{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,27]],"date-time":"2026-09-27T22:44:04Z","timestamp":1790549044733,"version":"4.1.0"},"reference-count":46,"publisher":"American Medical Association (AMA)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"Importance<\/jats:title>Racial and ethnic disparities in pathologic complete response (pCR) and overall survival (OS) have been reported in patients with triple-negative breast cancer (TNBC). In addition to socioeconomic factors and access to care, differences in tumor biology may affect outcomes. The association of ERBB2-<\/jats:italic>low expression with outcomes in patients with TNBC has been minimally explored, including studies evaluating outcomes based on race and ethnicity.<\/jats:p><\/jats:sec>Objective<\/jats:title>To investigate whether ERBB2-<\/jats:italic>low expression among patients with TNBC varies by race and ethnicity and is associated with pCR and OS.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>This retrospective cohort study used the National Cancer Database, a national hospital-based tumor registry, from 2010 to 2019. Participants included adult female patients with stages I to III TNBC treated with neoadjuvant chemotherapy followed by surgery. Tumors with immunohistochemistry scores of 1+ or 2+, in situ hybridization nonamplified, were classified as ERBB2-<\/jats:italic>low; those with immunohistochemistry scores of 0, as ERBB2<\/jats:italic>-zero. Primary analysis was conducted from September 18 to October 18, 2023.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>Rates of ERBB2<\/jats:italic>-low vs ERBB2<\/jats:italic>-zero TNBC by race and ethnicity and pCR and OS by race and ethnicity and by ERBB2<\/jats:italic> status.<\/jats:p><\/jats:sec>Results<\/jats:title>Overall, 31\u202f888 patients with TNBC were identified (median age, 53 [IQR, 44-61] years). Of those, 1078 patients (3.4%) were Asian; 7642 (24.0%), Black; 2578 (8.1%), Hispanic; 20\u202f264 (63.5%), White; and 326 (1.0%), other. Over half of the study population (16 332 [51.2%]) displayed ERBB2<\/jats:italic>-low expression and 15 556 (48.8%), ERBB2<\/jats:italic>-zero expression. Patients with ERBB2<\/jats:italic>-low expression demonstrated lower rates of pCR than those with ERBB2<\/jats:italic>-zero expression (4675 [28.6%] vs 4787 [30.8%]; P<\/jats:italic>\u2009&amp;lt;\u2009.001); ERBB2<\/jats:italic>-low expression was associated with lower odds of pCR after adjustment for patient, socioeconomic, and tumor variables (odds ratio, 0.93; 95% CI, 0.88-0.99; P<\/jats:italic>\u2009=\u2009.01). When patients were stratified by race and ethnicity, Hispanic patients had higher rates of ERBB2<\/jats:italic>-zero expression than ERBB2<\/jats:italic>-low expression (1391 of 2578 [54.0%] vs 1187 of 2578 [46.0%]; P<\/jats:italic>\u2009&amp;lt;\u2009.001); no differences were noted among other racial and ethnic groups. Hispanic patients also had higher rates of pCR among those with ERBB2<\/jats:italic>-low (Hispanic, 30.7%; Asian, 24.6%; Black, 29.5%; White, 27.1%) and ERBB2<\/jats:italic>-zero (Hispanic, 33.2%; Asian, 32.1%; Black, 27.1%; White, 31.7%) TNBC. Non-Hispanic Asian patients had the highest 60-month OS among both those with ERBB2<\/jats:italic>-zero (79%; 95% CI, 75%-83%) and ERBB2<\/jats:italic>-low expression (84%; 95% CI, 80%-87%). Among Asian and White patients, ERBB2<\/jats:italic>-low expression was associated with prolonged OS compared with ERBB2<\/jats:italic>-zero expression (hazard ratios, 0.69 [95% CI, 0.50-0.95] [P<\/jats:italic>\u2009=\u2009.02] and 0.85 [95% CI, 0.79-0.92] [P<\/jats:italic>\u2009&amp;lt;\u2009.001], respectively). Black patients had lower pCR and OS rates regardless of ERBB2<\/jats:italic> status.<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>In this cohort study of patients with TNBC, ERBB2<\/jats:italic>-low expression and its association with clinical outcomes varied across racial and ethnic groups. These findings highlight the need for further research to understand the biological implications of ERBB2<\/jats:italic>-low expression in diverse populations of patients with TNBC.<\/jats:p><\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.14864","type":"journal-article","created":{"date-parts":[[2025,6,11]],"date-time":"2025-06-11T15:00:36Z","timestamp":1749654036000},"page":"e2514864","source":"Crossref","is-referenced-by-count":2,"title":["ERBB2<\/i>-Low Expression by Race and Ethnicity Among Patients With Triple-Negative Breast Cancer"],"prefix":"10.1001","volume":"8","author":[{"given":"Astrid","family":"Botty van den Bruele","sequence":"first","affiliation":[{"name":"Department of Surgery, Duke University School of Medicine, Durham, North Carolina"},{"name":"Duke Cancer Institute, Duke University, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kerri-Anne","family":"Crowell","sequence":"additional","affiliation":[{"name":"Duke Cancer Institute, Duke University, Durham, North Carolina"},{"name":"Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samantha M.","family":"Thomas","sequence":"additional","affiliation":[{"name":"Duke Cancer Institute, Duke University, Durham, North Carolina"},{"name":"Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hannah E.","family":"Woriax","sequence":"additional","affiliation":[{"name":"Department of Surgery, Duke University School of Medicine, Durham, North Carolina"},{"name":"Duke Cancer Institute, Duke University, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kendra M.","family":"Parrish","sequence":"additional","affiliation":[{"name":"Department of Surgery, Duke University School of Medicine, Durham, North Carolina"},{"name":"Duke Cancer Institute, Duke University, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Akiko","family":"Chiba","sequence":"additional","affiliation":[{"name":"Department of Surgery, Duke University School of Medicine, Durham, North Carolina"},{"name":"Duke Cancer Institute, Duke University, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura H.","family":"Rosenberger","sequence":"additional","affiliation":[{"name":"Department of Surgery, Duke University School of Medicine, Durham, North Carolina"},{"name":"Duke Cancer Institute, Duke University, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ton","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Surgery, Duke University School of Medicine, Durham, North Carolina"},{"name":"Duke Cancer Institute, Duke University, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer K.","family":"Plichta","sequence":"additional","affiliation":[{"name":"Department of Surgery, Duke University School of Medicine, Durham, North Carolina"},{"name":"Duke Cancer Institute, Duke University, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maggie L.","family":"DiNome","sequence":"additional","affiliation":[{"name":"Department of Surgery, Duke University School of Medicine, Durham, North Carolina"},{"name":"Duke Cancer Institute, Duke University, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2025,6,11]]},"reference":[{"issue":"31","key":"zoi250486r1","doi-asserted-by":"publisher","first-page":"3997","DOI":"10.1200\/JCO.2013.50.9984","article-title":"Recommendations for human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical Oncology\/College of American Pathologists clinical practice guideline update.","volume":"31","author":"Wolff","year":"2013","journal-title":"J Clin Oncol"},{"issue":"20","key":"zoi250486r2","doi-asserted-by":"publisher","first-page":"2105","DOI":"10.1200\/JCO.2018.77.8738","article-title":"Human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical Oncology\/College of American Pathologists clinical practice guideline focused update.","volume":"36","author":"Wolff","year":"2018","journal-title":"J Clin Oncol"},{"issue":"5","key":"zoi250486r3","doi-asserted-by":"publisher","first-page":"444","DOI":"10.1200\/JCO.19.01455","article-title":"NSABP B-47\/NRG Oncology phase III randomized trial comparing adjuvant chemotherapy with or without trastuzumab in high-risk invasive breast cancer negative for HER2 by FISH and with IHC 1+ or 2.","volume":"38","author":"Fehrenbacher","year":"2020","journal-title":"J Clin Oncol"},{"issue":"1","key":"zoi250486r4","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1056\/NEJMoa2203690","article-title":"Trastuzumab deruxtecan in previously treated HER2-low advanced breast cancer.","volume":"387","author":"Modi","year":"2022","journal-title":"N Engl J Med"},{"issue":"4","key":"zoi250486r5","doi-asserted-by":"publisher","first-page":"500","DOI":"10.1001\/jamaoncol.2022.7476","article-title":"Clinicopathologic characteristics and prognosis of ERBB2-low breast cancer among patients in the National Cancer Database.","volume":"9","author":"Peiffer","year":"2023","journal-title":"JAMA Oncol"},{"issue":"1","key":"zoi250486r6","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1038\/s41523-020-00208-2","article-title":"Clinical, pathological, and PAM50 gene expression features of HER2-low breast cancer.","volume":"7","author":"Schettini","year":"2021","journal-title":"NPJ Breast Cancer"},{"issue":"8","key":"zoi250486r7","doi-asserted-by":"publisher","first-page":"1177","DOI":"10.1001\/jamaoncol.2022.2286","article-title":"Prognostic and biologic significance of ERBB2-low expression in early-stage breast cancer.","volume":"8","author":"Tarantino","year":"2022","journal-title":"JAMA Oncol"},{"issue":"3","key":"zoi250486r8","doi-asserted-by":"publisher","first-page":"364","DOI":"10.1007\/s12282-022-01431-4","article-title":"HER2-low-positive and response to NACT and prognosis in HER2-negative non-metastatic BC.","volume":"30","author":"Li","year":"2023","journal-title":"Breast Cancer"},{"issue":"2","key":"zoi250486r9","doi-asserted-by":"publisher","first-page":"234","DOI":"10.1007\/s12282-021-01303-3","article-title":"The frequency of low HER2 expression in breast cancer and a comparison of prognosis between patients with HER2-low and HER2-negative breast cancer by HR status.","volume":"29","author":"Horisawa","year":"2022","journal-title":"Breast Cancer"},{"issue":"4","key":"zoi250486r10","doi-asserted-by":"publisher","DOI":"10.1016\/j.esmoop.2023.101592","article-title":"Prognostic value of HER2-low status in breast cancer: a systematic review and meta-analysis.","volume":"8","author":"Molinelli","year":"2023","journal-title":"ESMO Open"},{"issue":"8","key":"zoi250486r11","doi-asserted-by":"publisher","first-page":"1151","DOI":"10.1016\/S1470-2045(21)00301-6","article-title":"Clinical and molecular characteristics of HER2-low-positive breast cancer: pooled analysis of individual patient data from four prospective, neoadjuvant clinical trials.","volume":"22","author":"Denkert","year":"2021","journal-title":"Lancet Oncol"},{"issue":"3","key":"zoi250486r12","doi-asserted-by":"publisher","first-page":"e309","DOI":"10.1093\/oncolo\/oyad275","article-title":"HER2-low status was associated with better breast cancer-specific survival in early-stage triple-negative breast cancer.","volume":"29","author":"Ma","year":"2024","journal-title":"Oncologist"},{"key":"zoi250486r13","doi-asserted-by":"publisher","DOI":"10.1007\/s10549-024-07565-7","article-title":"Racial disparities in treatment and outcomes between Hispanic and non-Hispanic black women with triple-negative breast cancer.","author":"Anampa","journal-title":"Breast Cancer Res Treat"},{"issue":"22","key":"zoi250486r14","doi-asserted-by":"publisher","first-page":"e35","DOI":"10.1200\/JCO.2008.21.5509","article-title":"African American women who receive primary anthracycline- and taxane-based chemotherapy for triple-negative breast cancer suffer worse outcomes compared with White women.","volume":"27","author":"Balmanoukian","year":"2009","journal-title":"J Clin Oncol"},{"issue":"21","key":"zoi250486r15","doi-asserted-by":"publisher","first-page":"2492","DOI":"10.1001\/jama.295.21.2492","article-title":"Race, breast cancer subtypes, and survival in the Carolina Breast Cancer Study.","volume":"295","author":"Carey","year":"2006","journal-title":"JAMA"},{"issue":"7","key":"zoi250486r16","doi-asserted-by":"publisher","first-page":"1016","DOI":"10.1001\/jamaoncol.2021.1254","article-title":"Evaluation of racial\/ethnic differences in treatment and mortality among women with triple-negative breast cancer.","volume":"7","author":"Cho","year":"2021","journal-title":"JAMA Oncol"},{"issue":"4","key":"zoi250486r17","doi-asserted-by":"publisher","first-page":"95","DOI":"10.3892\/mco.2022.2528","article-title":"Racial disparities in health insurance, triple-negative breast cancer diagnosis, tumor stage, treatment and survival in a large nationwide SEER cohort in the United States.","volume":"16","author":"Du","year":"2022","journal-title":"Mol Clin Oncol"},{"issue":"36","key":"zoi250486r18","doi-asserted-by":"publisher","first-page":"4267","DOI":"10.1200\/JCO.2015.63.7801","article-title":"Racial differences in the use and outcome of neoadjuvant chemotherapy for breast cancer: results from the National Cancer Data Base.","volume":"33","author":"Killelea","year":"2015","journal-title":"J Clin Oncol"},{"issue":"14","key":"zoi250486r19","doi-asserted-by":"publisher","first-page":"1635","DOI":"10.1200\/JCO.23.01199","article-title":"Racial\/ethnic disparities in pathologic complete response and overall survival in patients with triple-negative breast cancer treated with neoadjuvant chemotherapy.","volume":"42","author":"Woriax","year":"2024","journal-title":"J Clin Oncol"},{"issue":"1","key":"zoi250486r20","doi-asserted-by":"publisher","first-page":"106","DOI":"10.1186\/s12957-024-03382-w","article-title":"Survival outcomes in HER2-low versus HER2-zero breast cancer after neoadjuvant chemotherapy: a meta-analysis.","volume":"22","author":"Xia","year":"2024","journal-title":"World J Surg Oncol"},{"issue":"11","key":"zoi250486r21","doi-asserted-by":"publisher","DOI":"10.1016\/j.esmoop.2024.103973","article-title":"Clinical outcomes of early-stage triple-negative breast cancer after neoadjuvant chemotherapy according to HER2-low status?.","volume":"9","author":"Raghavendra","year":"2024","journal-title":"ESMO Open"},{"issue":"1","key":"zoi250486r22","doi-asserted-by":"publisher","first-page":"89","DOI":"10.1007\/s10549-023-07171-z","article-title":"Impact of HER2-low status for patients with early-stage breast cancer and non-pCR after neoadjuvant chemotherapy: a National Cancer Database Analysis.","volume":"204","author":"Li","year":"2024","journal-title":"Breast Cancer Res Treat"},{"issue":"1","key":"zoi250486r23","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1097\/XCS.0000000000001214","article-title":"American College of Surgeons cancer program annual report from 2021 Participant User File.","volume":"240","author":"Habermann","year":"2025","journal-title":"J Am Coll Surg"},{"issue":"16","key":"zoi250486r24","doi-asserted-by":"publisher","first-page":"2784","DOI":"10.1200\/JCO.2009.25.6529","article-title":"American Society of Clinical Oncology\/College of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer.","volume":"28","author":"Hammond","year":"2010","journal-title":"J Clin Oncol"},{"issue":"22","key":"zoi250486r25","doi-asserted-by":"publisher","first-page":"5463","DOI":"10.1002\/cncr.27581","article-title":"Clinicopathologic features, patterns of recurrence, and survival among women with triple-negative breast cancer in the National Comprehensive Cancer Network.","volume":"118","author":"Lin","year":"2012","journal-title":"Cancer"},{"key":"zoi250486r26","doi-asserted-by":"publisher","journal-title":"BMC Cancer","DOI":"10.1186\/1471-2407-14-62"},{"key":"zoi250486r27","doi-asserted-by":"publisher","journal-title":"Breast Cancer Res","DOI":"10.1186\/s13058-025-01989-9"},{"issue":"1","key":"zoi250486r29","doi-asserted-by":"publisher","first-page":"34","DOI":"10.1186\/s13058-023-01639-y","article-title":"Clinical and biological heterogeneities in triple-negative breast cancer reveals a non-negligible role of HER2-low.","volume":"25","author":"Hu","year":"2023","journal-title":"Breast Cancer Res"},{"issue":"1","key":"zoi250486r30","doi-asserted-by":"publisher","first-page":"12974","DOI":"10.1038\/s41598-022-16898-6","article-title":"HER2-low breast cancer shows a lower immune response compared to HER2-negative cases.","volume":"12","author":"van den Ende","year":"2022","journal-title":"Sci Rep"},{"issue":"1","key":"zoi250486r31","doi-asserted-by":"publisher","first-page":"41","DOI":"10.1186\/s13058-024-01783-z","article-title":"HER2-low and tumor infiltrating lymphocytes in triple-negative breast cancer: are they connected?","volume":"26","author":"Baez-Navarro","year":"2024","journal-title":"Breast Cancer Res"},{"issue":"3","key":"zoi250486r32","doi-asserted-by":"publisher","first-page":"793","DOI":"10.1007\/s10549-011-1554-7","article-title":"Tumor-infiltrating lymphocytes are correlated with response to neoadjuvant chemotherapy in triple-negative breast cancer.","volume":"132","author":"Ono","year":"2012","journal-title":"Breast Cancer Res Treat"},{"key":"zoi250486r33","doi-asserted-by":"publisher","DOI":"10.1016\/j.anndiagpath.2020.151634","article-title":"Predictive markers for pathological complete response after neo-adjuvant chemotherapy in triple-negative breast cancer.","volume":"49","author":"Van Bockstal","year":"2020","journal-title":"Ann Diagn Pathol"},{"issue":"1","key":"zoi250486r34","doi-asserted-by":"publisher","first-page":"5","DOI":"10.3892\/mco.2022.2601","article-title":"Characterization of triple negative breast cancer gene expression profiles in Mexican patients.","volume":"18","author":"Ortiz Valdez","year":"2022","journal-title":"Mol Clin Oncol"},{"key":"zoi250486r35","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2024.42.16_suppl.e12663","author":"Ng\u2019ang\u2019a","year":"2024","journal-title":"J Clin Oncol"},{"key":"zoi250486r36","doi-asserted-by":"publisher","DOI":"10.3389\/fimmu.2023.1153990","article-title":"Molecular mechanisms of immunotherapy resistance in triple-negative breast cancer.","volume":"14","author":"Zheng","year":"2023","journal-title":"Front Immunol"},{"issue":"11","key":"zoi250486r37","doi-asserted-by":"publisher","first-page":"3223","DOI":"10.1038\/s41591-024-03249-3","article-title":"Neoadjuvant nivolumab or nivolumab plus ipilimumab in early-stage triple-negative breast cancer: a phase 2 adaptive trial.","volume":"30","author":"Nederlof","year":"2024","journal-title":"Nat Med"},{"issue":"15","key":"zoi250486r38","doi-asserted-by":"publisher","first-page":"1796","DOI":"10.1200\/JCO.2011.38.8595","article-title":"Definition and impact of pathologic complete response on prognosis after neoadjuvant chemotherapy in various intrinsic breast cancer subtypes.","volume":"30","author":"von Minckwitz","year":"2012","journal-title":"J Clin Oncol"},{"key":"zoi250486r39","article-title":"Response to neoadjuvant therapy and long-term survival in patients with triple-negative breast cancer.","author":"Liedtke","journal-title":"J Clin Oncol"},{"issue":"1","key":"zoi250486r40","doi-asserted-by":"publisher","first-page":"5112","DOI":"10.1038\/s41467-023-40715-x","article-title":"Molecular features and clinical implications of the heterogeneity in Chinese patients with HER2-low breast cancer.","volume":"14","author":"Dai","year":"2023","journal-title":"Nat Commun"},{"issue":"3","key":"zoi250486r41","doi-asserted-by":"publisher","first-page":"428","DOI":"10.1016\/j.ccell.2019.02.001","article-title":"Genomic and transcriptomic landscape of triple-negative breast cancers: subtypes and treatment strategies.","volume":"35","author":"Jiang","year":"2019","journal-title":"Cancer Cell"},{"issue":"1","key":"zoi250486r42","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1093\/aje\/kwt233","article-title":"Obesity and mortality after breast cancer by race\/ethnicity: the California Breast Cancer Survivorship Consortium.","volume":"179","author":"Kwan","year":"2014","journal-title":"Am J Epidemiol"},{"issue":"1","key":"zoi250486r43","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1007\/s10549-016-3918-5","article-title":"Impact of race, ethnicity, and BMI on achievement of pathologic complete response following neoadjuvant chemotherapy for breast cancer: a pooled analysis of four prospective Alliance clinical trials (A151426).","volume":"159","author":"Warner","year":"2016","journal-title":"Breast Cancer Res Treat"},{"issue":"5","key":"zoi250486r44","doi-asserted-by":"publisher","first-page":"858","DOI":"10.1007\/s12282-024-01600-7","article-title":"Trastuzumab deruxtecan versus treatment of physician\u2019s choice in previously treated Asian patients with HER2-low unresectable\/metastatic breast cancer: subgroup analysis of the DESTINY-Breast04 study.","volume":"31","author":"Yamashita","year":"2024","journal-title":"Breast Cancer"},{"issue":"22","key":"zoi250486r45","doi-asserted-by":"publisher","first-page":"2110","DOI":"10.1056\/NEJMoa2407086","article-title":"Trastuzumab deruxtecan after endocrine therapy in metastatic breast cancer.","volume":"391","author":"Bardia","year":"2024","journal-title":"N Engl J Med"},{"key":"zoi250486r46","doi-asserted-by":"publisher","journal-title":"JAMA Oncol","DOI":"10.1001\/jamaoncol.2021.7239"},{"key":"zoi250486r28","volume-title":"Official Proceedings of the 25th Annual Meeting of the American Society of Breast Surgeons","author":"Ahn"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2835174\/botty_van_den_bruele_2025_oi_250486_1748985890.69675.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,6,11]],"date-time":"2025-06-11T15:00:37Z","timestamp":1749654037000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2835174"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,11]]},"references-count":46,"journal-issue":{"issue":"6","published-print":{"date-parts":[[2025,6,2]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2025.14864","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,11]]}}}