastatic breast cancer who were treated with ADCs.7

From commencement to December 2020, searches for phase 2 and phase 3 trials reporting the frequency and severity of gastrointestinal adverse effects in patients treated with ADCs were conducted.7 Data on nausea, vomiting, diarrhea, constipation, and abdominal pain were gathered.7 Toxicity rates were graded as per clinical trial guidelines.7 A prespecified subgroup analysis by each ADC drug was also carried out.7

The researchers looked at 10 studies with a total of 4020 patients.7 Gastrointestinal adverse events were common with sacituzumab govitecan and trastuzumab deruxtecan, but they were mainly minor.7 In comparison to T-DM1, these novel ADCs had significantly greater rates of nausea (65.6% with sacituzumab govitecan, 77.2% with trastuzumab deruxtecan), vomiting (43.7% and 46.6%), and diarrhea (59.7% and 30.2%).7 The most common adverse effects related to treatment with sacituzumab govitecan were diarrhea and vomiting.7 Constipation and abdominal pain were mentioned less frequently.7

In patients with metastatic breast cancer treated with new ADCs, gastrointestinal adverse effects, particularly nausea and diarrhea, are prevalent.7 To maintain the dose intensity of ADCs and enhance patient adherence, it is critical to prevent and treat these adverse effects through timely healthcare interventions.7

Cardiovascular Disease Outcomes and Risk Factors in Breast Cancer Survivors

There are few studies on the long-term risk of cardiovascular disease in breast cancer survivors.8 At Kaiser Permanente Northern California (KPNC), the Pathways Heart Study is assessing cardiovascular disease outcomes and risk factors in women with breast cancer.8 Cardiovascular disease outcomes were assessed using specific codes (ischemic heart disease, heart failure/cardiomyopathy, and stroke).8

Cancer therapies were not linked to cardiovascular disease in 4181 breast cancer survivors.8 Cardiovascular disease risks, on the other hand, differed depending on body mass index and the prevalence of risk factors at the time of diagnosis.8 Women of normal weight who took anthracyclines had a higher risk of ischemic heart disease and heart failure/cardiomyopathy than women of normal weight who did not take these drugs.8 Normal-weight women who received cyclophosphamide or left-sided radiation had a higher risk of heart failure/cardiomyopathy and stroke than normal-weight women who did not get these treatments.8 Non-diabetic women receiving cyclophosphamide, non-dyslipidemic women receiving anthracyclines, and non-hypertensive women receiving either anthracyclines or cyclophosphamide had higher heart rates, a risk factor for cardiovascular disease.8

Certain chemotherapy medicines may raise the risk of cardiovascular disease in normal weight breast cancer survivors; however, obese and overweight breast cancer survivors may be at lower risk than normal weight women.8 This could be because obese patients are given a reduced chemotherapy dose per kilogram of body weight.9

Chemotherapy appears to raise the incidence of heart failure/cardiomyopathy in women who do not have diabetes, dyslipidemia, or hypertension. However, these diseases are more common in overweight/obese women.8 Further research is necessary within these groupings.8

Endocrine therapy is linked to cardiovascular risk in breast cancer survivors, with aromatase inhibitors (AIs) and tamoxifen having conflicting effects.10 A study looked at the impact of AIs or tamoxifen on the occurrence of newly diagnosed hypertension, diabetes, and dyslipidemia in a group of breast cancer survivors at KPNC.10 The researchers wanted to see if AIs and tamoxifen use were linked to hypertension, diabetes, and dyslipidemia in breast cancer survivors compared with those who did not take either of these drugs.10

Of the breast cancer survivors in the study, AIs were used by 40.6%; tamoxifen was used by 11.8%; and neither was used by 47.6%.10 In comparison to breast cancer survivors who did not use endocrine therapy, AI usage was linked to an elevated risk of hypertension and dyslipidemia.10 In comparison to breast cancer survivors who did not use endocrine therapy, tamoxifen use was linked with a lower risk of dyslipidemia.10 Neither AIs nor tamoxifen use were linked to the development of diabetes.10 More research is needed to determine the long-term implications of these results.10

Cardiovascular Fitness Can and Should Be Maintained in Breast Cancer Survivors

Cardiorespiratory fitness relates to the fitness of our heart and lungs.11 Better cardiorespiratory fitness has been linked to improved survival in breast cancer.11 Furthermore, a change in body composition might lead to a worse prognosis and more treatment adverse effects.11 Generally, breast cancer survivors have lower cardiorespiratory fitness levels than women who have not had breast cancer.11 Breast cancer survivors gain on average around 1.8 kg to 5.0 kg after chemotherapy, continuing to gain weight with hormone therapy, and approximately 3% of breast cancer survivors are obese.11 Exercise has been shown to benefit breast cancer survivors by reducing treatment adverse effects and improving cardiorespiratory fitness, along with improving body composition during and after therapy.11 However, it is not clear whether active breast cancer survivors can obtain similar cardiorespiratory fitness levels and body composition levels as active healthy women, or what effect lack of exercise has on them.11

A study was undertaken in Madrid, Spain, to see how physical activity affects cardiorespiratory fitness and body composition in breast cancer survivors compared with women who have never had breast cancer.11

Women with and without breast cancer were invited to a sports center, to assess their general physical condition and body composition.11 The women were classified as active or inactive and divided into 4 groups (Inactive-Breast Cancer, Active-Breast Cancer, Inactive-Healthy, Active-Healthy).11 Different physical tests were undertaken to assess their cardiorespiratory fitness levels.11

Ninety-two women were recruited in total (23 in each group).11 There were significant differences in the VO2max of the active and inactive breast cancer groups.11 VO2max is the maximum or optimal rate that the heart, lungs, and muscles use oxygen during exercise and is often used to measure aerobic fitness.11 There were no differences in VO2max between the active breast cancer and healthy groups.11 When compared with inactive women, active women with breast cancer showed better results than both inactive groups in other physical tests, but not when compared with the active healthy group.11 Total weight, hydration, and visceral mass differed significantly between the active breast cancer and inactive groups.11

This study showed that breast cancer survivors who maintain an active lifestyle can achieve the same physical fitness levels as active healthy women, and far better fitness levels than inactive women.11 These findings also imply that physical activity may be a more powerful predictor of body composition than a prior history of breast cancer.11

Potential Advantages of Regular Aspirin Use on Breast Tumor Growth and Long-Term Breast Cancer Survival

Aspirin has been shown in studies to suppress breast tumor growth and lessen the invasiveness of breast cancer cells.12 Aspirin use after breast cancer diagnosis was linked to lower breast cancer–specific and all-cause mortality in major population-based studies.12 This study looked at 10 years of follow-up to a previous study, as well as at the molecular underpinnings of aspirin’s impact in breast cancer prognosis.12

The Nurses’ Health Study (NHS) and NHSII included 7949 women diagnosed with stage I, II, or III breast cancer.12 Post-diagnostic aspirin consumption was tracked for ≥12 months after diagnosis and then updated every 2 years.12 The study also looked at the link between post-diagnostic aspirin use and overall survival based on tumor characteristics.12

Deaths (N = 2502) were observed over the course of a 12-year median follow-up after a breast cancer diagnosis, including 1373 deaths from breast cancer.12 Women who took aspirin frequently after diagnosis had reduced breast cancer–specific mortality compared with those who did not.12 In primary breast tumors and/or normal-adjacent tissues, long-term regular aspirin use was linked with less inflammation and other proliferation.12 The large-scale population-based investigation with long-term follow-up highlights the potential advantage of aspirin as a secondary prevention strategy across a variety of tumor genetic features.12

Life After Breast Cancer: Cardiac Health, Fertility Preservation, and Returning to Life

Breast cancer survivors frequently experience severe repercussions as a result of their disease, treatment, and psychosocial factors.9 Although vital and life-saving, breast cancer treatment can have serious health consequences for the breast cancer survivor.9

Among breast cancer survivors, therapy-induced heart dysfunction is extensively recognized.9 Cardioprotective pharmacological treatments are well-tolerated and appear to protect against cancer therapy-related cardiac dysfunction in patients with breast cancer who are receiving anthracycline-based chemotherapy.9

The risk of cardiovascular disease (CVD) is linked to body mass index.9 For breast cancer survivors of normal weight, certain chemotherapy medications and left-sided radiation may increase the risk of CVD.9 When compared with normal-weight breast cancer survivors, some chemotherapy medications appear to reduce the incidence of stroke in obese breast cancer survivors.9

Fertility preservation is a major priority for breast cancer patients of childbearing age.9 At the time of diagnosis, controlled ovarian stimulation and assisted reproductive therapies do not appear to worsen the prognosis of young women with breast cancer, even those with hormone receptor–positive disease.9 In patients with a history of breast cancer and BRCA1/2 mutations, ART has been demonstrated to be safe.9 These findings are supported by validated onco-fertility guidelines, which should give patients and oncologists more reassurance.9 The LONGFAST study looked at the length of the overnight fast and its impact on patients with breast cancer.9 It has been discovered that 12 weeks of extended nocturnal fasting after breast cancer therapy is feasible and beneficial.9 A lengthier overnight fast led to a slight reduction in body mass index as well as improvements in anxiety, depression, and fatigue.9 More research is needed in this area.9 Hot flushes and peripheral neuropathy are 2 long-term side effects of chemotherapy.9 For patients, these can be concerning.9 It is possible to distinguish between predictors of acute (up to 12 months) and persistent (18-24 months) symptoms after chemotherapy.9 The factors that influence each phase are not always the same.9 This could aid healthcare providers in providing more specific advice to patients about what to expect.9

Adjuvant chemotherapy causes a significant percentage of women to become new users of sedative-hypnotic medicines, with many of them filling prescriptions for up to a year following the treatment.9 This could be an avoidable consequence in the treatment of early-stage breast cancer.9 A countrywide sample of 1324 Norwegian long-term breast cancer survivors was studied for changes in work status and associated variables.9 The majority of breast cancer survivors who were employed at the time of diagnosis were still employed 8 years afterward.9 The number of people receiving disability benefits climbed by a factor of 4.9 Chemotherapy, decreased cognitive function, and fatigue have all been linked to a decrease in employment status.9

The effects of breast cancer treatment on job loss, return to work, and multidimensional well-being in working-age black and white women have been studied.9 In all categories, sustained work and return to work resulted in improved well-being.9 When compared with white women, black women are more likely to lose their jobs.9 Black women who lost their jobs expressed lower well-being and more disability and work-related issues. Patients’ experiences will vary depending on who they are as individuals when they present for diagnosis.9

References

  1. Chazelas E, Pierre F, Druesne-Pecollo N, et al. Breast and prostate cancer risk associated with nitrites and nitrates from food additives: results from the NutriNet-Sante Cohort. 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021. P1-09-01.
  2. Debra C, Chazelas E, Srour B, et al. Risk of breast and other cancers associated with the consumption of artificial sweeteners: results from the prospective NutriNet-Sante Cohort. 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021. P1-09-02.
  3. Magliocco G, Khalife R, Magliocco A, Distinct and targetable molecular features of breast cancer in African American women. 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021. P3-14-12.
  4. Hurvitz S, Kim S, Chung W, et al. Trastuzumab deruxtecan (T-DXd) vs. trastuzumab emtansine (T-DM1) in patients (pts) with HER2+ metastatic breast cancer (mBC): subgroup analyses from the randomized phase 3 study DESTINY-Breast03. 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021. GS3-01.
  5. Ganz P, Bandos H, Spanic T, et al. Quality of life results from OlympiA: a phase III, multicenter, randomized, placebo-controlled trial of adjuvant olaparib after (neo)-adjuvant chemotherapy in patients with germline BRCA1/2 mutations and high-risk HER-2 negative early breast cancer. 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021. GS4-09.
  6. Petit T, Hajjaji N, Antoine E, et al. Trastuzumab deruxtecan in previously treated HER2-positive metastatic or unresectable breast cancer: first real-life data from the cohort temporary authorization for use (cATU) program in France. 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021. P2-13-26.
  7. Di Mauro P, Pedersini R, Petrelli F, et al. Gastrointestinal toxicity of antibody-drug conjugates (ADCs) in metastatic breast cancer: a pooled analysis. 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021. P5-18-15.
  8. Greenlee H, Rillamas-Sun E, Iribarren C, et al. Cardiovascular disease risk of breast cancer therapies: the Pathways Heart Study. 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021. PD5-01.
  9. Greenlee H, Meattini I, Henry NL, et al. Life after breast cancer: cardiac health, fertility preservation, and returning to life. 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021. PD501, PD503, PD5-11.
  10. Greenlee H, Rillamas-Sun E, Iribarren C, et al. Development of cardiometabolic risk factors following endocrine therapy: the Pathways Heart Study. 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021. PD5-03.
  11. Herrero L, Santamaría M, Jimenez M, et al. The importance of physical exercise in cardiovascular fitness in breast cancer survivors. A cross sectional study: WIM 2.0. 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021. P4-11-26.
  12. Peng C, Holmes M, Wang T, et al. Regular aspirin use, breast tumor characteristics and long-term breast cancer survival. 2021 San Antonio Breast Cancer Symposium; December 7-10, 2021. P3-12-01.

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