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Blood plasma can harbor DNA changes that could flag cancer years before existing diagnostic tests, an early study hints.

The recent study, published May 22 in the journal Cancer Discovery, found traces of free-floating DNA from dead precancerous or cancerous cells in plasma that had been donated three years before a diagnosis.

LA JOLLA, CA, & PITTSBURGH, PA—New research from the University of Pittsburgh School of Medicine and La Jolla Institute for Immunology, published today in Nature Microbiology, reveals an opportunity for developing a therapy against cytomegalovirus (CMV), the leading infectious cause of birth defects in the United States.

Researchers discovered a previously unappreciated mechanism by which CMV, a herpes virus that infects the majority of the world’s adult population, enters cells that line the blood vessels and contributes to vascular disease. In addition to using molecular machinery that is shared by all herpes viruses, CMV employs another molecular “key” that allows the virus to sneak through a side door and evade the body’s natural immune defenses.

The finding might explain why efforts to develop prophylactic treatments against CMV have, so far, been unsuccessful. This research also highlights a new potential avenue for the development of future antiviral drugs and suggests that other viruses of the herpes family, such as Epstein-Barr and varicella-zoster virus (which causes chickenpox and shingles), could use similar molecular structures to spread from one infected cell to the next while avoiding immune detection.

“If we don’t know what weapons the enemy is using, it is hard to protect against it,” said senior author Jeremy Kamil, Ph.D., associate professor of microbiology and molecular genetics at Pitt. “We found a missing puzzle piece that represents one possible reason why immunization efforts against CMV have been unsuccessful.”

In the United States, approximately one in every 200 babies is born with congenital CMV infection. Of the babies infected, one in five will have birth defects, such as hearing loss, or go on to have long-term health challenges. For most adults, CMV infections are asymptomatic. But a CMV infection during pregnancy presents significant health risks to the developing child and could be deadly for people who are immunosuppressed, including organ transplant recipients.

Because of the large size of its genome and its complicated molecular machinery, CMV long evaded attempts to develop prophylactic treatments. Similar to other herpes viruses, CMV relies on a protein called gH to enter cells of the vessel lining. But unlike other herpes viruses, which use a protein partner called gL to facilitate infection, the new study found that CMV replaces gL with another partner called UL116 and recruits a protein called UL141. The resulting complex of gH-UL116-UL141, called GATE by the authors, then becomes an alternative tool for breaking into cells lining the blood vessels and causing internal damage while simultaneously preventing the body’s own immune system from recognizing the signs of infection.

The newly discovered GATE could become a potential vaccine target for CMV and other herpes viruses.

“Previous attempts to generate a CMV vaccine have failed, but that was before we identified the GATE complex. We hope that new strategies targeting GATE will improve our chances to combat CMV infection, and also perhaps cleanse our bodies of this lifelong infection,” said Chris Benedict, Ph.D., Associate Professor at La Jolla Institute for Immunology and co-senior author of the study with Kamil and LJI Professor, President & CEO Erica Ollmann Saphire, Ph.D., MBA. “If we can develop antiviral drugs or vaccines that inhibit CMV entry, this will allow us to combat the many diseases this virus causes in developing babies and immune-compromised people.”

Other authors of the study, “The GATE glycoprotein complex enhances human cytomegalovirus entry in endothelial cells,” are Michael Norris, Ph.D., of the University of Toronto; Lauren Henderson, Mohammed Siddiquey, Ph.D., both of Louisiana State University Health Shreveport; and Jieyun Yin, Ph.D., Kwangsun Yoo, Ph.D., Simon Brunel, Ph.D., and Michael Mor, Ph.D., all of La Jolla Institute for Immunology.

This research was supported by the National Institutes of Health (grants AI11685, AI139749, AI101423 and T32HL155022) and by ARPA-H APECx contract 1AY1AX000055.

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About the University of Pittsburgh School of Medicine

As one of the nation’s leading academic centers for biomedical research, the University of Pittsburgh School of Medicine integrates advanced technology with basic science across a broad range of disciplines in a continuous quest to harness the power of new knowledge and improve the human condition. Driven mainly by the School of Medicine and its affiliates, Pitt has ranked among the top recipients of funding from the National Institutes of Health since 1998. In rankings released by the National Science Foundation, Pitt is in the upper echelon of all American universities in total federal science and engineering research and development support.

Likewise, the School of Medicine is equally committed to advancing the quality and strength of its medical and graduate education programs, for which it is recognized as an innovative leader, and to training highly skilled, compassionate clinicians and creative scientists well-equipped to engage in world-class research. The School of Medicine is the academic partner of UPMC, which has collaborated with the University to raise the standard of medical excellence in Pittsburgh and to position health care as a driving force behind the region’s economy. For more information about the School of Medicine, see www.medschool.pitt.edu.

A three-dimensional model of lung tissue developed by University of Colorado Cancer Center member Chelsea Magin, PhD, will help the U.S. military better research, treat and prevent lung cancer.

“Military service members are more likely to develop lung cancer than the general population due to a combination of occupational exposures and lifestyle factors,” Magin explains. “Many veterans were exposed to hazardous substances, such as particulate matter from burn pits or diesel exhaust, during military service. Additionally, smoking rates among veterans are approximately twice as high as the general population. Due to these factors, nearly 1 million veterans remain at high risk for lung cancer.”

A three-dimensional model of lung tissue developed by CU Cancer Center member Chelsea Magin, PhD, will help the U.S. military better research, treat, and prevent lung cancer

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— CU Cancer Center (@cucancercenter.bsky.social) June 26, 2025 at 2:02 PM

Cancer in three dimensions

In response to a call for novel research on lung cancer treatment and prevention, Magin recently received a Department of Defense (DoD) grant for her 3D hydrogel lung modeling system, which she says is superior to the petri dish cultures commonly used to study lung cancer cells.

“Our research uses hydrogel materials that contain proteins from the lungs,” says Magin, principal investigator of the Bio-Inspired Pulmonary Engineering Laboratory in the Department of Bioengineering at the CU School of Medicine. “We want to compare healthy lungs, lungs from people who smoke, and lungs from lung cancer patients. We can put those proteins into our material, then put our material around a very thin slice of lung tissue that has all the cells and architecture of the lung. We can use that model to look at how the different proteins in the lungs influence the initiation of lung cancer.”

Collaborative effort

Magin’s research lab is also working with the lab of CU Cancer Center member Erin Schenk, MD, PhD, to study how different immunotherapy treatments interact with different types of lung tissue. The research also includes collaboration with Bradford Smith, PhD, associate professor of bioengineering, and CU Cancer Center member Robert Keith, MD, professor of pulmonary sciences and critical care medicine.

“The material that holds your cells together is called the extracellular matrix, and it’s made up of proteins and carbohydrates and other big molecules,” says Magin, also an associate professor in the Department of Pediatrics and Division of Pulmonary Sciences and Critical Care Medicine. “We think that different exposures, like being exposed to smoking or not, creates changes in that microenvironment that can influence the initiation of or susceptibility to cancer. It could also influence whether you are a good candidate for immunotherapy treatment.”

Predictive path

Over the course of the three-year project, Magin and her co-researchers plan to analyze the proteins they put into the hydrogels, looking for differing protein signatures in healthy, cancerous and smoke-exposed lungs.

“What we learn about how the tissue responds to each protein signature will help us understand things like, ‘If a patient has this protein signature, they’re more likely to get cancer, or their cancer is more likely to be aggressive,’” Magin says. “We also hope to learn which protein signatures are most responsive to the immunotherapies.”

Eventually, Magin hopes, the research could lead to a clinician’s ability to biopsy a small amount of lung tissue and analyze its protein signature to determine the best course of treatment.

“They could tailor the therapies based on that combination of proteins,” she says.

This article was originally published June 9, 2025, by the University of Colorado Cancer Center. It is republished with permission.

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From lowering blood pressure to reducing blood sugar levels, pomegranates are known for their many health benefits. But did you know that the peels are equally nourishing and a powerhouse of nutrients too? According to a study, the peel is a rich source of bioactive compounds with diverse pharmacological effects. It is a rich reservoir of antioxidants, polyphenols, dietary fiber, and vitamins, which contribute to its remarkable bioactivity. Studies have demonstrated the anti-inflammatory, cardioprotective, wound-healing, anticancer, and antimicrobial properties of pomegranate peel owing to the presence of phytochemicals, such as gallic acid, ellagic acid, and punicalagin. This piece of information explores the 5 key benefits of consuming pomegranate peel regularly.

Photo: Erdem Hospital via FL Communications

ISTANBUL, June 30, 2025 (GLOBE NEWSWIRE) — Erdem Hospital in Istanbul has announced the launch of a new pre-operative education program tailored specifically for bariatric patients. This initiative marks another step in the hospital’s ongoing commitment to compassionate, informed, and individualized care. By preparing patients more thoroughly emotionally, physically, and mentally before surgery, the program reinforces the hospital’s philosophy that true healing begins long before the operation itself.

Amid rising interest in weight management drugs like Ozempic, with their promise of rapid results, a growing number of people are turning to a more enduring path: gastric sleeve surgery. While pharmacological options may appeal for their convenience, many healthcare professionals emphasize that true, sustainable transformation often requires medical intervention rooted in both science and empathy.

The Promise of Permanent Change

Gastric sleeve, or sleeve gastrectomy, does more than restrict portions; it fundamentally reshapes hunger-regulating hormones and supports lasting metabolic adjustment. For patients seeking genuine change, not just a temporary shift, this surgery offers a lifelong solution rather than a short-term treatment.

In Istanbul, a prominent hospital has quietly achieved consistent success: performing thousands of gastric sleeve procedures with strong outcomes and patient satisfaction. With nearly 37 years of healthcare experience, Erdem Hospital has built a formidable reputation in bariatric care.

Patient Stories That Speak Volumes

Statistics tell one part of the story but it’s the voices of patients that truly capture the transformation:

“I can’t think of better care from the beginning to my discharge home… My only regret is not having my gastric sleeve surgery performed before. … Now I’m happy and have already lost 30 kg in four months.”

This testimonial underscores how life-changing the procedure can be, and that emotional reassurance is just as crucial as surgical skill.

Another article described the philosophy at Erdem Hospital, noting they treat patients “not as ‘cases’ or ‘surgeries,’ but as guests, companions, and… individuals navigating one of the most courageous decisions of their lives.” This ethos is woven into every interaction from multilingual coordinators helping arrange travel to personalized nutrition and mental wellness support.

A Caregiver-Driven Philosophy

Photo: Erdem Hospital

What sets this hospital apart is its caregiver model, a deeply human approach that sees each patient as a partner. The moment they arrive, every effort is made to provide comfort, clarity, and confidence.

Rather than delivering a pre-packaged service, the team offers guidance tailored to each individual’s story: family inclusion, culturally sensitive care, and remote follow-ups to make sure no one is left to navigate recovery alone. After all, healing isn’t complete at discharge; it lasts a lifetime.

A New Chapter in Compassionate Healthcare

In Istanbul, Erdem Hospital is laying the foundation for a new medical facility that reflects both its long-standing values and a modern understanding of patient care. Designed to meet the needs of international patients, the hospital will combine nearly four decades of clinical experience with thoughtful architectural choices and personalized support systems. Rather than focusing on luxury or high patient turnover, this new center is being built around trust, clarity, and comfort offering a calm, reliable space for those seeking not just treatment, but genuine healing.

Hope Returned, One Life at a Time

Photo: Erdem Hospital

In a world where fast fixes dominate headlines, this Istanbul hospital’s success reminds us of a simple truth: lasting impact requires deep care. Through thousands of gastric sleeve surgeries, they haven’t just impacted waistlines, they’ve restored ambition, renewed mobility, and reignited hope.

For patients wary of temporary solutions, this proves a powerful alternative: surgery rooted not in transaction, but in human trust and support.

Why This Matters Now

With obesity-related health issues soaring worldwide, they’re not the whole answer. Sales of weight-loss drugs may surge, but they come with questions about sustainability and side effects.

Here, the combination of proven surgical technique and a compassionate care framework offers a comprehensive pathway to health. It’s a reminder that behind every life-changing procedure is a story of vulnerability and a team dedicated to guiding healing.

Compassion + Expertise = Confidence to Heal

For anyone weighing their options be it medication or surgery what truly matters isn’t just efficacy, but the ecosystem of care around them. This Istanbul hospital is a testament to that model: extensive expertise supported by a caregiver philosophy that values human connection as much as clinical outcome.

In giving thousands of patients not just weight loss, but confidence and renewed purpose, they aren’t just performing surgeries, they’re seeding hope, one life at a time.

About Erdem Hospital

Photo: Erdem Hospital

Established in Istanbul in 1988, Erdem Hospital is one of Türkiye’s leading private healthcare networks, with three facilities specializing in bariatric surgery, organ transplantation, advanced diagnostics, and robotic systems.
More information: https://erdemhospital.com

Media Contact:

FL PR and Communications

Mail: info@erdemhospital.com

Web: https://erdemhospital.com/

asset@flcommunications.co.uk

Photos accompanying this announcement are available at: 

https://www.globenewswire.com/NewsRoom/AttachmentNg/9c513658-5f08-4625-8399-749fb6e44859

https://www.globenewswire.com/NewsRoom/AttachmentNg/488c58ff-8c0a-4693-8bf4-1a30ad29df13

https://www.globenewswire.com/NewsRoom/AttachmentNg/51cb2243-c70f-4360-a51a-9ecf972fec98

https://www.globenewswire.com/NewsRoom/AttachmentNg/8c3cd4a3-bc41-4b3f-b585-c5dac4ba19bf

Community-embedded healthcare: A critical strategy

Given these factors, embedding healthcare workers directly within communities is crucial. Dijon Jullien, a healthcare assistant on Gakaba Island, a small community bordering Suriname and French Guiana, has witnessed the positive impact of the country’s primary healthcare service on local malaria reduction. “When individuals visit the clinic, they feel reassured that they will receive proper care. The health assistants are like sisters to the community, making it easy for everyone to discuss their health concerns openly,” she shared.

From 2000 to 2005, Suriname faced a high malaria incidence, with about 160 reported cases per 1000 people. However, thanks to the country’s dedicated efforts – including universal access to diagnosis and treatment, an extensive network of community health workers, and nationwide malaria screening at border crossings – Suriname has successfully eliminated the disease.

“Being malaria-free means that our population is no longer at risk from malaria and will also have positive effects on our healthcare sector, the economy and tourism,” said Dr. Amar Ramadhin, Suriname’s Minister of Health. “We are the first Amazonian country to be malaria-free, setting an example for other nations in the region that are still struggling with this disease.”

PAHO has continued to collaborate with Suriname throughout the elimination process on the development of policies and programs to strengthen prevention, surveillance, and treatment.  With support from the US Government, PAHO has provided cooperation for the country’s anti-malaria campaign. In addition to support provide by the Global Fund since 2005, Suriname has also benefited from financing provided by the Inter-American Development Bank to tackle infectious diseases, including malaria.

Malaria is one of the diseases targeted by PAHO’s Disease Elimination Initiative, which aims to eliminate over 30 communicable diseases, including malaria, across the Americas by 2030. 

Introduction

Breast cancer, a common malignant tumor among women, poses a significant threat in China due to its high incidence and mortality rates.¹ Medical advancements have improved early detection and treatment, with surgery combined with adjuvant chemotherapy as the standard treatment.^2,3 While this regimen has increased five-year survival rates and reduced recurrence risks,^4–7 adjuvant chemotherapy still causes considerable biological toxicity, including side effects such as nausea, vomiting, and hair loss. These side effects severely impact patients’ daily lives and psychological well-being, reducing their overall quality of life.⁸ Additionally, chemotherapy often leads to physical and psychological stress, contributing to emotional disorders. Addressing these psychological challenges and improving patients’ care experiences have become critical focuses of breast cancer nursing research.⁹

Traditional Chinese culture often conceals bad news, especially regarding serious illnesses like cancer, imposing taboos that restrict emotional expression.^10,11 Breast cancer patients endure not only physical pain and discomfort during treatment but also enormous psychological stress.¹² Patients may feel the urge to express emotions but often struggle with whether others will understand or accept their feelings, leading to emotional expression conflicts.^13,14 Emotional expression conflict refers to the internal struggle individuals experience when they want to express emotions—whether positive or negative—while fearing negative social consequences or judgment from others.^15,16 This internal-external conflict exacerbates patients’ anxiety and depression, further impeding their treatment progress and negatively affecting their quality of life.¹⁷

Emotional expression conflict significantly contributes to psychological distress, physical discomfort, and social maladjustment among breast cancer patients.^18–20 Suppressing emotions and failing to express negative feelings can intensify anxiety, depression, impair immune function, and reduce treatment efficacy, thereby diminishing quality of life. Understanding the sources, characteristics, and influencing factors of emotional expression conflict is crucial for developing personalized interventions to improve patients’ mental health.²¹

This study is conceptually guided by the ABC-X model,^19,22 a widely used framework in family and psychological stress research. Within this model, A (stressor) refers to the diagnosis and chemotherapy of breast cancer; B (resources) includes individual and environmental protective factors such as family resilience; C (cognitive appraisal) is represented by cognitive fusion, reflecting how patients mentally process and internalize their cancer experience; and X (outcome) denotes the emotional expression conflict, viewed as a psychological adaptation response.

Based on this framework, we hypothesized that emotional expression conflict in breast cancer patients is shaped not only by objective stressors, but also by subjective interpretations and available resources. Therefore, the inclusion of family resilience and cognitive fusion as key variables in this study is theoretically grounded. Prior studies have supported the association between these factors and emotional regulation in cancer populations.

Currently, most studies on emotional expression conflict among cancer patients rely on scale scores to assess the overall level of emotional expression, but this approach does not account for the heterogeneity within patient populations.²³ Emotional expression conflict levels can vary significantly between individuals due to differences in psychological characteristics, living environments, cultural backgrounds, and disease cognition. To address this issue, this study employs Latent Profile Analysis (LPA) to explore the characteristics of emotional expression conflict and its potential influencing factors in breast cancer patients undergoing postoperative chemotherapy. By conducting a more nuanced group division and analysis, this study aims to provide more targeted psychological intervention strategies to reduce emotional expression conflict, enhance patients’ psychological adaptation, and improve long-term health outcomes.

In conclusion, this study not only focuses on the physiological treatment outcomes of breast cancer patients but also emphasizes their psychological and emotional responses during treatment. Through more refined emotional management, the goal is to help patients better cope with the physical and psychological challenges posed by cancer, thereby promoting comprehensive improvements in their treatment outcomes and quality of life.

Methods

Subjects

From March 2023 to March 2024, a convenience sampling method was employed to select breast cancer patients from the Breast and Oncology Wards of Fenyang Hospital in Shanxi Province as study participants. Inclusion criteria: ① Patients diagnosed with primary breast cancer based on histopathological examinations; ② Patients who have undergone surgery and completed at least one cycle of chemotherapy; ③ Female patients aged ≥18 years; ④ Patients who are aware of their medical condition and have a certain level of comprehension and expressive ability; ⑤ Patients who provided informed consent and voluntarily participated in the study. Exclusion criteria: ① Patients with recurrent breast cancer or distant metastasis; ② Patients with severe diseases of the heart, lungs, kidneys, liver, or other organs; ③ Patients with a history of mental illness or severe trauma. Based on research on sample size calculations, the required sample size was 5 to 10 times the number of observed variables.²⁴ With 21 independent variables in this study and considering a 20% invalid questionnaire rate, the required sample size ranged from 126 to 252 cases. Ultimately, 238 breast cancer patients were surveyed in this study.

Research Tools

Self-Designed Questionnaire: This questionnaire consists of two parts: demographic information and disease-related information. Demographic information includes age, marital status, education level, etc.; disease-related information includes pathological staging, chemotherapy cycles, and other relevant data. Personal information was provided by the patients themselves, while disease-related information was collected by the researchers through a review of the patients’ medical records.

Ambivalence over Emotional Expressiveness Questionnaire-G28 (AEQ-G28): Developed by King and Emmons,¹⁵ and translated and revised into Chinese by Ji Lili et al²⁵ this questionnaire measures emotional expression conflict in breast cancer patients. The Chinese version retains 24 items, which are based on the cognitive patterns of Chinese breast cancer patients, and is a unidimensional scale. It uses a 5-point Likert scale, ranging from “Never” to “Often”, scored from 0 to 4 points. Higher scores indicate a greater degree of emotional expression conflict. The scale demonstrated good reliability and validity, with a Cronbach’s alpha coefficient of 0.897 in this study.

Cognitive Fusion Questionnaire (CFQ): Developed by Gillanders et al²⁶ and adapted into Chinese by Zhang Weichen et al²⁷ only the CFQ-F version, consisting of 9 unidimensional items, was retained for use across different age groups. It employs a 7-point Likert scale, ranging from “Never” to “Always”, scored from 1 to 7 points, with total scores ranging from 9 to 63 points. Higher scores indicate a higher degree of cognitive fusion, reflecting more severe negative emotions and a tendency toward psychological rigidity. In this study, the scale’s Cronbach’s alpha coefficient was 0.866.

Family Resilience Assessment (FRA): This is the first family resilience assessment tool specifically developed for women with a history of breast cancer. Developed by Lane et al²⁸ and translated and revised into Chinese by Zhang Shanshan et al²⁹ in 2021, it assesses the family resilience levels of Chinese breast cancer patients. The scale includes five dimensions: positive attitude, family connectedness, social and economic resources, clear communication, and collaborative problem-solving, with a total of 28 items. The scale demonstrated good reliability and validity, with a Cronbach’s alpha coefficient of 0.834 in this study.

Data Collection

Before the survey, three investigators underwent standardized training. They used standardized instructions to explain the significance, objectives, and methods of the study to the patients and obtained their informed consent before instructing them to complete the questionnaires independently. Data collection was conducted with paper-based questionnaires. For patients who had difficulties reading or writing, the investigators assisted them in completing the questionnaires using neutral language. During the survey, patients were informed of the methods and precautions for completing the questionnaires. After the survey, the completeness of the questionnaires was checked, and any incomplete questionnaires were returned to the patients for correction. Once verified, the questionnaires were collected. In total, 280 questionnaires were distributed, of which 42 were invalid, leaving 238 valid responses and resulting in an effective recovery rate of 85%.

Statistical Processing

Latent profile analysis was performed using Mplus 8.3 software. Latent Profile Analysis (LPA) was employed to identify unobserved subgroups of emotional expression conflict based on 24 continuous item responses. Unlike traditional clustering methods such as K-means—which rely on distance metrics and assume equal variance—LPA models the probability of latent class membership and allows for statistical model selection using fit indices (AIC, BIC, entropy). This approach is especially suitable for uncovering psychological heterogeneity and identifying subtypes with clinical relevance. The model fit indices were the Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), Adjusted Bayesian Information Criterion (aBIC), Lo-Mendell-Rubin Likelihood Ratio Test (LMRT), Bootstrap Likelihood Ratio Test (BLRT), and Entropy. Lower values of AIC, BIC, and aBIC indicate a better model fit. The LMRT compares the differences between models with different latent classes. A P-value of <0.05 indicates that the k-class model fits significantly better than the (k-1)-class model. Based on the fit results, the optimal model was selected, categorizing breast cancer patients undergoing postoperative chemotherapy, and profile plots were generated.³⁰

Data analysis was performed using SPSS 27.0. Normally distributed quantitative data were expressed as means and standard deviations, and categorical data as frequencies and percentages. Chi-square tests and analysis of variance (ANOVA) were used to compare the general characteristics and questionnaire scores across different patient groups. Ordered logistic regression analysis was used to identify the influencing factors of emotional expression conflict among different categories of breast cancer patients. A P-value of <0.05 was considered statistically significant. To assess potential multicollinearity among predictors, we conducted correlation analysis and calculated Variance Inflation Factors (VIFs). All pairwise correlations were below 0.6, and VIF values were less than 3.0, indicating that multicollinearity did not significantly affect the model.

Results

General Characteristics of Breast Cancer Patients Undergoing Postoperative Chemotherapy

A total of 238 breast cancer patients were successfully surveyed, with ages ranging from 25 to 80 (mean age = 54.11 ± 14.52). Of these, 140 patients were from urban areas, and 98 from rural areas. The duration of illness was ≤0.5 years in 20 patients, between 0.5 and 1.5 years in 118 patients, and ≥1.5 years in 100 patients. Of the patients, 173 were married. The number of chemotherapy cycles was ≤3 in 79 patients, between 3 and 6 in 118 patients, and ≥6 in 41 patients. Health insurance covered 230 patients. Additionally, 66 patients had ≥2 comorbidities, and 76 had religious beliefs. A total of 122 patients underwent breast-conserving surgery. Other details are presented in Table 1.

Table 1 Univariate Analysis of Latent Categories of Emotional Expression Conflict in Breast Cancer Patients

Scores of Emotional Expression Conflict, Cognitive Fusion, and Family Resilience in Breast Cancer Patients

The emotional expression conflict score for breast cancer patients was 52.43 ± 16.56; the cognitive fusion score was 38.88 ± 7.37; and the family resilience score was 83.37 ± 14.39. The scores for the five dimensions—positive attitude, family connectedness, social and economic resources, clear communication, and collaborative problem-solving—were 12.53 ± 3.15, 30.58 ± 6.89, 14.98 ± 3.31, 13.50 ± 3.65, and 11.77 ± 3.17, respectively.

Latent Category Model Analysis and Naming of Emotional Expression Conflict in Breast Cancer Patients

Based on the 24 items measuring emotional expression conflict, latent category models ranging from 1 to 5 were constructed. Model fit indices, including Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), Adjusted Bayesian Information Criterion (aBIC), Entropy, Lo-Mendell-Rubin Likelihood Ratio Test (LMRT), and Bootstrap Likelihood Ratio Test (BLRT), were used to identify the heterogeneity of emotional expression conflict among breast cancer patients undergoing postoperative chemotherapy. The results of the latent profile analysis and the model fit indices are shown in Figure 1. As the number of models increased, the values of the AIC, BIC, and aBIC model fit indices gradually decreased. The VLMR values for models 4 and 5 were 0.294 and 0.117, respectively, which did not reach significant levels. This indicated that the fit of models 4 and 5 was not as good as that of model 3 (VLMR = 0.019). Moreover, the average probability of category membership in model 3 was 97.7%, 96.1%, and 98.8% for each category— all exceeding 90%, indicating high accuracy of category assignment and credible model results (see Table 2).

Table 2 Model Fit Indices for Latent Profile Analysis of Emotional Expression Conflict in Breast Cancer Patients (n = 238)

Figure 1 Latent profile distribution of emotional expression conflict among breast cancer patients receiving postoperative chemotherapy. The figure shows three distinct groups identified through latent profile analysis: ● Low Conflict Emotional Expression Group. ▲ Medium Conflict Emotional Expression Group □ High Conflict-Expression Inhibited Group.

The comprehensive analysis indicated that model 3 had the best fit, ultimately classifying emotional expression conflict in breast cancer patients into three latent categories. Based on their characteristics, the categories were named as follows:

Category 1 had low scores on all items, reflecting a low level of emotional expression conflict among breast cancer patients undergoing postoperative chemotherapy. This group was named the “Low Conflict Emotional Expression Group” (33.6%).

Category 2 had intermediate scores between Categories 1 and 3, with medium-level scores on all items. This group was named the “Medium Conflict Emotional Expression Group” (42.4%).

Category 3 had the highest emotional expression conflict scores among the three categories, particularly scoring high on the following items: Item 4”: When I am proud of an achievement, I want to tell others, but worry that they will think I am arrogant”. Item 5: “I try not to worry others, even when they should know the truth”. Item 6: “ When I want to express my feelings, I feel as if something is preventing me from doing so”. This group was named the High Conflict-Expression Inhibited Group” (23.9%).

Univariate Analysis of Latent Profile Analysis of Emotional Expression Conflict in Breast Cancer Patients

The univariate analysis revealed no statistically significant differences among the three patient groups in terms of marital status, residence, comorbidities, duration of illness, medical payment status, surgical method, number of chemotherapy cycles, or presence of religious beliefs (all P > 0.05), as shown in Table 1.

Multivariate Analysis of Factors Influencing Emotional Expression Conflict in Breast Cancer Patients

Using the latent categories of emotional expression conflict in breast cancer patients undergoing postoperative chemotherapy as the dependent variable (Low Conflict Emotional Expression Group = 1, Medium Conflict Emotional Expression Group = 2, High Conflict-Expression Inhibited Group = 3; with the High Conflict-Expression Inhibited Group as the reference), variables found to be statistically significant in the univariate analysis were included as independent variables in the logistic regression model. The parallelism test yielded χ²= 20.532, P = 0.197, confirming the suitability of an ordered logistic regression analysis. The results indicated that age (≤35 years = 1, 35–60 years = 2, ≥60 years = 3; with ≥60 years as the reference), sleep quality (Poor = 1, Fair = 2, Good = 3; with Good sleep quality as the reference), education level (Junior high school and below = 1, High school = 2, College/Vocational and above = 3; with College/Vocational and above as the reference), per capita monthly household income (≤3000 RMB = 1, 3000–5000 RMB = 2, ≥5000 RMB = 3; with ≥5000 RMB as the reference), cognitive fusion (original score input), and family resilience (original score input) were significant factors influencing the latent categories of emotional expression conflict among breast cancer patients undergoing postoperative chemotherapy. The detailed results are presented in Table 3.

Table 3 Multivariate Analysis of Latent Profiles of Emotional Expression Conflict in Breast Cancer Patients Undergoing Postoperative Chemotherapy (n=238)

Discussion

Heterogeneity in Emotional Expression Conflict Among Breast Cancer Patients

Breast cancer is one of the most common malignant tumors among women globally, and its rising incidence poses a significant threat to women’s health. In recent years, with advancements in early screening and treatment technologies, surgery combined with adjuvant chemotherapy has become the standard treatment regimen, significantly improving the survival rate of patients. However, despite the remarkable progress in treatment, patients still face substantial physiological and psychological stress during the process. Especially during postoperative chemotherapy, patients not only endure severe physical side effects but also experience emotional fluctuations such as anxiety, depression, and fear, which impact their emotional regulation and psychological adaptation. Emotional expression conflict, as a common psychological response, has become an important factor influencing the mental health of breast cancer patients. During treatment, patients often suppress or experience conflict in expressing their emotions due to concerns that others may not understand or accept them. This internal-external emotional conflict not only exacerbates their psychological burden but may also affect their treatment outcomes and quality of life. Therefore, a comprehensive exploration of the sources and influencing factors of emotional expression conflict in breast cancer patients is of great significance for developing more effective psychological interventions to improve patients’ mental health.

The results of this study indicate that the emotional expression conflict score for breast cancer patients undergoing postoperative chemotherapy was 52.43 ± 16.56, which is consistent with the findings of Li Xuekun²⁵ in middle-aged and young patients. Latent profile analysis revealed that emotional expression conflict among patients was categorized into three groups: the “Low Conflict Emotional Expression Group” (33.6%), the “Medium Conflict Emotional Expression Group” (42.4%), and the “High Conflict, Expression Inhibited Group” (23.9%).

Low Conflict Emotional Expression Group: This group exhibited a generally low level of emotional expression conflict. This may be attributed to the fact that patients in this group tend to be older, have higher educational levels, and possess extensive life experience. Consequently, they are better equipped to calmly and rationally handle significant life changes and effectively regulate their emotions. For such patients, healthcare providers should maintain effective communication, continuously monitor changes in their emotional states, and proactively address any barriers to emotional expression.

Medium Conflict Emotional Expression Group: This group comprised the largest number of patients, which may be due to these patients having a preliminary understanding of their illness and basic emotional management skills. However, they may struggle to integrate their cognitive understanding with their actions, resulting in obstacles to emotional expression. Healthcare providers should equip these patients with appropriate emotional expression pathways and techniques, encouraging them to express their emotions. Additionally, it is crucial to actively monitor the emotional distress in this category of patients to prevent their transition into the high conflict group.

High Conflict-Expression Inhibited Group: Patients in this category exhibited the highest levels of emotional expression conflict. This may be because many study participants are middle-aged and young women who, due to treatment, experience changes in their physical appearance related to breast cancer. As a result, they may be more sensitive to bodily defects and struggle with psychological regulation. Moreover, patients in this group demonstrated lower levels of family resilience and had fewer accessible family and social resources, exacerbating their fear of communicating with family members and making emotional expression more challenging. Therefore, healthcare professionals should proactively identify high-risk patients early on and implement stratified interventions tailored to the different categories of breast cancer patients. Encouraging self-disclosure and reducing emotional expression conflict levels are essential strategies for improving patient outcomes.

Multiple Factors Affecting the Categories of Emotional Expression Conflict in Breast Cancer Patients Undergoing Postoperative Chemotherapy

Education Level and Per Capita Monthly Household Income

Lower-educated patients exhibited significantly higher likelihood of High Conflict-Expression Inhibited Group membership compared to Low/Medium Conflict Groups (all P<0.05). This association may arise through two pathways: (a) Limited health literacy impedes emotional articulation and breast cancer knowledge acquisition, fostering shame-driven expression avoidance;³¹ (b) Reduced per capita income linked to lower education amplifies treatment-related financial strain,³² exacerbating familial guilt and emotional suppression.

Higher-educated counterparts demonstrated superior emotional regulation through enhanced illness comprehension. Clinical interventions should prioritize: (a) Simplified health education materials (such as short videos);³¹ (b) Family communication training using plain language;³³ (c) Mitigation of hierarchical doctor-patient dynamics in China to promote therapeutic dialogue.³³

Age and Sleep Quality

This study found that, compared to the Low Conflict Emotional Expression Group and the Medium Conflict Emotional Expression Group, younger patients and those with poorer sleep quality were more likely to belong to the High Conflict—Expression Inhibited Group (P < 0.05). Studies have shown that younger breast cancer patients have more active hormone metabolism, faster cell proliferation, earlier metastasis, higher risks of disease staging, recurrence, and mortality, and poorer prognosis.³⁴ The patients in this study were mostly middle-aged and young, carrying multiple social roles. Cancer not only increases their economic burdens but also hinders career development, leading to a loss of social roles and preventing them from achieving self-worth. Moreover, anticancer treatments inevitably cause destruction or loss of fertility,³⁵ adding psychological pressure and emotional conflicts to younger patients.¹⁴ Additionally, younger women have a higher prevalence and severity of sleep disorders,³⁶ and treatments such as surgery and chemotherapy are common causes of sleep disturbances.³⁷ Patients with poorer sleep quality experience lighter sleep, difficulty falling back asleep after waking, and long-term sleep deprivation, which can easily disrupt physiological rhythms, impair emotional cognition and regulation functions, and lead to emotional expression conflicts.³⁸ Furthermore, these patients are prone to daytime lethargy and drowsiness, leading to difficulties in concentration and handling various tasks. This results in the continuous accumulation of negative emotions, increasing the likelihood of emotional expression conflicts. Therefore, healthcare providers should pay more attention to younger breast cancer patients, disseminate disease knowledge and psychological care, encourage them to face cancer, strengthen health education on disease communication, and encourage them to seek help from their support systems to alleviate physical and mental stress and burdens. Additionally, healthcare providers should help patients improve sleep quality through methods such as mindfulness training to enhance their perception of their physiological states, thereby increasing their sense of self-control and improving their ability to regulate emotions.

Cognitive Fusion

The results of this study showed that, compared to the Low Conflict Emotional Expression Group and the Medium Conflict Emotional Expression Group, patients with higher levels of cognitive fusion were more likely to belong to the High Conflict—Expression Inhibited Group. Psychological rigidity can cause patients to experience negative emotions during the rehabilitation process, leading to distorted cognitions influenced by their subjective awareness. This makes it difficult to process their emotions and increases their psychological burden,³⁹ which can lead to emotional expression conflicts. This suggests that healthcare providers should pay attention to patients with different psychological states, help them establish accurate disease cognition, address their doubts, build positive beliefs, and adopt a rational attitude toward coping with the disease. Additionally, healthcare providers should guide patients to appropriately express their needs and improve their emotional management abilities.

Family Resilience

Regression analysis showed that patients with lower family resilience were more likely to belong to the High Conflict—Expression Inhibited Group compared to the Low and Medium Conflict Groups. Family resilience refers to a family’s capacity to mobilize internal and external resources to adapt to illness challenges.⁴⁰ Higher family resilience correlates with harmonious relationships and optimistic disease attitudes, promoting proactive emotional expression and reducing conflicts. When families actively listen to patients, mutual understanding improves, enabling better coping with disease stress and forming a resilience-conflict resilience cycle.

Therefore, healthcare providers should conduct comprehensive and multi-dimensional assessments for patients, offer sufficient emotional care to patients with low family resilience, establish good communication with patients and their families, encourage family members to participate in the patient’s treatment, and provide patients with more family support. Additionally, healthcare providers should monitor the psychological development trends of patients and offer targeted assistance in a timely manner.

This study identified age, education, income, sleep quality, cognitive fusion, and family resilience as key predictors of emotional conflict in breast cancer patients. These findings underscore the urgent need for personalized nursing interventions, including cognitive-behavioral and mindfulness therapies to improve emotional regulation, alongside family-centered strategies to strengthen resilience and communication dynamics. While preliminary, the results emphasize the critical role of integrated psychological support and family engagement in oncology care. Future multi-center studies with larger cohorts are warranted to validate these findings and refine culturally adaptive intervention frameworks.

Limitations and Future Research

Despite the meaningful findings, several limitations of this study should be considered, which also highlight directions for future research. The use of self-report instruments may introduce bias due to measurement error. Although we employed validated tools with strong psychometric properties, the reliance on observed total scores rather than latent constructs may limit precision. Structural Equation Modeling (SEM), which offers advantages for testing causal pathways and explicitly modeling measurement error, was not employed in this exploratory study, which aimed primarily to identify latent subgroups of emotional expression conflict and examine associated influencing factors.

Furthermore, while our analysis identified several significant correlates of subgroup membership, we did not examine potential mediating or moderating effects—such as the roles of cognitive fusion or family resilience—due to the cross-sectional design and modest sample size (n = 238). Future research should adopt longitudinal designs and SEM-based frameworks to rigorously explore the psychological mechanisms underlying emotional expression conflict in breast cancer patients.

Although the variable-to-sample ratio in our regression analysis meets recommended thresholds, the possibility of Type I error cannot be excluded. Future studies should consider larger sample sizes and explore alternative modeling techniques, such as penalized regression (eg, LASSO), to ensure the robustness of the findings.

Conclusion

Emotional expression conflicts among breast cancer patients undergoing postoperative chemotherapy exhibit distinct categorical characteristics. Age, education level, per capita monthly income, sleep quality, cognitive fusion, and family resilience are key influencing factors for different categories of emotional expression conflict. It is recommended that nursing staff promptly implement personalized psychological interventions, cognitive-behavioral therapy, mindfulness-based interventions, and other strategies to encourage patients to actively express their emotions and describe their experiences. This can help reduce the sense of guilt following a cancer diagnosis and alleviate emotional expression conflicts. The sample size of this study was relatively small, and future research should involve multi-regional, large-sample surveys to further validate and refine the conclusions drawn in this study. Furthermore, as the global demand for cancer care continues to rise, the findings of this study offer valuable insights for emotional support and psychological health interventions in oncology nursing practices worldwide.

Ethics Approval

This study was reviewed and approved by the Ethics Committee of Fenyan College of Shanxi Medical University. The ethics approval number is 2023031. Informed consent was obtained from all patients, and the process was reviewed by the Ethics Committee of Fenyan College of Shanxi Medical University. The study was conducted in accordance with the ethical standards set forth in the 1964 Declaration of Helsinki and its later amendments.

Author Contributions

Zhaoxia Tian and Ruishan Sheng contributed equally to this work and are co-first authors. All authors made substantial contributions to the work reported, including in the conception, study design, execution, data acquisition, analysis and interpretation, or in all these areas; participated in drafting, revising, or critically reviewing the manuscript; approved the final version to be published; agreed on the journal to which the article has been submitted; and are accountable for all aspects of the work.

Funding

The authors received the following financial support for the research, data collection, authorship, and publication of this article: This study was funded by the Science and Technology Project of Lvliang City, Key Laboratory Project of Clinical Nursing Research (No. 2020ZDSYS15).

Disclosure

The authors declare that there are no financial or non-financial competing interests associated with the conduct or publication of this research.

References

1. Tao X, Li T, Gandomkar Z, Brennan PC, Reed WM. Incidence, mortality, survival, and disease burden of breast cancer in China compared to other developed countries. Asia Pac J Clin Oncol. 2023;19(6):645–654. doi:10.1111/ajco.13958

2. Sun K, Zhang B, Lei S, et al. Incidence, mortality, and disability-adjusted life years of female breast cancer in China, 2022. Chin Med J. 2024;137(20):2429–2436. doi:10.1097/cm9.0000000000003278

3. Wan X. The relationship between perceived stress and posttraumatic growth in breast cancer patients after chemotherapy and the mediating effect. [Master’s thesis] Henan Agricultural University; 2023. 10.27114/d.cnki.ghnau.2023.001774.

4. Trayes KP, Cokenakes SEH. Breast cancer treatment. Am Fam Physician. 2021;104(2):171–178.

5. Wang X, Feng Z, Huang Y, et al. A nomogram to predict the overall survival of breast cancer patients and guide the postoperative adjuvant chemotherapy in China. Cancer Manag Res. 2019;11:10029–10039. doi:10.2147/CMAR.S215000

6. Wang X, Ouyang Q. Survival analysis of 4720 female breast cancer cases. J Hunan Norm Univ. 2014;11(3):35–40.

7. Keilty D, Nezafat Namini S, Swain M, et al. Patterns of recurrence and predictors of survival in breast cancer patients treated with neoadjuvant chemotherapy, surgery, and radiation. Int J Radiat Oncol Biol Phys. 2020;108(3):676–685. doi:10.1016/j.ijrobp.2020.04.044

8. Schettini F, Nucera S, Pascual T, et al. Efficacy and safety of antibody-drug conjugates in pretreated HER2-low metastatic breast cancer: a systematic review and network meta-analysis. Cancer Treat Rev. 2025;132:102865. doi:10.1016/j.ctrv.2024.102865

9. Lahart IM, Metsios GS, Nevill AM, Carmichael AR. Physical activity for women with breast cancer after adjuvant therapy. Cochrane Database Syst Rev. 2018;1(1):CD011292. doi:10.1002/14651858.CD011292.pub2

10. Zhang F, Meng X, Ye P. Study on psychological resilience and influencing factors in breast cancer patients. Chin J Nurs. 2015;50(9):1087–1090.

11. Zhu P, Fu J, Wang B, et al. Care burden and influencing factors among spouses of 243 breast cancer patients. Chin J Nurs. 2013;48(8):718–721.

12. Penberthy JK, Stewart AL, Centeno CF, Penberthy DR. Psychological aspects of breast cancer. Psychiatr Clin North Am. 2023;46(3):551–570. doi:10.1016/j.psc.2023.04.010

13. Tsai W, Lu Q. Ambivalence over emotional expression and intrusive thoughts as moderators of the link between self-stigma and depressive symptoms among Chinese American breast cancer survivors. J Behav Med. 2019;42(3):452–460. doi:10.1007/s10865-018-9996-6

14. Cao X, Bao Y, Luo J, Zeng L, Chen G. Research progress on emotional expression conflicts in breast cancer patients. Chin J Nurs. 2023;58(21):2598–2603.

15. King LA, Emmons RA. Conflict over emotional expression: psychological and physical correlates. J Pers Soc Psychol. 1990;58(5):864–877. doi:10.1037/0022-3514.58.5.864

16. Ji L, Wang L, Q L, Lu G. Reliability and validity of the Chinese version of the emotional expression conflict questionnaire in breast cancer patients. Chin J Behav Med Brain Sci. 2018;27(12):1138–1142. doi:10.3760/cma.j.issn.1674-6554.2018.12.017

17. IHC W, McNeill LH, Lu Q. Ambivalence over emotional expression and physical functioning and limitations: mediating and moderating effects of PTSD symptoms and acculturation among Chinese breast cancer survivors. Support Care Cancer. 2019;27(1):311–319. doi:10.1007/s00520-018-4329-4

18. Chen L, Liu Y. A review of research on emotional expression conflict abroad. J Guangzhou Univ. 2012;11(3):43–48.

19. Lu Q, Man J, You J, LeRoy AS. The link between ambivalence over emotional expression and depressive symptoms among Chinese breast cancer survivors. J Psychosom Res. 2015;79(2):153–158. doi:10.1016/j.jpsychores.2015.01.007

20. Ji LL, Tsai W, Sun XL, et al. The detrimental effects of ambivalence over emotional expression on well-being among Mainland Chinese breast cancer patients: mediating role of perceived social support. Psycho Oncol. 2019;28(5):1142–1148. doi:10.1002/pon.5069

21. Han E, Tao X, Zhang Z, Li J, Xu H. Empathy fatigue and its influencing factors among operating room nurses based on the ABC-X model. Chin J Health Psychol. 2021;29(7):1046–1050. doi:10.13342/j.cnki.cjhp.2021.07.020

22. Li L, Zhang X, Ba R. Application of the ABC-X model in improving negative emotions and quality of life in patients with colorectal cancer. J Pract Tradit Chin Intern Med. 2022;36(3):141–143. doi:10.13729/j.issn.1671-7813.Z20211421

23. Miaskowski C, Barsevick A, Berger A, et al. Advancing symptom science through symptom cluster research: expert panel proceedings and recommendations. J Natl Cancer Inst. 2017;109(4):djw253. doi:10.1093/jnci/djw253

24. Ni P, Chen J, Liu N. Sample size estimation in quantitative nursing research. Zhonghua Hu Li Za Zhi. 2010;45(4):378–380. doi:10.3761/j.issn.0254-1769.2010.04.037

25. Li X, Du R, Cui P, et al. Mediating effect of fear of progression between emotional expression conflict and social alienation in young and middle-aged breast cancer patients. Chin J Health Psychol. 2022;30(11):1632–1637. doi:10.13342/j.cnki.cjhp.2022.11.007

26. Gillanders DT, Bolderston H, Bond FW, et al. The development and initial validation of the cognitive fusion questionnaire. Behav Ther. 2014;45(1):83–101. doi:10.1016/j.beth.2013.09.001

27. Cao J, Ji Y, Zhu Z. Reliability and validity of the Chinese version of the acceptance and action questionnaire-II among college students. Chin Ment Health J. 2013;27(11):873–877. doi:10.3969/j.issn.1000-6729.2013.11.014

28. Duncan-Lane C, Meszaros PS, Savla J. Measuring Walsh’s family resilience framework: reliability and validity of the family resilience assessment among women with a history of breast cancer. Marriage Fam Rev. 2016;53(7):667–682. doi:10.1080/01494929.2016.1263588

29. Zhang S, Li H, Song J, Zhou M, Gao J, Li J. Sinicization and psychometric evaluation of the family resilience assessment scale in breast cancer patients. J Nurs Sci. 2021;28(24):1–5. doi:10.16460/j.issn1008-9969.2021.24.001

30. Zeng X, Xiao L, Zhang Y. Principles and application of latent class analysis: an example-based study. Chin J Health Stat. 2013;30(6):815–817.

31. Qin R, Zhang Y, Wang N, Ma S. Influencing factors and intervention research progress on alexithymia in breast cancer patients. Chin Gen Pract Nurs. 2023;21(27):3803–3806. doi:10.12104/j.issn.1674-4748.2023.27.015

32. Li J, Shen Z, Li J, Wang S, Xie J, Zhang Q. Research progress on influencing factors of alexithymia in elderly patients with chronic diseases. J Clin Pathol Res. 2023;43(10):1880–1887. doi:10.11817/j.issn.2095-6959.2023.230086

33. Guo C, Yan J, Zhao Y. Analysis of doctor–patient communication barriers in China. Chin Med Ethics. 2018;31(7):845–850.

34. Li M, Li H, Zhang J, et al. Analysis of positivity and its influencing factors in young and middle-aged postoperative breast cancer patients. J Nurs. 2024;39(1):52–55.

35. Liu C, Chen L, Chen C, et al. Latent profile analysis of fertility-related anxiety characteristics and nursing strategies in young female breast cancer patients. Zhonghua Hu Li Za Zhi. 2023;58(16):1989–1995.

36. Lu T, Chen S, Ying Y, Xu Y. Research progress on factors influencing sleep disorders in postoperative breast cancer patients undergoing chemotherapy. Evid Based Nurs. 2023;9(22):4036–4041.

37. Li R, Luo F. Research progress on sleep disorders in breast cancer patients undergoing chemotherapy. Mod Med Health. 2023;39(11):1893–1900.

38. Ku M, Zhou Q, Zhou J, Wu H. Status and influencing factors of alexithymia among empty-nest elderly in the community. J PLA Nurs. 2020;37(4):19–22.

39. Zhao W, Li L, Zhang M, Bai X, Li X. Psychological distress and its related factors of psychological inflexibility in breast cancer patients during postoperative chemotherapy. J Nurs. 2020;35(13):65–68.

40. Wang Z, Zhang X, Ding Y, Yu X, Wang T. Concept analysis of family resilience in adult cancer patients. J Nurs. 2021;36(19):12–15.