BREAST CANCER

BY: MEITY MASITHA ANGGRAINI KESUMA Class B

PROGRAM STUDI ILMU KEPERAWATAN FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA 201

BREAST CANCER
A. Definition

Breast cancer is a tumor that has become malignant, it has developed from the breast cells. A malignant tumor can spread to other parts of the body, it may also invade surrounding tissue. When it spreads arround the body, we call it metastasis. Breast cancer is a ind of cancer that develops from breast cells. Breast cancer usually starts off in the inner lining of mil ducts or the lobules that supply them with mil . A malignant tumor can spread to other parts of the body. A breast cancer that started off in the lobules is nown as lobular carcinoma, while one that developed from the ducts is called ductal carcinoma. B. Causes of Breast Cancer !"perts are not sure what causes breast cancer. #t is hard to say why one person develops the disease while another does not. We now that some ris factors can impact on a woman$s li elihood of developing breast cancer. %. Getting older & the older a woman gets, the higher is her ris of developing breast cancer' age is a ris factor. (ver )*+ of all female breast cancers occur among women aged ,*- years .after the menopause/. 0. Genetics & women who have a close relative who has1had breast or ovarian cancer are more li ely to develop breast cancer. #f two close family members develop the disease, it does not necessarily mean they

shared the genes that ma e them more vulnerable, because breast cancer is a relatively common cancer. 2he ma3ority of breast cancers are not hereditary. Women who carry the B45A% and B45A0 genes have a considerably higher ris of developing breast and1or ovarian cancer. 2hese genes can be inherited. 26,7, another gene, is also lin ed to greater breast cancer ris . 7. A history of breast cancer & women who have had breast cancer, even non&invasive cancer, are more li ely to develop the disease again, compared to women who have no history of the disease. 8. Having had certain ty es of breast lu! s & women who have had some types of benign .non&cancerous/ breast lumps are more li ely to develop cancer later on. !"amples include atypical ductal hyperplasia or lobular carcinoma in situ. ,. 9. Dense breast tissue & women with more dense breast tissue have a greater chance of developing breast cancer. Estrogen e" osure & women who started having periods earlier or entered menopause later than usual have a higher ris of developing breast cancer. 2his is because their bodies have been e"posed to estrogen for longer. !strogen e"posure begins when periods start, and drops dramatically during the menopause. :. #besity & post&menopausal obese and overweight women may have a higher ris of developing breast cancer. !"perts say that there are higher levels of estrogen in obese menopausal women, which may be the cause of the higher ris . ). Height & taller&than&average women have a slightly greater li elihood of developing breast cancer than shorter&than&average women. !"perts are not sure why. ;. Alcohol consu! tion & the more alcohol a woman regularly drin s, the higher her ris of developing breast cancer is. 2he <ayo 5linic says that if a woman wants to drin , she should not e"ceed one alcoholic beverage per day.

%*. Radiation e" osure & undergoing =&rays and 52 scans may raise a woman$s ris of developing breast cancer slightly. >cientists at the <emorial >loan&?ettering 5ancer 5enter found that women who had been treated with radiation to the chest for a childhood cancer have a higher ris of developing breast cancer. %%. HRT $hor!one re lace!ent thera y% & both forms, combined and estrogen&only @42 therapies may increase a woman$s ris ris . %0. Certain &obs & Arench researchers found that women who wor ed at night prior to a first pregnancy had a higher ris of eventually developing breast cancer. 5anadian researchers found that certain 3obs, especially those that bring the human body into contact with possible carcinogens and endocrine disruptors are lin ed to a higher ris of developing breast cancer. !"amples include bar1gambling, automotive plastics manufacturing, metal&wor ing, food canning and agriculture. 2hey reported their findings in the Bovember 0*%0 issue of Environmental Health. %7. Cos!etic i! lants !ay under!ine breast cancer survival & women who have cosmetic breast implants and develop breast cancer may have a higher ris of dying prematurely form the disease compared to other females, researchers from 5anada reported in the BMJ (British Medical Journal) .<ay 0*%7 issue/. 2he team loo ed at twelve peer&reviewed articles on observational studies which had been carried out in !urope, the C>A and 5anada. !"perts had long&wondered whether cosmetic breast implants might ma e it harder to spot malignancy at an early stage, because they produce shadows on mammograms. #n this latest study, the authors found that a woman with a cosmetic breast implant has a 0,+ higher ris of being diagnosed with breast cancer when the disease has already advanced, compared to those with no implants.Women with cosmetic breast implants who are diagnosed with 8 of developing breast cancer slightly. 5ombined @42 causes a higher

breast cancer have a 7)+ higher ris of death from the disease, compared to other patients diagnosed with the same disease who have no implants, the researchers wrote. After warning that there were some limitations in the twelve studies they loo ed at, the authors concluded DAurther investigations are warranted into the long term effects of cosmetic breast implants on the detection and prognosis of breast cancer, ad3usting for potential confounders.D Breast 5ancer C? says that up to % in ) women in the C? will e"perience breast cancer at some point in their lives. 2he charity says this figure cannot be attributed to genetic and lifestyle factors alone. C. Sign and Sy! to!

A symptom is only felt by the patient, and is described to the doctor or nurse, such as a headache or pain. A sign is something the patient and others can detect, for e"ample, a rash or swelling. 2he first symptoms of breast cancer are usually an area of thic ened tissue in the woman$s breast, or a lump. 2he ma3ority of lumps are not cancerous' however, women should get them chec ed by a health care professional. According to the Bational @ealth >ervice, C?, women who detect any of the following signs or symptoms should tell their doctorE %. A lump in a breast 0. A pain in the armpits or breast that does not seem to be related to the woman$s menstrual period

7. 6itting or redness of the s in of the breast' li e the s in of an orange 8. A rash around .or on/ one of the nipples ,. A swelling .lump/ in one of the armpits 9. An area of thic ened tissue in a breast :. (ne of the nipples has a discharge' sometimes it may contain blood ). 2he nipple changes in appearance' it may become sun en or inverted ;. 2he siFe or the shape of the breast changes %*. 2he nipple&s in or breast&s in may have started to peel, scale or fla e D. Stages of breast cancer 2he first stage is stage * this stage is sometimes referred to as a non& evasive circoma. #n this stage there are abnormal cells present that might suggest that one is at higher ris for cancer. >ome women chose to have a double mastectomy to avoid the potential of cancer, while others ta e tomo"ifen. !ither way its important to have regular chec doctor. >tage # 2his stage is where the tumor is less than % cm across, and has not spread into the surrounding areas. >tage ## >tage ## is when the cancer is anywhere from %&0 cm across, and has spread into the surrounding areas including the lymph nodes .which must also be removed to prevent the further spread of the cancer/ >tage ### 2his is the stage for cancer in the advanced stages. #ts more than 0 cm across and has spread to the lymph nodes. A type of cancer most associated with this is called inflammatory breast cancer, because the breast is inflamed because the cancer is bloc ing the lymph nodes. 2he last stage of cancer is stage #G. 9 with your

#n stage #G, the cancer has spread past the breast and the lymph nodes and needs immediate treatment of chemotherapy and hormonal therapy to eep it under control. 2hen there is remission. #f you are in remission you have an e"tremely high ris of reoccurrence with in the first , years after the last now cancer is illed. E. Diagnosis of breast Cancer Women are usually diagnosed with breast cancer after a routine breast cancer screening, or after detecting certain signs and symptoms and seeing their doctor about them. #f a woman detects any of the breast cancer signs and symptoms described above, she should spea to her doctor immediately. 2he doctor, often a primary care physician .general practitioner, H6/ initially, will carry out a physical e"am, and then refer the patient to a specialist if he1she thin s further assessment is needed. Below are e"amples of diagnostic tests and procedures for breast cancerE
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Breast e"a! & the physician will chec both the patient$s breasts, loo ing out for lumps and other possible abnormalities, such as inverted nipples, nipple discharge, or change in breast shape. 2he patient will be as ed to sit1stand with her arms in different positions, such as above her head and by her sides.

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'(ray $!a!!ogra!% & commonly used for breast cancer screening. #f anything unusual is found, the doctor may order a diagnostic mammogram. Breast cancer screening has become a controversial sub3ect over the last few years. !"perts, professional bodies, and patient groups cannot currently agree on when mammography screening should start and how often it should occur. >ome say routine screening should start when the woman is 8* years old, others insist on ,* as the best age, and a few believe that only high&ris groups should have routine screening.

#n Iuly, 0*%0, 2he American <edical Association said that women should be eligible for screening mammography from the age of 8*, and it should be covered by insurance. #n a >pecial 4eport in The Lancet .(ctober 7*th, 0*%0 issue/, a panel of e"perts e"plained that breast cancer screening does reduce the ris of death from the disease. @owever, they added that it also creates more cases of false&positive results, where women end up having unnecessary biopsies and harmless tumors are surgically removed. Another study, carried out by scientists at the 2he Jartmouth #nstitute for @ealthy 6olicy K 5linical 6ractice in Lebanon, B.@., and reported in the New England Journal of Medicine .Bovember 0*%0 issue/, found that mammograms do not reduce breast cancer death rates. A team from the Cniversity of 5openhagen reported that women who have false&positive mammogram outcomes may suffer long&lasting stress and an"iety, in some cases this can last up to three years. 2hey published their findings in Annals of amil! Medicine .<arch 0*%7 issue/. 4esearchers from the Barbara Ann ?armanos 5ancer #nstitute in Jetroit, <ichigan, found that breast cancer mortality was higher among older women whose time&lapses between their last mammogram and their breast cancer diagnosis were longer. 2hey presented their findings at the American Association for 5ancer 4esearch .AA54/ Annual <eeting 0*%7. 2eam leader, <ichael >. >imon, <.J., <.6.@., said DWe found that for women age :, and older, a longer time interval between the last mammogram and the date of breast cancer diagnosis was associated with a greater chance for dying from breast cancer.D
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)D co!bined *ith +D !a!!ogra!s & 7J mammograms, when used in collaboration with regular 0J mammograms were found to reduce the incidence of false positives, researchers from the Cniversity of >ydney$s >chool of 6ublic @ealth, Australia, reported in The Lancet "ncolog!.

2he researchers screened :,0;0 adult females, average age ,) years. 2heir initial screening was done using 0J mammograms, and then they underwent a combination of 0J and 7J mammograms. 6rofessor Behmat @oussami and team found ,; cancers in ,: patients. 99+ of the cancers were detected in both 0J and combined 0J17J screenings. @owever, 77+ of them were only detected using the 0J plus 7J combination. 2he team also found that 0J plus 7J combination screenings were lin ed to a much lower number of false positives. When using 3ust 0J screenings there were %8% false positives, compared to :7 using the 0J plus 7J combination. 6rof. @oussami said DAlthough controversial, mammography screening is the only population&level early detection strategy that has been shown to reduce breast cancer mortality in randomiFed trials. #rrespective of which side of the mammography screening debate one supports, efforts should be made to investigate methods that enhance the Muality of, and hence potential benefit from, mammography screening. We have shown that integrated 0J and 7J mammography in population breast&cancer screening increases detection of breast cancer and can reduce false&positive recalls depending on the recall strategy. (ur results do not warrant an immediate change to breast&screening practice, instead, they show the urgent need for randomised controlled trials of integrated 0J and 7J versus 0J mammography.D
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Breast ultrasound & this type of scan may help doctors decide whether a lump or abnormality is a solid mass or a fluid&filled cyst. Bio sy & a sample of tissue from an apparent abnormality, such as a lump, is surgically removed and sent to the lab for analysis. #t the cells are found to be cancerous, the lab will also determine what type of breast cancer it is, and the grade of cancer .aggressiveness/. >cientists from the 2echnical Cniversity of <unich found that for an accurate diagnosis, multiple tumor sites need to be ta en.

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Breast ,R- $!agnetic resonance i!aging% scan & a dye is in3ected into the patient. 2his type of scan helps the doctor determine the e"tent of the cancer. 4esearchers from the Cniversity of 5alifornia in >an Arancisco found that <4# provides a useful indication of a breast tumor$s response to pre&surgical chemotherapy much earlier than possible through clinical e"amination.

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Staging describes the e"tent of the cancer in the patient$s body and is based on whether it is invasive or non&invasive, how large the tumor is, whether lymph nodes are involved and how many, and whether it has metastasiFed .spread to other parts of the body/. A cancer$s stage is a crucial factor in deciding what treatment options to recommend, and in determining the patient$s prognosis. >taging is done after cancer is diagnosed. 2o do the staging, the doctor may order several different tests, including blood tests, a mammogram, a chest =&ray, a bone scan, a 52 scan, or a 6!2 scan.

.. Treat!ents for Breast Cancer A multidisciplinary team will be involved in a breast cancer patient$s treatment. 2he team may consists of an oncologist, radiologist, specialist cancer surgeon, specialist nurse, pathologist, radiologist, radiographer, and reconstructive surgeon. >ometimes the team may also include an occupational therapist, psychologist, dietitian, and physical therapist. 2he team will ta e into account several factors when deciding on the best treatment for the patient, includingE
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2he type of breast cancer 2he stage and grade of the breast cancer & how large the tumor is, whether or not it has spread, and if so how far Whether or not the cancer cells are sensitive to hormones 2he patient$s overall health 2he age of the patient .has she been through the menopauseN/ 2he patient$s own preferences

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2he main breast cancer treatment options may includeE

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4adiation therapy .radiotherapy/ >urgery 5hemotherapy @ormone therapy Biological therapy .targeted drug therapy/ 5ontrolled doses of radiation are targeted at the tumor to destroy the

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Radiation thera y $radiothera y% cancer cells. Csually, radiotherapy is used after surgery, as well as chemotherapy to ill off any cancer cells that may still be around. 2ypically, radiation therapy occurs about one month after surgery or chemotherapy. !ach session lasts a few minutes' the patient may reMuire three to five sessions per wee for three to si" wee s. 2he type of breast cancer the woman has will decide what type of radiation therapy she may have to undergo. #n some cases, radiotherapy is not needed. 4adiation therapy types includeE

Breast radiation thera y & after a lumpectomy, radiation is administered to the remaining breast tissue Chest *all radiation thera y & this is applied after a mastectomy Breast boost & a high&dose of radiation therapy is applied to where the tumor was surgically removed. 2he appearance of the breast may be altered, especially if the patient$s breasts are large.

0y! h nodes radiation thera y & the radiation is aimed at the a"illa .armpit/ and surrounding area to destroy cancer cells that have reached the lymph nodes

Breast brachythera y & scientists at C5 >an Jiego <oores 5ancer 5enter revealed that patients with early&stage breast cancer in the mil ducts which has not spread, seem to benefit from undergoing breast brachytherapy with a strut&based applicator. 2his ,&day treatment is given to patients after they have undergone lumpectomy surgery. 2he researchers found that women who received strut&based breast

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brachytherapy had lower recurrence rates, as well as fewer and less severe side effects. >horter radiation therapy for early breast cancerN & scientists at 2he #nstitute of 5ancer 4esearch in !ngland carried out a %*&year study to determine whether giving radiation therapy to women with early breast cancer might be as effective and safe as current standard treatment .with a higher overall dose/. #n an article in The Lancet "ncolog!, Iohn Oarnold and colleagues wrote that their findings confirmed this. >horter radiation therapy is at least as safe and effective. 6rofessor Oarnold, said D2hese %*&year results reassure us that 7 wee s of radiotherapy is as good as the , wee s still used in many countries, with less damage to nearby healthy tissue, as well as being more convenient for women .shorter waiting lists and fewer hospital visits/ and cheaper for health services.D 2he study authors added that the outcomes of the women given shorter radiation therapy were similar Dirrespective of age, tumor grade, stage, chemotherapy use, or use of tumor bed boost.D >ide effects of radiation therapy may include fatigue, lymphedema, dar ening of the breast s in, and irritation of the breast s in. ).

Surgery 0u! ecto!y & surgically removing the tumor and a small margin of healthy tissue around it. #n breast cancer, this is often called breast&sparing surgery. 2his type of surgery may be recommended if the tumor is small and the surgeon believes it will be easy to separate from the tissue around it. British researchers reported that about one fifth of breast cancer patients who choose breast&conserving surgery instead of mastectomy eventually need a reoperation.

,astecto!y & surgically removing the breast. #im$le mastectom! involves removing the lobules, ducts, fatty tissue, nipple, areola, and some s in. %adical mastectom! means also removing muscle of the chest wall and the lymph nodes in the armpit.

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<any undergo pointless mastectomies due to fear & a study carried out at the Jana&Aaber 5ancer #nstitute and published in Annals of &nternal Medicine found that many young women choose to have their healthy breast removed after being diagnosed with cancer in one breast. Cnfortunately, doing so does not improve survival rates, the authors e"plained.

Sentinel node bio sy & one lymph node is surgically removed. #f the breast cancer has reached a lymph node it can spread further through the lymphatic system into other parts of the body.

A"illary ly! h node dissection & if the sentinel node was found to have cancer cells, the surgeon may recommend removing several nymph nodes in the armpit.

Breast reconstruction surgery & a series of surgical procedures aimed at recreating a breast so that it loo s as much as possible li e the other breast. 2his procedure may be carried out at the same time as a mastectomy. 2he surgeon may use a breast implant, or tissue from another part of the patient$s body.

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Che!othera y <edications are used to ill the cancer cells & these are called c!toto'ic drugs. 2he oncologist may recommend chemotherapy if there is a high ris of cancer recurrence, or the cancer spreading elsewhere in the body. 2his is called ad3uvant chemotherapy. #f the tumors are large, chemotherapy may be administered before surgery. 2he aim is to shrin the tumor, ma ing its removal easier. 2his is called neo&ad3uvant chemotherapy. 5hemotherapy may also be administered if the cancer has metastasiFed & spread to other parts of the body. 5hemotherapy is also useful in reducing some of the symptoms caused by cancer. 5hemotherapy may help stop estrogen production. !strogen can encourage the growth of some breast cancers. >ide effects of chemotherapy may include nausea, vomiting, loss of appetite, fatigue, sore mouth, hair loss, and a slightly higher susceptibility

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to infections. <any of these side effects can be controlled with medications the doctor can prescribe. Women over 8* may enter early menopause. 1. Hor!one thera y $hor!one bloc2ing thera y% Csed for breast cancers that are sensitive to hormones. 2hese types of cancer are often referred to as !4 positive .estrogen receptor positive/ and 64 positive .progesterone receptor positive/ cancers. 2he aim is to prevent cancer recurrence. @ormone bloc ing therapy is usually used after surgery, but may sometimes be used beforehand to shrin the tumor. #f for health reasons, the patient cannot undergo surgery, chemotherapy or radiotherapy, hormone therapy may be the only treatment she receives. @ormone therapy will have no effect on cancers that are not sensitive to hormones. @ormone therapy usually lasts up to five years after surgery. 2he following hormone therapy medications may be usedE

Ta!o"ifen & prevents estrogen from binding to !4&positive cancer cells. >ide effects may include changes in periods, hot flashes, weight gain, headaches, nausea, vomiting, fatigue, and aching 3oints. A biomar er in breast cancer patients who do not respond, or who have become resistant to 2amo"ifen has been discovered by researchers at the Cniversity of <anchester, !ngland. 2hey say that their discovery will help doctors decide which patients are suitable or not for ad3uvant .complementary/ hormone therapy with 2amo"ifen. Biomar er may predict breast cancer recurrence after 2amo"ifen & scientists from the 5ancer 5enter and Jepartment of 6athology at <assachusetts Heneral @ospital, Boston, say that it may be possible to predict which women will have a higher ris of cancer recurrence after completing tamo"ifen treatment. 2he biomar er measures the ratio of gene e"pression in the @(=B%7 and #L%:B4 genes.

Aro!atase inhibitors & this type of medication may be offered to women who have been through the menopause. #t bloc s aromatase. Aromatase %8

helps estrogen production after the menopause. Before the menopause, a woman$s ovaries produce estrogen. !"amples of aromatase inhibitors include letroFole, e"emestane, and anastroFole. >ide effects may include nausea, vomiting, fatigue, s in rashes, headaches, bone pain, aching 3oints, loss of libido, sweats, and hot flashes.

#varian ablation or su

ression & pre&menopausal women produce

estrogen in their ovaries. (varian ablation or suppression stop the ovaries from producing estrogen. Ablation is done either through surgery or radiation therapy & the woman$s ovaries will never wor again, and she will enter the menopause early. A luteinising hormone&releasing hormone agonist .L@4@a/ drug called Hoserelin will suppress the ovaries. 2he patient$s periods will stop during treatment, but will start again when she stops ta ing Hoserelin. Women of menopausal age .about ,* years/ will probably never start having periods again. >ide effects may include mood changes, sleeping problems, sweats, and hot flashes. 3.

Biological treat!ent $targeted drugs% Trastu4u!ab $Herce tin% & this monoclonal antibody targets and destroys cancer cells that are @!40&positive. >ome breast cancer cells produce large amounts of @!40 .growth factor receptor 0/' @erceptin targets this protein. 6ossible side effects may include s in rashes, headaches, and1or heart damage.

0a atinib $Ty2erb% & this drug targets the @!40 protein. #t is also used for the treatment of advanced metastatic breast cancer. 2y erb is used on patients who did not respond well to @erceptin. >ide effects include painful hands, painful feet, s in rashes, mouth sores, e"treme tiredness, diarrhea, vomiting, and nausea.

Bevaci4u!ab $Avastin% & stops the cancer cells from attracting new blood vessels, effectively causing the tumor to be starved of nutrients and o"ygen. >ide effects may include congestive heart failure, hypertension .high blood pressure/, idney damage, heart damage, blood clots, headaches, mouth sores. Although not approved by the AJA for this use,

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doctors may prescribe it Doff&labelD. Csing this drug for breast cancer is controversial. #n 0*%%, the AJA said that Avastin is neither effective nor safe for breast cancer. >wiss researchers found that Avastin offers only a modest benefit regarding disease progression in women with advanced stage breast cancer. 2hey added that it has no impact on survival.

0o* dose as irin 4esearch carried out on laboratory mice and test tubes suggests that regular low&dose aspirin may halt the growth and spread of breast cancer. >cientists from the Geterans Affairs <edical 5enter in ?ansas 5ity and the Cniversity of ?ansas <edical 5enter e"plained that their tests on cancer lines and in mice showed that aspirin not only slowed the growth of cancer cells and shran tumors considerably, but also stopped metastasis .cancer spreading to new sites/. 2heir research involved assessing aspirin$s effects on two types of cancer, including the aggressive Dtriple&negativeD breast cancer which is resistant to most current treatments. 5ancer campaigners cautioned that although the current results show great promise, this research is at a very early stage and has yet to be shown to be effective on humans.

G. 5reventing Breast Cancer

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>ome lifestyle changes can help significantly reduce a woman$s ris of developing breast cancer.

Alcohol consu! tion & women who drin in moderation, or do not drin alcohol at all, are less li ely to develop breast cancer compared to those who drin large amounts regularly. <oderation means no more than one alcoholic drin per day.

5hysical e"ercise & e"ercising five days a wee has been shown to reduce a woman$s ris of developing breast cancer. 4esearchers from the Cniversity of Borth 5arolina Hillings >chool of Hlobal 6ublic @ealth in 5hapel @ill reported that physical activity can lower breast cancer ris , whether it be either mild or intense, or before1after menopause. @owever, considerable weight gain may negate these benefits.

Diet & some e"perts say that women who follow a healthy, well&balanced diet may reduce their ris of developing breast cancer. Aish oils help reduce breast cancer ris & a study published in BMJ .Iune 0*%7 issue/ found that women who regularly consumed fish and marine n&7 polyunsaturated fatty acids had a %8+ lower ris of developing breast cancer, compared to other women. 2he authors, from Phe3iang Cniversity, 5hina, e"plained that a Dregular consumerD should be eating at least % or 0 portions of oily fish per wee .tuna, salmon, sardines, etc/.

5ost!eno ausal hor!one thera y & limiting hormone therapy may help reduce the ris of developing breast cancer. #t is important for the patient to discuss the pros and cons thoroughly with her doctor.

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Body*eight & women who have a healthy bodyweight have a considerably lower chance of developing breast cancer compared to obese and overweight females.

6o!en at high ris2 of breast cancer & the doctor may recommend estrogen&bloc ing drugs, including tamo"ifen and ralo"ifene. 2amo"ifen may raise the ris of uterine cancer. 6reventive surgery is a possible option for women at very high ris .

Breast cancer screening & patients should discuss with their doctor when to start breast cancer screening e"ams and tests. Breastfeeding & women who breastfeed run a lower ris of developing breast cancer compared to other women. A team of researchers from the Cniversity of Hranada in >pain reported in the Journal of (linical Nursing that breastfeeding for at least si" months reduces the ris of early breast cancer. 2his only applies to non&smo ing women, the team added. 2hey found that mothers who breastfed for si" months or more, if they developed breast cancer, did so on average ten years later than other women. Refrence7 httpE11www.medicalnewstoday.com1articles17:%79.php

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