Meet Your Child’s New Nanny: A Robot
Would you leave your small child in the care of a robot for several hours a day? It may sound laughable at first, but think carefully.
"Given the huge amounts of money we pay for childcare, a [robot caregiver] is a very attractive proposition."
Robots that can care for children would be a godsend to many parents, especially the financially strapped. In the U.S., 62 percent of women who gave birth in 2016 worked outside the home, and day care costs are often exorbitant. In California, for instance, the annual cost for day care for a single child averages over $22,000. The price is lower in some states, but it still accounts for a hefty chunk of the typical family's budget.
"We're talking about the Holy Grail of parenting," says Zoltan Istvan, a technology consultant and futurist. "Imagine a robot that could assume 70 percent to 80 percent of the caregiver's role for your child. Given the huge amounts of money we pay for childcare, that's a very attractive proposition."
Both China and Japan are on the leading edge of employing specially designed social robots for the care of children. Due to long work schedules, shifting demographics and China's long-term (but now defunct) one-child policy, both countries have a severe shortage of family caregivers. Enter the iPal, a child-sized humanoid robot with a round head, expressive face and articulated fingers, which can keep children engaged and entertained for hours on end. According to its manufacturer, AvatarMind Robot Technology, iPal is already selling like hotcakes in Asia and is expected to be available in the U.S. within the next year. The standard version of iPal sells for $2,499, and it's not the only robot claimed to be suitable for childcare. Other robots being fine-tuned are Softbank's humanoid models Pepper and NAO, which are also considered to be child-friendly social robots.
iPal talks, dances, plays games, reads stories and plugs into social media and the internet. According to AvatarMind, over time iPal learns your child's likes and dislikes, and can independently learn more about subjects your child is interested in to boost learning. In addition, it will wake your child up in the morning and tell him when it's time to get dressed, brush his teeth or wash his hands. If your child is a diabetic, it will remind her when it's time to check her blood sugar. But iPal isn't just a fancy appliance that mechanically performs these functions; it does so with "personality."
iPal robot interacting with a boy.
The robot has an "emotion management system" that detects your child's emotions and mirrors them (unless your child is sad, and then it tries to cheer him up). But it's not exactly like iPal has the kind of emotion chip long sought by Star Trek's android Data. What it does is emotional simulation--what some would call emotional dishonesty--considering that it doesn't actually feel anything. But research has shown that the lack of authenticity doesn't really matter when it comes to the human response to feigned emotion.
Children, and even adults, tend to respond to "emotional" robots as though they're alive and sentient even when we've seen all the wires and circuit boards that underlie their wizardry. In fact, we're hardwired to respond to them as though they are human beings in a real relationship with us.
The question is whether the relationships we develop with robots causes social maladaptation, especially among the most vulnerable among us—young children just learning how to connect and interact with others. Could a robot in fact come close to providing the authentic back-and-forth that helps children develop empathy, reciprocity, and self-esteem? Also, could steady engagement with a robot nanny diminish precious time needed for real family bonding?
It depends on whom you ask.
Because iPal is voice-activated, it frees children to learn by interacting in a way that's more natural than interacting with traditional toys, says Dr. Daniel Xiong, Co-founder and Chief Technology Officer at AvatarMind. "iPal is like a "real" family member with you whenever you need it," he says.
Xiong doesn't put a time limit on how long a child should interact with iPal on a daily basis. He sees the relationship between the child and the robot as healthy, though he admits that the technology needs to advance substantially before iPal could take the place of a human babysitter.
It's no coincidence that many toymakers and manufacturers are designing cute robots that look and behave like real children or animals, says Sherry Turkle, a Professor of Social Studies and Science at MIT. "When they make eye contact and gesture toward us, they predispose us to view them as thinking and caring," she has written in The Washington Post. "They are designed to be cute, to provide a nurturing response" from the child. "And when it comes to sociable AI, nurturance is the killer app: We nurture what we love, and we love what we nurture."
What are we saying to children about their importance to us when we're willing to outsource their care to a robot?
The problem is that we get lulled into thinking that we're in an actual relationship, when a robot can't possibly love us back. If adults have these vulnerabilities, what might such lopsided relationships do to the emotional development of a small child? Turkle notes that while we tend to ascribe a mind and emotions to a socially interactive robot, "Simulated thinking may be thinking, but simulated feeling is never feeling, and simulated love is never love."
Still, is active, playful engagement with a robot for a few hours a day any more harmful than several hours in front of a TV or with an iPad? Some, like Xiong, regard interacting with a robot as better than mere passive entertainment. iPal's manufacturers say that their robot can't replace parents or teachers and is best used by three- to eight-year-olds after school, while they wait for their parents to get off of work. But as robots become ever more sophisticated, they're expected to become more and more captivating, and to perform more of the tasks of day-to-day care.
Some studies, performed by Turkle and fellow MIT colleague Cynthia Breazeal, have revealed a darker side to child-robot interaction. Turkle has reported extensively on these studies in The Washington Post and in her 2011 book, Alone Together: Why We Expect More from Technology and Less from Each Other. Most children love robots, but some act out their inner bully on the hapless machines, hitting and kicking them and otherwise trying to hurt them. The trouble is that the robot can't fight back, teaching children that they can bully and abuse without consequences. Such harmful behavior could carry over into the child's human relationships.
And it turns out that communicative machines don't actually teach kids good communication skills. It's well known that parent-child communication in the first three years of life sets the stage for a child's intellectual and academic success. Verbal back-and-forth with parents and caregivers is like food for a child's growing brain. One article published in JAMA Pediatrics showed that babies who played with electronic toys—like the popular robot dog AIBO—show a decrease in both the quantity and quality of their language skills.
Anna V. Sosa of the Child Speech and Language Lab at Northern Arizona University studied 26 ten- to 16-month-old infants to compare the growth of their language skills after they played with three types of toys: Electronic toys like a baby laptop and talking farm; traditional toys like wooden puzzles and building blocks; and books read aloud by their parents.
The play that produced the most growth in verbal ability was having books read to them, followed by play with traditional toys. Language gains after playing with electronic toys came dead last. This form of play involved the least use of adult words, the least conversational turn-taking with parents, and the least verbalizations from the children. While the study sample was small, it's not hard to extrapolate that no electronic toy or even more abled robot could supply the intimate responsiveness of a parent reading stories to a child, explaining new words, answering the child's questions, and modeling the kind of back-and-forth interaction that promotes empathy and reciprocity in human relationships.
Most experts acknowledge that robots can be valuable educational tools, but they can't make a child feel truly loved, validated, and valued.
Research suggests that the main problem of leaving children in the care of robots on a regular basis is the risk of their stunted, unhealthy emotional development. In Alone Together, Turkle asks: What are we saying to children about their importance to us when we're willing to outsource their care to a robot? A child might be superficially entertained by the robot while her self-esteem is systematically undermined.
Two of the most vocal critics of robot nannies are researchers at the University of Sheffield in the U.K., Noel and Amanda Sharkey. In an article published in the journal Interaction Studies, they claim that the overuse of childcare robots could have serious consequences for the psychological and emotional wellbeing of children.
They acknowledge that limited use of robots can have positive effects like keeping a child safe from physical harm, allowing remote monitoring and supervision by parents, keeping a child entertained, and stimulating an interest in science and engineering. But the Sharkeys see the overuse of robots as a source of emotional alienation between parents and children. Just regularly plopping a child down with a robot for hours of interaction could be a form of neglect that panders to busy parents at the cost of a child's emotional development.
Robots, the Sharkeys argue, prey upon a child's natural tendency to anthropomorphize, which sucks them into a pseudo-relationship with a machine that can never return their affection. This can be seen as a form of emotional exploitation—a machine that promises connection but can never truly deliver. Furthermore, as robots develop more intimate skills such as bathing, feeding and changing diapers, children will lose out on some of the most fundamental and precious bonding activities with their parents.
Critics say that children's natural ability to bond is prime territory for exploitation by toy and robot manufacturers, who ultimately have a commercial agenda. The Sharkeys noted one study in which a state-of-the-art robot was employed in a daycare center. The ten- to 20-month-old children bonded more deeply with the robot than with a teddy bear. It's not hard to see that starting the robot-bonding process early in life is good for robot business, as babies and toddlers graduate to increasingly sophisticated machines.
"It is possible that exclusive or near exclusive care of a child by a robot could result in cognitive and linguistic impairments," say the Sharkeys. They cite the danger of a child developing what is called in psychology a pathological attachment disorder. Attachment disorders occur when parents are unpredictable or neglectful in their emotional responsiveness. The resulting shaky bond interferes with a child's ability to feel trust, pleasure, safety, and comfort in the presence of the parent. Unhealthy patterns of attachment include "insecure attachment," a form of anxiety that arises when a child cannot trust his caregiver with meeting his emotional needs. Children with attachment disorders may anxiously avoid attachments and may not be able to experience empathy, the cornerstone of relationships. Such patterns can follow a child throughout life and infect every other relationship they have.
An example of the inadequacy of robot nannies rests on the pre-programmed emotional responses they have in their repertoires. They're designed to detect and mirror a child's emotions and do things like play a child's favorite song when he's crying or in distress. But such a response could be the height of insensitivity. It discounts and belittles what may be a child's authentic response to an upsetting turn of events, like a scraped knee from a fall. A robot playing a catchy jingle is a far cry from having Mom clean and dress the wound, and perhaps more importantly, kiss it and make it better.
Most experts acknowledge that robots can be valuable educational tools. But they can't make a child feel truly loved, validated, and valued. That's the job of parents, and when parents abdicate this responsibility, it's not only the child that misses out on one of life's most profound experiences.
So consider buying a robot to entertain and educate your little one—just make sure you're close by for the true bonding opportunities that arrive so fast and last so fleetingly in the life of a child.
From infections with no symptoms to why men are more likely to be hospitalized in the ICU and die of COVID-19, new research shows that your genes play a significant role
Early in the pandemic, genetic research focused on the virus because it was readily available. Plus, the virus contains only 30,000 bases in a dozen functional genes, so it's relatively easy and affordable to sequence. Additionally, the rapid mutation of the virus and its ability to escape antibody control fueled waves of different variants and provided a reason to follow viral genetics.
In comparison, there are many more genes of the human immune system and cellular functions that affect viral replication, with about 3.2 billion base pairs. Human studies require samples from large numbers of people, the analysis of each sample is vastly more complex, and sophisticated computer analysis often is required to make sense of the raw data. All of this takes time and large amounts of money, but important findings are beginning to emerge.
Asymptomatics
About half the people exposed to SARS-CoV-2, the virus that causes the COVID-19 disease, never develop symptoms of this disease, or their symptoms are so mild they often go unnoticed. One piece of understanding the phenomena came when researchers showed that exposure to OC43, a common coronavirus that results in symptoms of a cold, generates immune system T cells that also help protect against SARS-CoV-2.
Jill Hollenbach, an immunologist at the University of California at San Francisco, sought to identify the gene behind that immune protection. Most COVID-19 genetic studies are done with the most seriously ill patients because they are hospitalized and thus available. “But 99 percent of people who get it will never see the inside of a hospital for COVID-19,” she says. “They are home, they are not interacting with the health care system.”
Early in the pandemic, when most labs were shut down, she tapped into the National Bone Marrow Donor Program database. It contains detailed information on donor human leukocyte antigens (HLAs), key genes in the immune system that must match up between donor and recipient for successful transplants of marrow or organs. Each HLA can contain alleles, slight molecular differences in the DNA of the HLA, which can affect its function. Potential HLA combinations can number in the tens of thousands across the world, says Hollenbach, but each person has a smaller number of those possible variants.
She teamed up with the COVID-19 Citizen Science Study a smartphone-based study to track COVID-19 symptoms and outcomes, to ask persons in the bone marrow donor registry about COVID-19. The study enlisted more than 30,000 volunteers. Those volunteers already had their HLAs annotated by the registry, and 1,428 tested positive for the virus.
Analyzing five key HLAs, she found an allele in the gene HLA-B*15:01 that was significantly overrepresented in people who didn’t have any symptoms. The effect was even stronger if a person had inherited the allele from both parents; these persons were “more than eight times more likely to remain asymptomatic than persons who did not carry the genetic variant,” she says. Altogether this HLA was present in about 10 percent of the general European population but double that percentage in the asymptomatic group. Hollenbach and her colleagues were able confirm this in other different groups of patients.
What made the allele so potent against SARS-CoV-2? Part of the answer came from x-ray crystallography. A key element was the molecular shape of parts of the cold virus OC43 and SARS-CoV-2. They were virtually identical, and the allele could bind very tightly to them, present their molecular antigens to T cells, and generate an extremely potent T cell response to the viruses. And “for whatever reasons that generated a lot of memory T cells that are going to stick around for a long time,” says Hollenbach. “This T cell response is very early in infection and ramps up very quickly, even before the antibody response.”
Understanding the genetics of the immune response to SARS-CoV-2 is important because it provides clues into the conditions of T cells and antigens that support a response without any symptoms, she says. “It gives us an opportunity to think about whether this might be a vaccine design strategy.”
Dead men
A researcher at the Leibniz Institute of Virology in Hamburg Germany, Guelsah Gabriel, was drawn to a question at the other end of the COVID-19 spectrum: why men more likely to be hospitalized and die from the infection. It wasn't that men were any more likely to be exposed to the virus but more likely, how their immune system reacted to it
Several studies had noted that testosterone levels were significantly lower in men hospitalized with COVID-19. And, in general, the lower the testosterone, the worse the prognosis. A year after recovery, about 30 percent of men still had lower than normal levels of testosterone, a condition known as hypogonadism. Most of the men also had elevated levels of estradiol, a female hormone (https://pubmed.ncbi.nlm.nih.gov/34402750/).
Every cell has a sex, expressing receptors for male and female hormones on their surface. Hormones docking with these receptors affect the cells' internal function and the signals they send to other cells. The number and role of these receptors varies from tissue to tissue.
Gabriel began her search by examining whole exome sequences, the protein-coding part of the genome, for key enzymes involved in the metabolism of sex hormones. The research team quickly zeroed in on CYP19A1, an enzyme that converts testosterone to estradiol. The gene that produces this enzyme has a number of different alleles, the molecular variants that affect the enzyme's rate of metabolizing the sex hormones. One genetic variant, CYP19A1 (Thr201Met), is typically found in 6.2 percent of all people, both men and women, but remarkably, they found it in 68.7 percent of men who were hospitalized with COVID-19.
Lung surprise
Lungs are the tissue most affected in COVID-19 disease. Gabriel wondered if the virus might be affecting expression of their target gene in the lung so that it produces more of the enzyme that converts testosterone to estradiol. Studying cells in a petri dish, they saw no change in gene expression when they infected cells of lung tissue with influenza and the original SARS-CoV viruses that caused the SARS outbreak in 2002. But exposure to SARS-CoV-2, the virus responsible for COVID-19, increased gene expression up to 40-fold, Gabriel says.
Did the same thing happen in humans? Autopsy examination of patients in three different cites found that “CYP19A1 was abundantly expressed in the lungs of COVID-19 males but not those who died of other respiratory infections,” says Gabriel. This increased enzyme production led likely to higher levels of estradiol in the lungs of men, which “is highly inflammatory, damages the tissue, and can result in fibrosis or scarring that inhibits lung function and repair long after the virus itself has disappeared.” Somehow the virus had acquired the capacity to upregulate expression of CYP19A1.
Only two COVID-19 positive females showed increased expression of this gene. The menopause status of these women, or whether they were on hormone replacement therapy was not known. That could be important because female hormones have a protective effect for cardiovascular disease, which women often lose after going through menopause, especially if they don’t start hormone replacement therapy. That sex-specific protection might also extend to COVID-19 and merits further study.
The team was able to confirm their findings in golden hamsters, the animal model of choice for studying COVID-19. Testosterone levels in male animals dropped 5-fold three days after infection and began to recover as viral levels declined. CYP19A1 transcription increased up to 15-fold in the lungs of the male but not the females. The study authors wrote, “Virus replication in the male lungs was negatively associated with testosterone levels.”
The medical community studying COVID-19 has slowly come to recognize the importance of adipose tissue, or fat cells. They are known to express abundant levels of CYP19A1 and play a significant role as metabolic tissue in COVID-19. Gabriel adds, “One of the key findings of our study is that upon SARS-CoV-2 infection, the lung suddenly turns into a metabolic organ by highly expressing” CYP19A1.
She also found evidence that SARS-CoV-2 can infect the gonads of hamsters, thereby likely depressing circulating levels of sex hormones. The researchers did not have autopsy samples to confirm this in humans, but others have shown that the virus can replicate in those tissues.
A possible treatment
Back in the lab, substituting low and high doses of testosterone in SARS-COV-2 infected male hamsters had opposite effects depending on testosterone dosage used. Gabriel says that hormone levels can vary so much, depending on health status and age and even may change throughout the day, that “it probably is much better to inhibit the enzyme” produced by CYP19A1 than try to balance the hormones.
Results were better with letrozole, a drug approved to treat hypogonadism in males, which reduces estradiol levels. The drug also showed benefit in male hamsters in terms of less severe disease and faster recovery. She says more details need to be worked out in using letrozole to treat COVID-19, but they are talking with hospitals about clinical trials of the drug.
Gabriel has proposed a four hit explanation of how COVID-19 can be so deadly for men: the metabolic quartet. First is the genetic risk factor of CYP19A1 (Thr201Met), then comes SARS-CoV-2 infection that induces even greater expression of this gene and the deleterious increase of estradiol in the lung. Age-related hypogonadism and the heightened inflammation of obesity, known to affect CYP19A1 activity, are contributing factors in this deadly perfect storm of events.
Studying host genetics, says Gabriel, can reveal new mechanisms that yield promising avenues for further study. It’s also uniting different fields of science into a new, collaborative approach they’re calling “infection endocrinology,” she says.
New device finds breast cancer like earthquake detection
Mammograms are necessary breast cancer checks for women as they reach the recommended screening age between 40 and 50 years. Yet, many find the procedure uncomfortable. “I have large breasts, and to be able to image the full breast, the radiographer had to manipulate my breast within the machine, which took time and was quite uncomfortable,” recalls Angela, who preferred not to disclose her last name.
Breast cancer is the most widespread cancer in the world, affecting 2.3 million women in 2020. Screening exams such as mammograms can help find breast cancer early, leading to timely diagnosis and treatment. If this type of cancer is detected before the disease has spread, the 5-year survival rate is 99 percent. But some women forgo mammograms due to concerns about radiation or painful compression of breasts. Other issues, such as low income and a lack of access to healthcare, can also serve as barriers, especially for underserved populations.
Researchers at the University of Canterbury and startup Tiro Medical in Christchurch, New Zealand are hoping their new device—which doesn’t involve any radiation or compression of the breasts—could increase the accuracy of breast cancer screening, broaden access and encourage more women to get checked. They’re digging into clues from the way buildings move in an earthquake to help detect more cases of this disease.
Earthquake engineering inspires new breast cancer screening tech
What’s underneath a surface affects how it vibrates. Earthquake engineers look at the vibrations of swaying buildings to identify the underlying soil and tissue properties. “As the vibration wave travels, it reflects the stiffness of the material between that wave and the surface,” says Geoff Chase, professor of engineering at the University of Canterbury in Christchurch, New Zealand.
Chase is applying this same concept to breasts. Analyzing the surface motion of the breast as it vibrates could reveal the stiffness of the tissues underneath. Regions of high stiffness could point to cancer, given that cancerous breast tissue can be up to 20 times stiffer than normal tissue. “If in essence every woman’s breast is soft soil, then if you have some granite rocks in there, we’re going to see that on the surface,” explains Chase.
The earthquake-inspired device exceeds the 87 percent sensitivity of a 3D mammogram.
That notion underpins a new breast screening device, the brainchild of Chase. Women lie face down, with their breast being screened inside a circular hole and the nipple resting on a small disc called an actuator. The actuator moves up and down, between one and two millimeters, so there’s a small vibration, “almost like having your phone vibrate on your nipple,” says Jessica Fitzjohn, a postdoctoral fellow at the University of Canterbury who collaborated on the device design with Chase.
Cameras surrounding the device take photos of the breast surface motion as it vibrates. The photos are fed into image processing algorithms that convert them into data points. Then, diagnostic algorithms analyze those data points to find any differences in the breast tissue. “We’re looking for that stiffness contrast which could indicate a tumor,” Fitzjohn says.
A nascent yet promising technology
The device has been tested in a clinical trial of 14 women: one with healthy breasts and 13 with a tumor in one breast. The cohort was small but diverse, varying in age, breast volume and tumor size.
Results from the trial yielded a sensitivity rate, or the likelihood of correctly detecting breast cancer, of 85 percent. Meanwhile, the device’s specificity rate, or the probability of diagnosing healthy breasts, was 77 percent. By combining and optimizing certain diagnostic algorithms, the device reached between 92 and 100 percent sensitivity and between 80 and 86 percent specificity, which is comparable to the latest 3D mammogram technology. Called tomosynthesis, these 3D mammograms take a number of sharper, clearer and more detailed 3D images compared to the single 2D image of a conventional mammogram, and have a specificity score of 92 percent. Although the earthquake-inspired device’s specificity is lower, it exceeds the 87 percent sensitivity of a 3D mammogram.
The team hopes that cameras with better resolution can help improve the numbers. And with a limited amount of data in the first trial, the researchers are looking into funding for another clinical trial to validate their results on a larger cohort size.
Additionally, during the trial, the device correctly identified one woman’s breast as healthy, while her prior mammogram gave a false positive. The device correctly identified it as being healthy tissue. It was also able to capture the tiniest tumor at 7 millimeters—around a third of an inch or half as long as an aspirin tablet.
Diagnostic findings from the device are immediate.
When using the earthquake-inspired device, women lie face down, with their breast being screened inside circular holes.
University of Canterbury.
But more testing is needed to “prove the device’s ability to pick up small breast cancers less than 10 to 15 millimeters in size, as we know that finding cancers when they are small is the best way of improving outcomes,” says Richard Annand, a radiologist at Pacific Radiology in New Zealand. He explains that mammography already detects most precancerous lesions, so if the device will only be able to find large masses or lumps it won’t be particularly useful. While not directly involved in administering the clinical trial for the device, Annand was a director at the time for Canterbury Breastcare, where the trial occurred.
Meanwhile, Monique Gary, a breast surgical oncologist and medical director of the Grand View Health Cancer program in Pennsylvania, U.S., is excited to see new technologies advancing breast cancer screening and early detection. But she notes that the device may be challenging for “patients who are unable to lay prone, such as pregnant women as well as those who are differently abled, and this machine might exclude them.” She adds that it would also be interesting to explore how breast implants would impact the device’s vibrational frequency.
Diagnostic findings from the device are immediate, with the results available “before you put your clothes back on,” Chase says. The absence of any radiation is another benefit, though Annand considers it a minor edge “as we know the radiation dose used in mammography is minimal, and the advantages of having a mammogram far outweigh the potential risk of radiation.”
The researchers also conducted a separate ergonomic trial with 40 women to assess the device’s comfort, safety and ease of use. Angela was part of that trial and described the experience as “easy, quick, painless and required no manual intervention from an operator.” And if a person is uncomfortable being topless or having their breasts touched by someone else, “this type of device would make them more comfortable and less exposed,” she says.
While mammograms remain “the ‘gold standard’ in breast imaging, particularly screening, physicians need an option that can be used in combination with mammography.
Fitzjohn acknowledges that “at the moment, it’s quite a crude prototype—it’s just a block that you lie on.” The team prioritized function over form initially, but they’re now planning a few design improvements, including more cushioning for the breasts and the surface where the women lie on.
While mammograms remains “the ‘gold standard’ in breast imaging, particularly screening, physicians need an option that is good at excluding breast cancer when used in combination with mammography, has good availability, is easy to use and is affordable. There is the possibility that the device could fill this role,” Annand says.
Indeed, the researchers envision their new breast screening device as complementary to mammograms—a prescreening tool that could make breast cancer checks widely available. As the device is portable and doesn’t require specialized knowledge to operate, it can be used in clinics, pop-up screening facilities and rural communities. “If it was easily accessible, particularly as part of a checkup with a [general practitioner] or done in a practice the patient is familiar with, it may encourage more women to access this service,” Angela says. For those who find regular mammograms uncomfortable or can’t afford them, the earthquake-inspired device may be an option—and an even better one.
Broadening access could prompt more women to go for screenings, particularly younger women at higher risk of getting breast cancer because of a family history of the disease or specific gene mutations. “If we can provide an option for them then we can catch those cancers earlier,” Fitzjohn syas. “By taking screening to people, we’re increasing patient-centric care.”
With the team aiming to lower the device’s cost to somewhere between five and eight times less than mammography equipment, it would also be valuable for low-to-middle-income nations that are challenged to afford the infrastructure for mammograms or may not have enough skilled radiologists.
For Fitzjohn, the ultimate goal is to “increase equity in breast screening and catch cancer early so we have better outcomes for women who are diagnosed with breast cancer.”