The FDA Granted Approval for New Breast Cancer Medication

The FDA, or U.S. Food and Drug Administration has recently approved two new medications for breast cancer treatments. The approval for these treatments was expedited due to the COVID-19 pandemic. One of these medications targets metastatic triple-negative breast cancer, while the other targets HER2-positive  cancers.

Richard Pazdur, the director of the FDA’s Oncology Center for Excellence, stated, “As part of FDA’s ongoing and aggressive commitment to address the novel coronavirus pandemic, we continue to keep a strong focus on patients with cancer who constitute a vulnerable population at risk of contracting the disease. At this critical time, we continue to expedite oncology product development.”

 

FDA Approval

The drug’s applications were granted by the FDA under the provision known as “accelerated approval” due to today’s current conditions. This means that the drugs may be distributed and administered under specific criteria. There will still be further data from further clinical trials required before full approval is granted.

The medications may be administered to patients only when certain conditions are met. For Todelvy, this means that it is “reasonably likely to predict a clinical benefit to patients” who have are in serious condition and have unmet medical needs. For Tukysa, the medication must be administered alongside chemotherapy, and there must be at least one prior attempt at treatment.

 

Trodelvy

Trodelvy, also known as sacituzumab govitecan, is one of the medications to receive accelerated approval. Produced by Immunomedics, Trodelvy received approval based on results from a clinical trial (phase 1/2) of 108 patients.  These patients had all received at least two treatments previously for their metastatic cancer.

It was given intravenously. It is formed of a combination of SN-38 (a metabolite of irinotecan, a chemo drug) and a monoclonal antibody that targets an antigen that induces cancer cell growth.  The response rate in breast cancer patients in the trial was 33%, and 55.6% of those responders maintained their response at least six months.

Some common side effects of Trodelvy are nausea, fatigue, anemia, low white blood cell counts, as well as hair loss, rash, and abdominal pain. There are chances of more severe side effects to keep an eye out for, such as severe diarrhea and neutropenia–an abnormally low level of neutrophils.

 

Tukysa

Tukysa is the brand name of tucatinib, a tyrosine kinase inhibitor of HER2 proteins. When taken with capecitabine and trastuzumab in adult patients, it is intended for advanced metastatic, HER2-positive breast cancer, including brain metastases. The patients must have attempted at least one anti-HER2-based treatment geared towards metastasis.

This medication has been shown to inhibit the phosphorylation of both HER2 and HER3 in-vitro, or in lab studies. Further clinical trials will be performed.

Some common side effects of Tukysa are fatigue, liver problems, decreased appetite, hand-foot syndrome, and mouth sores, as well as others. The liver problems can become more severe, as can diarrhea, leading to other health problems.

 

Breast Cancer Treatment

Many adjustments have had to be made in day-to-day life with the introduction of the Novel Coronavirus. This includes the treatment of breast cancer, the testing of medication, and FDA processes of approval. These new medications have been pushed forward into the market more speedily than usual, but that does not mean they were pushed forward recklessly.

Each was pushed forward by the Food and Drug Administration with certain conditions to met before application. Each must also continue testing before the FDA approves it fully.


Exploring New Findings in Breast Cancer Research

The week of December 10, Dr. Valerie Gorman attended the annual San Antonio Breast Cancer Symposium to give a poster presentation for her research in 5-day SBRT radiation. This symposium is an opportunity for those involved in breast cancer research to share what they have learned.

The SABCS’ stated objective states that the conference “is designed to provide state-of-the-art information on the experimental biology, etiology, prevention, diagnosis, and therapy of breast cancer and premalignant breast disease, to an international audience of academic and private physicians and researchers.” Research is brought from all of these categories to be shared and help other practitioners improve their own research or treatments.

Dr. Gorman praises this conference for the multidisciplinary spread of study. As her breast cancer team is interdisciplinary, she can gather information that will interest every member of her team. She noted that there were presentations this year on “molecular studies on circulating tumor cells, more targeted therapies, and many other topics. Together with our oncology colleagues and team members, we’re able to use these to treat our patients in a collaborative, multidisciplinary fashion.”

For example, while Dr. Gorman does not specialize or perform chemotherapy treatment, she took note of several tailored researched studies into chemotherapy. There is new research being done on HER2 positive cancer, or breast cancer that tests positive for human epidermal growth factor receptor 2. HER2 protein excess is found in approximately 20% of breast cancers, caused by a gene mutation in the cancer cells. There is also chemotherapy targeting metastatic breast cancer, which is cancer that has spread beyond the point of origin–in this case, the breast and lymph nodes nearby. Patients with these cancers tend to have a lot of, and many kinds of chemo throughout their treatment. These new studies are helping us to learn how to “study the tumor and retailor the chemotherapy to the individual patient and their needs.”

The presentation that Dr. Gorman and her team were most interested in, however, came from the University of Florence in Italy. They presented on the ten-year results of breast cancer patients who had been treated with Accelerated Partial Breast Irradiation (APBI), a treatment Dr. Gorman has been using and perfecting for many years.

The use of radiation therapy on breast cancer is a common occurrence. This treatment directs high energy rays directly at the cancerous area to kill any cancerous cells left over after surgery. Traditionally, radiation therapy is implemented over 30 days. This regimen includes visits every weekday for six weeks and can potentially lead to burns on the surrounding tissue as well as changes in the patient’s appearance. However, APBI shortens the number of days needed for the treatment. Some protocols of APBI give radiotherapy twice a day for five days, while others–including Dr. Gorman’s practice–only give it once a day for five days. While the treatment itself takes little time in office, doctors know transport and waiting room time can take up valuable time from the patient’s personal and work life. By minimizing how many office visits are required, these doctors are giving their patients more of their life back.
The presentation that the University of Florence gave reveals new results from patients ten years after their surgeries and radiotherapy treatments. The results found that survival rates at the ten-year mark for those who received APBI–as with the five-year mark–matched the survival rate of those who received longer treatments. However, APBI has better cosmetic results and less burn damage.

Dr. Gorman is pleased to know that this treatment helps her patients, not only by treating their breast cancer but also by lessening the impact that breast cancer has on their personal life. With few in-office treatments, there is less time away from the office or the family. The APBI also produces more favorable cosmetic results, which can help with a healthier mindset as you approach healing.
Dr. Gorman and her team offer APBI when necessary to provide the breast results and the least interference in her patients’ lives. They also provides necessary breast cancer surgery to best help a given case. As the Chief of Surgery and Medical Director of Surgical Service of Baylor Scott and White Medical Center in Waxahachie, Dr. Valerie Gorman, MD, FACS is ready to answer your questions and design a personalized cancer treatment plan for you.


The Cost of Breast Cancer Treatment: What are the Contributing Factors?

In a recent survey of patients diagnosed with early-stage breast cancer, 38% said they were worried about finances due to their treatment. 14% said that their breast cancer cost them at least 10% of their household income. 17% said that they had spent even more than that 10% on out-of-pocket medical expenses.

When doctors, surgeons, and radiation oncologists were asked about how their offices handle financial discussions with their patients, 50% of medical oncologists reported that someone in their practice “often or always discusses financial burden” with their patients. 43% of radiation oncologists said they did as well. Only 16% of surgeons reported the same.

Furthermore, no one seems to know, going in, just how far a diagnosis of breast cancer is going to set them back financially. It is difficult to find answers about the cost of treatment, whether for surgery, radiation, or other medications. We are taking this chance to clear the air between doctors and patients; we can give the answers that so many have been looking for and help to start the conversation so you can be prepared should this diagnosis ever come your way.

Total Costs

In 2010, breast cancer was the highest-costing cancer in the United States. Nationwide, it cost a total of $16.5 billion. By 2020, this is expected to increase to $20.5 billion. The American Cancer Society estimates that over $180 billion is spent on health care expenses and lost productivity every year due to cancer.

How Much Does Breast Cancer Surgery Cost?

Of course, each person’s case is unique. Their access to insurance must be taken into consideration. Different stages of cancer are harder to treat than others, which can affect overall treatment costs. Not to mention that disease takes root differently in each person, so it must be treated differently. And with no one-size-fits-all treatment, there is no one-size-fits-all price tag. All of these factors must be considered.

Stages

The stage at which a patient’s breast cancer is discovered significantly affects how difficult it is to treat. A study was done recently and published in The American Health and Drug Benefits1 on the cost and frequency of some treatments based on the cancer stage and how long it had been since the diagnosis.

It was not much of a surprise to find that those patients with more advanced stages of breast cancer spent more on treatments. For those with stage 0 cancer, the average cost of treatment at twelve months after diagnosis was $60, 637. After twenty-four months, the price had jumped to $71, 909 per patient overall.

For those whose cancer had advanced to stages I-II, their medical costs were approximately $82,121 in the first twelve months of treatment. In the second twelve months, each patient still in the study brought the total average to $97, 066.

With breast cancer in stage III, the average cost in the first twelve months continued to rise to $129,387. After a full twenty-four months, the study reported that patients spent an average of $159,442.

At stage IV, the most difficult to treat, the average treatment costs were $134,682 at twelve months and $182,655 at twenty-four.

According to the study, patients were paying an average of $85,772 within the first twelve months of being diagnosed with breast cancer, despite their cancer stage. And within the first two years of their diagnosis, the study reported their treatment costs averaging $103,735.

Treatments

Another major factor that will contribute to the overall cost of breast cancer treatment is the kind of treatment a patient is receiving. Which treatment you receive depends on the location, cancer stage, and extent to which the disease has spread. Sometimes the procedures are combined to get the best results and return you to health quicker and more effectively. The same study mentioned above also explored the average amount spent on categories of treatments, and how common these kinds of treatments were within the given periods.

Surgery

Surgery is a standard treatment for a breast cancer diagnosis. If applicable, it is a way to remove cancer physically from where it has taken root. Altogether, surgical treatment accounts for an average of 20% of the cost of breast cancer care treatments within the first year after diagnosis, and 4% in the second year.

  • Inpatient breast cancer surgery accounts for 6% of the cost treatment in the first year, and 2% in the second year. In the first year of treatment, the cost of breast cancer surgery is, on average, $4,762, while in the second year after diagnosis, the cost is approximately $347.
  • Outpatient breast cancer surgery accounts for approximately 14% of the price of breast cancer treatment in the first twelve months, and 2% in the second. The cost of outpatient surgery in the first and second years were found to be, on average, $11,691 and $389 respectively.

Chemotherapy

Chemotherapy is another well-known treatment of cancer. It accounts for approximately 19% of breast cancer treatment in both the first and second year after diagnosis.

  • For general chemotherapy, the average cost (including all costs on the day of the treatment) in the first year is $15,113. As this accounts for 18% of the payment for treatment for breast cancer, this is particularly significant. In the second year post-diagnosis, the average cost for this treatment is $3,625. This makes up 16% of all breast cancer treatment costs.
  • Oral chemotherapy is far less conventional. It only accounts for approximately 1% of the costs of first-year treatment, and 3% in the second year. Patients are usually paying $432 in their first year and $636 in their second year for this treatment.

Radiation

Radiation is used to kill the tumors by damaging cancer cells’ DNA. It is often used in combination with surgery. It makes up 18% of diagnosis treatment costs in the first year and 3% in the second year. In the first year, it costs an average of $15,455, while in the second year, patients pay $638.

Medication

Hand in hand with these major treatments come medications. Medications make up for 3% of the first year’s medical payments, and 7% of the second year. That equates to approximately $2,258 and $1,510, respectively.

Other Treatments

There are, of course, other treatments. Smaller subcategories that don’t quite fit these above, including hormone therapy, additional inpatient or outpatient care, or professional or specialist care. They make up about 42% of potential treatment costs in the first year and 67% of costs in the second year. That equates to $35,762 in the first twelve months and $14,980 in the second.

Health Insurance

Another factor that contributes to the overall cost of breast cancer treatment is health insurance. Healthcare, the amount of coverage you have, and the type of coverage you have, are all essential to discuss with your doctor, oncologist, and surgical team to make sure you understand where you stand.

Researchers in North Carolina found that patients who received a cancer diagnosis and did not have insurance or Medicare paid $6,711 for medication, while those with insurance paid $3,616 and those with Medicare paid $3,090 simply because they do not have the means to negotiate for a lower price.

Often, clinical appointments are more costly, as well. Where an insured patient might pay approximately $65-246, a patient without insurance coverage would pay around $129-391.

Ask Questions/Dr. Gorman

Getting a diagnosis of breast cancer is near impossible to imagine, and even harder to plan for. But if you ever find yourself in that place, you have a little more knowledge about what to expect. One should always be prepared for the unexpected, and it never hurts to have a little money saved up for emergencies. But breast cancer treatment costs will require more than just a bit of your savings. However, with communication with your team and laying out your healthcare terms and concerns as you discuss your health plan, everyone can be on the same page and do what they can to work within your needs.

Dr. Valerie Gorman knows about the financial burden that comes with breast cancer. She is dedicated to offering her patients a personalized approach to breast surgery and the treatment of breast cancer. She and her team will help to create a treatment plan that best meets your needs, and most fits your lifestyle. Because of the experience and breadth of our specialists, a multitude of treatment options exists which can be tailored to your situation.

There is no need to panic when you hear the word cancer. We have walked alongside many people who have been diagnosed and understand your fears and concerns. It is our privilege to walk with you and help you through this difficult process.

 

 

 

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822976/#idm139828318640480title

 

 


FAQs About Mastectomy

What are the types of mastectomy?

 

  • Simple/Total Mastectomy–The entire breast is removed; lymph nodes and muscle are not removed.
  • Radical Mastectomy–The entire breast is removed, this time including the pectoral muscles and lymph nodes extending under the arm. This is rarely done today.
  • Modified Radical Mastectomy–Removes the entire breast including the lymph nodes;
  • Double Mastectomy–Both breasts are removed.
  • Lumpectomy/Partial Mastectomy–Part of the breast is removed, namely abnormal tissue or cancer, rather than the whole breast, just removing the lump.
  • Nipple-Sparing Mastectomy–The breast tissue is removed, but the nipple and skin are left unscathed.
  • Skin-Sparing Mastectomy–The skin is left intact while the breast tissue, areola, and nipple are removed.

 

Mastectomies are recommended for those who have large tumors or tumors that affect multiple areas of the breast. They can also be used as a preventative measure for those who carry the BRCA1 or BRCA2 gene or other genetic mutations that increase your risk of breast cancer. The skin- and nipple-sparing mastectomies are newer surgeries. These are optimal for minimal scarring and reconstruction.

What is recovery like for a mastectomy?

Your stay in the hospital after a mastectomy will vary depending on the kind of mastectomy you had, your reactions to the anesthesia, and whether or not you had reconstruction done at the time. However, it can be guaranteed that after surgery, you will be taken to a recovery room until the nurses are sure you are stable and (mostly) alert. At this point, you will be wheeled along to your hospital room where you will stay approximately 1-2 days.

Then, once you are home, you must keep the incisions clean. Your surgeon will give you instructions on how to do so, as well as how to care for your drainage tube, which you will only have with you until your follow up exam.

Your doctor should prescribe you medication for your pain, though the levels vary depending on the location, type of mastectomy, and amount of tissue taken. Follow your doctor’s instructions for approved medication intake.

It usually only takes a few weeks to be back to normal activities, though anything that uses your arms a lot or seems strenuous to your body should be approached cautiously for a while. If you’re ever unsure, you can always check with your doctor. It’s better to be safe than sorry. But soon enough you’ll be back on your feet and facing the world again.

What are mastectomy recovery tools?

While you are recovering, there will be many things you will have directly on your mind. There will be drains to empty and keep untangled, pain medications and antibiotics to keep track of, what will be waiting at home after your stay in the hospital, and your life at large to consider. But there are some tools to help you stay comfortable while you heal. And some people have been patients before you. They have tips to recommend based on their experience.

Some tools that many find helpful are drain belts or robes and mastectomy pillows. There are variations on both of these tools, but both offer support and work to simplify your recovery.

After the mastectomy, drains are left in the area to allow any access fluid to leave the body rather than pooling. The fluid follows a tube to a bulb that you empty regularly and record the amount in them. However, the tubes can quickly become an inconvenience with a risk of snagging. The easiest solution is to attach the drains to your clothes with the velcro attachment or clip them onto a lanyard. But other people have come up with more comfortable and convenient solutions. There are now drain belts, which are comfortable belts with holster-like pockets in which the bulbs can sit. There are drain robes that have pockets to keep the drains out of your way. And some companies produce adhesive pockets that will attach to whatever clothes you wear, making your pajamas into drain holders. Dr. Gorman’s surgical team will provide a bra for you post-operatively that includes rings to which you can attach your drains.

Mastectomy pillows are pillows that are shaped or placed in a way to help support you after your surgery. This can be anything from a regular pillow that is placed under your knees to raise your legs and increase blood flow to the armpit pillow–a rectangular pillow that lays over your chest with notches cut out for your arms. Some provide support for both breasts, while others go between the breast tissue of one breast and the other. Find the pillow that minimizes pain and discomfort and offers the support and comfort you will need. Volunteers in our community sew rectangular post-op pillows for Dr. Gorman’s patients. Each of Dr. Gorman’s patients receives one of these pillows in recovery immediately after surgery.

Previous breast cancer patients have made suggestions to make your recovery as easy as possible. First, stock up on food—at least two weeks’ worth–before your surgery. You will not want to go shopping while you are healing. And while you may not want to eat right away, you should try to find something light on the stomach so you can take it with your pain medication, such as yogurt or pudding.

When you take your first shower about two days after your surgery—or when Dr. Gorman clears you to do so—it’s generally best to do so sitting in a shower chair. You have been off of your feet and on medication since your mastectomy. It’s safest to sit while you clean yourself off.

Avoid housework. Think of this as an excuse to avoid your chores for as long as you can. You need to heal before you start expending that kind of effort. Similarly, don’t try to rush back to work. Many women recommend waiting at least three weeks before returning to your job. Returning too quickly could not only tire you out but could potentially cause complications. This advice is especially relevant to those who have reconstruction surgery, as well.

Dr. Gorman’s team provides a one-on-one education time for each patient that covers all of this information and more prior to a mastectomy.

What will my mastectomy scars look like?

The type or amount of scarring will differ based on the type of mastectomy you are having done. The total, radical, and modified radical mastectomies will leave a visibly large scar as a large amount of tissue/skin is removed. However, with partial/lumpectomies, skin-sparing, and nipple-sparing mastectomies, the scars are less noticeable. Skin-sparing mastectomies tend to leave behind a scar that is usually where the nipple was previously. The scar of the lumpectomy is small and linear and tends to be hidden away in the crease or around the nipple to avoid detection. Lastly, the nipple-sparing mastectomy generally leaves a scar under the breast, where it can be tucked away in the bra-line to avoid visibility.

The Texas Breast Center utilizes Hidden Scar™ Breast Cancer Surgery to help minimalize scarring in patients. Dr. Gorman works with each patient to make the right decision for them on the right kind of mastectomy, and from there to ensure the scarring will be minimal and where it will as minimally intrusive as possible.

How does breast reconstruction work?

Not everyone has breast reconstruction after a mastectomy. For example, those having lumpectomies do not necessarily need one, because a majority of the breast tissue is left alone in the breast. With a mastectomy, reconstruction is more likely as all the tissue was removed. However, it really is up to the patient. Talk to your surgeon about your preferences so that they can be informed when discussing your options with you

What are the risks of a mastectomy?

A mastectomy, like any other surgery, has its risks. There will be swelling in the area, as well as bruising for a while after the surgery. The breast will be sore and scar tissue will form and likely harden. Some patients experience phantom pain in removed breasts. More seriously, however, the incisions could bleed or become infected, or, more rarely, skin necrosis. There is a risk of lymphedema or swelling in the arm where lymph nodes were removed. Seromas (fluid filling the now-empty breast) can form. And not the least of the risks can be a change in self-confidence.

Dr. Gorman is aware of these risks and is there to help prevent them. If they can’t be avoided, she will support you through them and work with you on a plan to improve, step by step.

Should I have radiation or chemo with my mastectomy?

Chemotherapy is not used in all cases of breast cancer. And, if it is used, it is not always used in the same way. There are two primary ways it is used concerning surgery.

Some kinds of chemotherapy–neoadjuvant chemotherapy–is used before surgery as an attempt to shrink the tumor to a more manageable size that requires less extensive surgery. Adjuvant chemotherapy is given after surgery to kill any possible remaining circulating cells that may have been left behind to prevent more tumor growth.

Radiation is often recommended after a mastectomy as a tool to prevent the recurrence of cancerous growth. Traditionally, radiation is administered for five to six weeks, up to five days a week. However, Dr. Gorman has experience with a method that only takes five days, with less waiting period between surgery and the radiation beginning for post-lumpectomy patients.

Can men get a mastectomy?

Breast cancer in men may be rare, but it is still very possible. Only 1% of breast cancer diagnoses are in men, but that still accounts for 1 in every 1,000 men. Invasive Ductal Carcinoma is the most common form of breast cancer found in men. Like in women, black men have a higher risk of getting breast cancer than those of other races. Take precautions and familiarize yourself with the breast area by firmly feeling over the breast tissue in the area for anything unusual.

If a man receives a diagnosis for breast cancer, there is a high chance surgery will be involved in treatment. The operation could be used to establish how far into the lymph nodes the cancer has spread (a sentinel lymph node biopsy, for example), to relieve symptoms of advanced cancer, or to remove as much of the tumor itself as possible (a mastectomy).

All of these and a few more can be performed on a man to help treat him for breast cancer. It is not just women who get this disease, and today’s treatments reflect that.

How do I take blood pressure after a mastectomy?

There is some question about where to have blood pressure taken and blood drawn from post-mastectomy; more specifically, patients ask whether it is safe to do these things on the same side of the body as the mastectomy. While you can have your blood pressure tested from either arm without causing any trouble to your healing process, there could be a (minimal) risk when it comes to drawing blood after breast cancer surgery.

After certain types of mastectomies–radical mastectomy, modified radical mastectomy, sentinel lymph biopsy, or any procedure when the lymph nodes are removed–there is a risk of lymphedema. Lymphedema is a swelling of the arm and usually stems from an infection of the arm. Because having blood drawn in a medical facility is done in a clinical environment with sterile equipment, the already small risk of infection becomes minimal. However, it is still recommended to take the ‘better safe than sorry’ route and instead have your blood drawn from the arm opposite your operation.

The same goes for vaccines and other injections. While the medication won’t cause any complications, it’s best to reduce the chances of introducing possible infections to the area soon after your breast surgery or years later.

What do I ask my surgeon?

You should always prepare a few questions when going into a procedure like this. Likely, a number of them will get answered simply through the surgeon’s explanation of the process, but it never hurts to be prepared. Here a few to get you started:

 

  • What are the risks of my type of mastectomy?
  • Will I need reconstruction? Can it be done in the same procedure?
  • How can I prepare my home for my recovery before the procedure?
  • How can I emotionally prepare for this?
  • What medicines/foods should I or shouldn’t I take on the day of the procedure?
  • Who will perform my breast reconstruction surgery?
  • How much breast tissue will be removed in my mastectomy?
  • Will I need radiation therapy?
  • How long will I stay in the hospital?
  • Will I need to return for additional surgery?

And remember, there really are no stupid questions. None. This is your surgery, you deserve to know about it, and Dr. Gorman is here to help you understand. Ask away and she will do her best to answer. She will help with your before questions, your after questions, and your it’s-been-a-while-but-this-just-occurred-to-me questions. Being informed is something she wants for all of her patients, and something she will do her best to ensure as she walks with you every step of the way.

Who performs a mastectomy?

A breast cancer surgeon will perform your mastectomy, and a plastic surgeon will perform your breast reconstruction should you have that done. When choosing your surgeon, Johns Hopkins recommends a surgeon who:

  • Specializes in breast cancer
  • Is recognized as a breast surgical oncologist
  • Performs many breast cancer surgeries each year

 

Looking at these qualifications, Dr. Valerie Gorman at the Texas Breast Center can be your breast cancer surgeon, and of course, is always ready to help. Her specialty is breast cancer surgery and its related topics. Her residency was in general surgery, though with a focus on detecting and treating breast cancer. She is also currently serving as the Chief of Surgery and Medical Director of Surgical Services at Baylor Scott & White Medical Center, as well as board-certified by the American Board of Surgery.

At the Texas Breast Center, mastectomies and other breast cancer surgeries are what Dr. Gorman is known for, and she performs them year-round.


Is Chemotherapy Necessary Before or After Breast Cancer Surgery, or At All?

Is Chemo necessary for breast cancerChemotherapy is an effective way to treat and prevent the spread of breast cancer, but new research suggests it is not always necessary.

A recent study found that breast cancer has been highly over treated with chemotherapy and doctors can now confidently provide an alternative treatment known as Endocrine Therapy.

However, each patient is different with a unique set of circumstances. Chemotherapy is necessary in advanced stages, as well as early stages when specific characteristics are present, such as spreading to the lymph nodes or other body parts.

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