CANCER CARE SPOTLIGHT: THE BEDSIDE MANNER (from an interview with Dr. Rajiv V. Datta)

In our unending search for inspiring clinicians and health specialists in the life-saving battle against cancer, our next spotlight goes to Rajiv V. Datta, MD, Director of the Division of Surgical Oncology and Head and Neck Surgery.  Dr. Datta is also the Medical Director of the Mount Sinai South Nassau. Dr. Datta is one of the leading head and neck surgeons in the U.S. and an international leader in surgical oncology.

Dr. Datta spent almost three decades in cancer care. Though his field is the surgical aspect of cancer care, he is also the director of the cancer program, which means that he oversees a comprehensive treatment of the cancer patient.  This includes surgical, medical, radiation, research, support services, radiation oncology, radiology. According to Dr. Datta, overseeing the wide scope of the cancer care process "is most gratifying". Having combined with Mount Sinai has given him more abilities for better technology, better expertise and better research.

 

DIRECT FROM THE INTERVIEW - By: Dr. Datta

PART 1: EMPATHY AND THE HUMAN CONNECTION IS MEDICINE #1

Oftentimes, patients are scared (of and) from this disease.  There's a lot of fear of the unknown and in today's world there is so much out on internet that it does may not ever give you the right answers about a specific condition... but it's usually scary.  Most of what's out there are horrific treatments and a horrific end of the patient. Understanding this, my first objective when seeing the patient is to talk about EMPATHY and that we are in this together. I address [the dark] loneliness of having cancer by expressing that WE ARE both are facing this same issue. They have cancer and my job is to guide them through the appropriate therapy so that we both can beat this thing-  and that to me is most important. I start with emotional support because they're facing a frightening diagnosis is anxiety, sadness, even sometimes anger.

I always explain to my team that if a patient is angry, they're not angry at you, they're angry at the diagnosis.  Never get into arguments with the patient because they have cancer-- it's not a level playing field. Compassion should start at the front desk when they call. We should bring them calm down and trust because the patients all seek to feel cared for. It's not about a doctor's line of degrees and all big words. If I have not connected with the patient, why would they even trust what I'm saying? It's the human connection. They have to trust who I am before they can start believing all the fancy stuff I'm trying to do.

THWARTING STRESS: What are the things the most stressful? It's amazing that what I think may be the most stressful part of the diagnosis may not be the patient's stressful part. Part of connecting with the patient is finding and addressing what is causing the patient stress. This can be quite complexed. I take time to listen to their question and answers and concerns and I never interrupt them because patients are not experts. By the time they come to me, they've looked on the internet, they have had 10 people talk to everybody in the family is a doctor. Everybody's telling them what to do. My job is just to listen to them. What do they think is going on with them and what are they concerned about? And then one by one, I break down what's going on, what is the reality?

BREAK DOWN THE MYTHS: I can tell you after my talk that the majority keep the entire folder site to the side. The more compassionate care earns the kind of trust between physician and patient, allowing them to accept the treatment in a more positive way- making for better outcome overall. If a patient is dragged into a treatment, the mind body healing may not allow for a good outcome. And finally, you also have to preserve their dignity where cancer can often make them feel their most vulnerable.  I always sit down when I talk because I'm very tall (6'4")  so I always sit down so I don't look like a towering person.

This level of connection is critical in building teamwork with the patient. It doesn't help to have a patient 'yessing' me- I need them to actually understand what I'm saying. They actually ask me pertinent questions and not being just a robot. Sometimes I stop my talk halfway if I sense that they're not asking me the right questions. Even when they come for a followup, we first spend a few minutes talking about who they are and what's going on with them.

To me, this synergy building is a great journey, which I try to navigate them through to get the best possible outcome.

"When you have a diagnosis of Cancer your first thought is where do I go? What do I do?  Will I live or die? When my son was diagnosed with Cancer in 1974 and my mother Breast Cancer the same time fear almost took over.  When my son asked me what he did wrong I realized I had to get the answers. Their diagnosis prepared me for when I was diagnosed with Breast Cancer and asking the right questions. But more importantly was getting the right Doctor. When I met Dr Rajiv Datta, I knew immediately he was the answer-not just for me but for so many who had Cancer. I admire his honesty, his dedication to his craft and his kindness to me as a patient.  He showed me the courage I needed to keep going by telling me the straight facts. I put my life in his hands and continue to do so to this day.  His understanding of Cancer and people (including our families) never ceases to amaze me. There isn't a place I go or a person that I mention his name that hasn't heard of his compassion and respect. Dr Datta is a great man and a wonderful Doctor with a beautiful family."

- Geri Barish, President of The Hewlett House

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Breast Cancer Incidence on Long Island: Environmental Impact
 A report by: Dr. Noelle Cutter (Molloy University) and Ben Honigsfeld

Breast cancer is a current health concern, affecting millions of women globally.  In 2023, it was the leading cause of death due to cancer in the United States (ref). While genetic factors and lifestyle choices play significant roles in its development, emerging evidence suggests that environmental exposures also contribute to breast cancer incidence rates. Long Island, New York, has garnered attention due to its elevated breast cancer rates compared to national averages, prompting investigations into the potential environmental factors driving this phenomenon. 

Whether environmental contaminants increase breast cancer risk among women on Long Island, NY, is unknown. In the early 1990s, breast cancer advocates petitioned the United States Congress to investigate the high rates of breast cancer on Long Island in the state of New York (1992-1996 117.8 per 100,000 in Nassau County, 113.6 in Suffolk county vs national average (NYS Cancer Registry, 2023). The resulting law led to the Long Island Breast Cancer Study Project (LIBCSP)--more than ten collaborative research projects designed to study the possible causes of this increased incidence of cancer. This project reported that there was no evidence that environmental exposures were responsible (ref, LIBCSP). However, the rate of BC on Long Island remains high compared to other regions in the United States (2016-2020 Nassau 145.9 and Suffolk 139.9) (NYS Cancer Registry, 2023). and has led to speculation that environmental risk factors remain an important cause of breast cancer. 

ENDOCRINE-DISRUPTING CHEMICALS (EDCS): Endocrine-disrupting chemicals (EDCs) are natural or human-made chemicals that may mimic, block, or interfere with the body’s hormones, which are part of the endocrine system. These chemicals are associated with a wide array of health issues, including cancers (Safe, 2000). Endocrine disruptors are found in many everyday products, including some cosmetics, food and beverage packaging, toys, carpet, and pesticides. Some chemicals that act as flame retardants may also be endocrine disruptors. Long Island’s environment is full of potential sources of EDCs, which have been linked to an increase in breast cancer development. 

A study by Soto et al. (2015) highlighted the presence of EDCs such as bisphenol A (BPA) and phthalates in everyday consumer products, including plastics and personal care items. These chemicals can interfere with hormonal signaling pathways, such as the estrogen, androgen, and growth factor signaling pathways. EDCs such as BPA, phthalates, and certain pesticides can mimic estrogen's action by binding to estrogen receptors (ERs) and activating estrogen-responsive genes and turning on downstream transcription factors which are involved in pathways associated with many cancers, including breast cancer. The Androgen Signaling Pathway can also be impacted by EPCs.  Androgens, such as testosterone, play crucial roles in the development and maintenance of male reproductive tissues and secondary sexual characteristics. EDCs can disrupt androgen signaling by interfering with androgen receptor (AR) activation or inhibiting androgen synthesis. This disruption can impact reproductive health, development, and hormone-sensitive tissues in both males and females (Akdag et al., 2016). 

Additionally, the Growth Hormone/Insulin-like Growth Factor (GH/IGF) Signaling Pathways are critical regulators of growth, development, and metabolism. EDCs like polychlorinated dibenzo-p-dioxins (PCDDs) and polychlorinated dibenzofurans (PCDFs) can interfere with GH/IGF signaling pathways, affecting cellular proliferation, differentiation, and apoptosis. Disruption of these pathways by EDCs may contribute to altered growth patterns and increased susceptibility to cancer and potentially increasing breast cancer risk. Moreover, Long Island's proximity to industrial sites and agricultural areas raises concerns about exposure to these environmental EDCs with studies suggesting a possible association between pesticide exposure and breast cancer incidence (Engel et al., 2017). Contact with these chemicals may occur through air, diet, skin, and water.

(See complete report)

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CHANGES IN BREAST CANCER CARE IN NEW YORK DURING THE COVID-19 PANDEMIC   By:  Alexandra Fiederlein | Cheyenne Rosado | Noelle Cutter

Breast cancer is the second most common malignancy among women in the United States. As such, the COVID-19 pandemic has caused medical facilities to change their methods of operation since March of 2020, including changes in diagnosis and treatment plans. New York (NY) has an unusually high incidence of breast cancer. This study analyzed the effects of the COVID-19 pandemic on breast cancer care (BCC) in NY. Women in NY that were diagnosed with or in remission for breast cancer were asked to take an online, anonymous survey regarding their BCC experience. For patients in treatment, 26% of women wished they had greater emotional support or had a family member included in their appointments. 39% of women do not feel they are receiving as good of care as before, while 31% feel they are receiving the same level of care. Additionally, 41% of women feel they received the same level of care over telemedicine. 

Our data show a negative correlation between the quality of care received during the pandemic and the wish for more emotional support and inclusion of supportive members in the care process (nonsignificant). There was less of a negative correlation between the quality of telemedicine care received during the pandemic and the wish for more emotional support and inclusion of supportive members in the care process (nonsignificant). This indicates that most women lacking emotional support reported worse BCC experiences, and telemedicine use was not as troublesome to patients as the lack of emotional support. Most women in treatment and in remission reported negative feelings like fear when asked about their BCC experiences. Our data show the importance of emotional support for breast cancer patients and those in remission during the COVID-19 pandemic. Our work could also provide clinicians with the knowledge necessary on how breast cancer care should be handled in an evolving pandemic such as COVID-19.

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A major concern is the presence of breast cancer in underserved communities, including those TOO YOUNG FOR A MAMMOGRAM.  Whereby the medical community touts the recommended (and legal/billable status) of getting a mammo scan should be between 40-50, what happens to the many women who do not fit this age criteria?  How would they even know to get checked without the support of their clinicians or an alarm from family history? Decades into the battle against breast cancer, clinicians and the public are much more educated about EARLY DETECTION, PREVENTION and the current protocols and modalities available to save lives.  Recent headlines on DENSE BREAST and the advancements in ULTRASOUND SCANNING supports a major part of this battle. SEE COMPLETE FEATURE

WATERBURY, Conn. (October 12, 2023) JOE CAPPELLO/ARE YOU DENSE? FOUNDATION RECEIVES KEY TO THE CITY FROM MAYOR O'LEARY
Waterbury celebrated a citywide Pink Out on Thursday, October 26th! Saint Mary’s Hospital Foundation has once again partnered with the City of Waterbury to recognize Breast Cancer Awareness. Waterbury Mayor Neil O’Leary, Saint Mary’s Hospital President, Kim Kalajainen and special guest Joe Cappello will address organizers and volunteers from the Waterbury Police and Fire Departments as well as the Education Department, area students and others at 11:00 a.m.  at Waterbury City Hall.  

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PinkSmart NEWS: National Dense Breast Disclosure Law 9/10/2024

FOR IMMEDIATE RELEASE:

National Dense Breast Disclosure Law, takes effect on 9/10/2024

6/18/2024 - Hartford, CT.  The Are You Dense Foundation is proud to confirm the National Dense Breast Disclosure Law on September 10, 2024 at the Connecticut Legislative Office Building. This groundbreaking law aims to empower women by ensuring they receive crucial information about their breast density during mammography screenings.

Connecticut is taking the lead in championing breast density awareness, recognizing the importance of transparency and informed decision-making for women's well-being. The National Dense Breast Disclosure Law requires healthcare providers to inform patients about their breast density during mammography screenings. By providing this vital information, women can better understand their individual risk factors and seek appropriate medical care. Together, we will celebrate this historic moment and the power of knowledge in women's healthcare decisions.

This event marks a significant milestone in women's health.  According to co-founder and executive director Joe Cappello, "this law is a bold step in implementing this law is expected to set a national precedent...  in September, this law will become effective nationwide, ensuring that women across the country have access to this essential information.  This law showcases Connecticut's commitment to women's health and its determination to make a positive impact on a national scale. By raising awareness about breast density and empowering women with knowledge, lives can be saved and the overall well-being of women can be improved." 

This event is welcome to the public to attend. September 10, 2024 (11am - 1pm) at the at the Connecticut Legislative Office Building 300 Capitol Ave #5100, 2nd Floor, Hartford, CT. There will be guest speakers and a light lunch. For more info, visit: www.AreYouDense.org and www.AreYouDenseAdvocacy.org

 From the press room of:

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REMEMBERING NANCY

6/15/2024- In celebration of the upcoming birthday of the late Dr. Nancy Cappello (Oct. 30), the ICRS (Integrative Cancer resource Society) gives honor to her courage and life-saving pursuits to bring global awareness about the risks of Breast Cancer from the link to dense breast tissue.  Dr. Cappello’s work to inform women about the risks of dense breast tissue led to density inform laws in 35 states.  Her advocacy also led to bringing clinical reform to earlier detection screening. According to Dr. Roberta Kline (Women's Health Digest medical publisher) and Dr. Leslie Valle- Montoya (ICRS exec. director), "...though we all know her passing to earmark a major movement in women's health, honoring the birthdate of such a figure posthumously (we feel) better resonates a more loving and eternal remembrance of message by breathing continued life to her legacy!"  (See original source: ITN NEWS)

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Breast Cancer Incidence on Long Island: Environmental Impact

 A report by: Dr. Noelle Cutter (Molloy University) and Ben Honigsfeld

Breast cancer is a current health concern, affecting millions of women globally.  In 2023, it was the leading cause of death due to cancer in the United States (ref). While genetic factors and lifestyle choices play significant roles in its development, emerging evidence suggests that environmental exposures also contribute to breast cancer incidence rates. Long Island, New York, has garnered attention due to its elevated breast cancer rates compared to national averages, prompting investigations into the potential environmental factors driving this phenomenon. 

Whether environmental contaminants increase breast cancer risk among women on Long Island, NY, is unknown. In the early 1990s, breast cancer advocates petitioned the United States Congress to investigate the high rates of breast cancer on Long Island in the state of New York (1992-1996 117.8 per 100,000 in Nassau County, 113.6 in Suffolk county vs national average (NYS Cancer Registry, 2023). The resulting law led to the Long Island Breast Cancer Study Project (LIBCSP)--more than ten collaborative research projects designed to study the possible causes of this increased incidence of cancer. This project reported that there was no evidence that environmental exposures were responsible (ref, LIBCSP). However, the rate of BC on Long Island remains high compared to other regions in the United States (2016-2020 Nassau 145.9 and Suffolk 139.9) (NYS Cancer Registry, 2023). and has led to speculation that environmental risk factors remain an important cause of breast cancer. 

ENDOCRINE-DISRUPTING CHEMICALS (EDCS):
Endocrine-disrupting chemicals (EDCs) are natural or human-made chemicals that may mimic, block, or interfere with the body’s hormones, which are part of the endocrine system. These chemicals are associated with a wide array of health issues, including cancers (Safe, 2000). Endocrine disruptors are found in many everyday products, including some cosmetics, food and beverage packaging, toys, carpet, and pesticides. Some chemicals that act as flame retardants may also be endocrine disruptors. Long Island’s environment is full of potential sources of EDCs, which have been linked to an increase in breast cancer development. 

A study by Soto et al. (2015) highlighted the presence of EDCs such as bisphenol A (BPA) and phthalates in everyday consumer products, including plastics and personal care items. These chemicals can interfere with hormonal signaling pathways, such as the estrogen, androgen, and growth factor signaling pathways. EDCs such as BPA, phthalates, and certain pesticides can mimic estrogen's action by binding to estrogen receptors (ERs) and activating estrogen-responsive genes and turning on downstream transcription factors which are involved in pathways associated with many cancers, including breast cancer. The Androgen Signaling Pathway can also be impacted by EPCs.  Androgens, such as testosterone, play crucial roles in the development and maintenance of male reproductive tissues and secondary sexual characteristics. EDCs can disrupt androgen signaling by interfering with androgen receptor (AR) activation or inhibiting androgen synthesis. This disruption can impact reproductive health, development, and hormone-sensitive tissues in both males and females (Akdag et al., 2016). 

Additionally, the Growth Hormone/Insulin-like Growth Factor (GH/IGF) Signaling Pathways are critical regulators of growth, development, and metabolism. EDCs like polychlorinated dibenzo-p-dioxins (PCDDs) and polychlorinated dibenzofurans (PCDFs) can interfere with GH/IGF signaling pathways, affecting cellular proliferation, differentiation, and apoptosis. Disruption of these pathways by EDCs may contribute to altered growth patterns and increased susceptibility to cancer and potentially increasing breast cancer risk. Moreover, Long Island's proximity to industrial sites and agricultural areas raises concerns about exposure to these environmental EDCs with studies suggesting a possible association between pesticide exposure and breast cancer incidence (Engel et al., 2017). Contact with these chemicals may occur through air, diet, skin, and water.

AIR & WATER POLLUTION:
Long Island's densely populated urban areas are susceptible to high levels of air pollution, including particulate matter and volatile organic compounds (VOCs), which have been implicated in breast cancer development (Hystad et al., 2013). Additionally, concerns have been raised about groundwater contamination from industrial activities and pesticide runoff from agricultural lands. A case control study investigating pesticide use on Long Island identified that women using higher amounts of pesticide in and around their homes had a greater than 30% increase in risk of developing breast cancer. In addition, use of most individual and combined lawn and garden pesticides examined by the study identified a consistent elevation in breast cancer risk (Teitelbaum et al., 2007). 

However, the lack of dose-response relationship and conflict of the LIBCSP study results indicates the need for additional research. In addition to pesticides, a major source of contamination is due to the Navy-Grumman groundwater plume. Beginning operation in the 1930s, the 600 acre Northrop Grumman-Bethpage Facility and Naval Weapons Industrial Reserve plant site was utilized for military industry and research until 1996 (DOJ, 2022). During this time, Northrop Grumman’s activities lead to the contamination of the soil and groundwater with volatile organic compounds, polychlorinated biphenyls, metals, and many others (NYSDOH, 2022). These contaminants were first detected in the 1970s, allowing for decades of unopposed groundwater, soil and air contamination. 

Furthermore, the New York Department of Health estimates that groundwater contamination reaches up to 750 feet deep, and stretches over 3800 acres (NYSDOH, 2022). This dumping took place on land now surrounded by residential neighborhoods, thus posing a major hazard to the community. As of March 2024, buried contaminants are still being discovered, with additional potential sources still expected to be present (DEC, 2024). 

There was also detection of similar contaminants at the Naval Weapons Industrial Reserve Plant in Calverton in eastern Long Island, which resulted in closure of all wells on the contaminated property in 2012 (NYSDOH, 2022). Amongst the contaminants identified as part of the Northrop-Grumman plume, concerns have been raised regarding 1,4 dioxane in particular, a solvent stabilizer rated by the EPA as a likely human carcinogen. In an evaluation of 4,400 water sources across the country, the EPA identified Long Island as having among the highest levels of 1,4 dioxane (EPA, 2021). In response, the Yale Superfund Research Center has initiated a series of 4 projects to measure the exposure to 1,4 dioxane and connection to adverse biological effects (Kim & Fortner, N.D.). 

In addition to spillage from Northrop-Grumman, the Hooker Chemical & Plastics Corp./Ruco Polymer Corp plant formerly located in Hicksville was discovered to have contaminated the groundwater with vinyl chloride, trichloroethylene, barium, cadmium, organic acids, and other compounds due to dumping practices. These activities were discovered in 1984 after several decades of operation, and groundwater cleanup is still underway (EPA, N.D.). Unfortunately, It is clear that Long Island has suffered decades of hazardous waste exposure through soil, water, and air. 

A study by Gammon et al. (2002) found an association between residential proximity to hazardous waste sites and increased breast cancer risk among Long Island women, highlighting the potential role of environmental pollutants in driving breast cancer incidence rates. Besides cancer, environmental pollution has also been linked to increased rates of cardiovascular, reproductive, neurological, gastrointestinal, respiratory, and developmental disorders among other complications (Shetty et al. 2023).

RADIATION EXPOSURE:
Long Island's history of nuclear facilities and radioactive waste sites raises concerns about radiation exposure and its impact on breast cancer risk. Namely, the Shoreham Nuclear Power Plant, decommissioned in 1994 before becoming fully operational due to public safety concerns. During the breakdown process, 5 million pounds of radioactive waste via 353 truckloads, as well as water barges to remove 560 irradiated fuel assemblies was required (NYT, 1994). In Upton, Suffolk County, Brookhaven National Laboratory experienced a tritium leak in 1998, leading to tritium in the groundwater above the state and federal drinking levels (Brookhaven Bulletin, 1998). This culminated in a shutdown of the High Flux Beam Reactor (ANS, 2022). The extent and harm of the leak remains a point of controversy, and has been designated as a superfund site by the EPA and is under periodic 5-year review (EPA, 2024). 

Irradiated surfaces were treated and the area remains at normal background levels according to state officials . While medical imaging and radiation therapy contribute to some extent, historical exposure to ionizing radiation from nuclear facilities may have long-term health consequences. A study by Boice et al. (2012) suggested an increased risk of breast cancer among individuals exposed to low-dose ionizing radiation, emphasizing the importance of monitoring and mitigating radiation hazards in the environment. The effects of ionizing radiation on the destabilization of DNA have been well documented, with research particularly emphasizing double strand breakage, and generation of reactive oxygen and nitrogen species (Helm & Rudel, 2020). 

(Click image for full view)

Furthermore, ionizing radiation has been found to cause epigenetic alterations, including alterations in DNA methylation and histone acetylation (Pogribny, 2019). with regards to breast cancer specifically, no association was found with high levels of UV radiation and overall breast cancer incidence (Gregoire et al., 2022) However, ionizing radiation has been demonstrated to increase the incidence of breast cancer in women in a dose-dependent manner, especially when the exposure occurs at a young age (Helm & Rudel, 2020).

Addressing the environmental impact on breast cancer incidence requires a collaborative effort involving community engagement, advocacy, and policy interventions. Clearly, more research is needed to ascertain the environmental impact on the increased incidence of breast cancer on Long Island.  By leveraging scientific research, community engagement, and policy advocacy, Long Island can work towards reducing breast cancer incidence rates and improving the overall health and well-being of its residents. 

References: https://prevention101.org/refs_6-13-2024-N.Cutter.html

CONTRIBUTORS

DR. NOELLE CUTTER is a professor of biology, ironman finisher, and advocate for dense breast screening.  United with an expanding research team dedicated to collecting data on women with dense breasts and screening options for these patients, her initiative aims to investigate and gather conclusive information about dense breasts in specific groups- including age, body mass index, and amount of physical activity and the underlying diagnostics of breast cancer tumors. This research program is under a partnership with Molloy College and Dr. Robert Bard, expert diagnostic cancer imaging specialist in NYC and other colleagues from the NY Cancer Resource Alliance. 

BENJAMIN HONIGSFELD began his interest in cancer research as part of the Advanced Science Research program in high school. Since then, Benjamin has contributed to research and publications regarding ovarian cancer, medulloblastoma, and brownfield site remediation, earning awards at LISEF, and MACUB. Benjamin is currently a third year medical student at Ben-Gurion University of the Negev and co-president of the internal medicine interest group.

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ALSO SEE:

CHANGES IN BREAST CANCER CARE IN NEW YORK DURING THE COVID-19 PANDEMIC   By:  Alexandra Fiederlein | Cheyenne Rosado | Noelle Cutter

Breast cancer is the second most common malignancy among women in the United States. As such, the COVID-19 pandemic has caused medical facilities to change their methods of operation since March of 2020, including changes in diagnosis and treatment plans. New York (NY) has an unusually high incidence of breast cancer. This study analyzed the effects of the COVID-19 pandemic on breast cancer care (BCC) in NY. Women in NY that were diagnosed with or in remission for breast cancer were asked to take an online, anonymous survey regarding their BCC experience. For patients in treatment, 26% of women wished they had greater emotional support or had a family member included in their appointments. 39% of women do not feel they are receiving as good of care as before, while 31% feel they are receiving the same level of care. Additionally, 41% of women feel they received the same level of care over telemedicine. 

Our data show a negative correlation between the quality of care received during the pandemic and the wish for more emotional support and inclusion of supportive members in the care process (nonsignificant). There was less of a negative correlation between the quality of telemedicine care received during the pandemic and the wish for more emotional support and inclusion of supportive members in the care process (nonsignificant). This indicates that most women lacking emotional support reported worse BCC experiences, and telemedicine use was not as troublesome to patients as the lack of emotional support. Most women in treatment and in remission reported negative feelings like fear when asked about their BCC experiences. Our data show the importance of emotional support for breast cancer patients and those in remission during the COVID-19 pandemic. Our work could also provide clinicians with the knowledge necessary on how breast cancer care should be handled in an evolving pandemic such as COVID-19.

 

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