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Clinicopathological characteristics, practical treatments, prognosis, and clinical issues of older breast cancer patients in Japan. Breast Cancer 2020; 28:1-8. [PMID: 33219915 DOI: 10.1007/s12282-020-01188-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 11/08/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Minimal data are available to support the clinical management of older breast cancer patients. Consequently, the standard of care remains unclear. Our aim was to clarify the clinicopathological characteristics, practical treatments, and prognosis of older Japanese breast cancer patients and discuss clinical issues. METHODS We reviewed 132,240 cases, diagnosed between 2004 and 2011, from the Japanese Breast Cancer Registry. Focusing on older patients, we compared data among three age groups: 75 years and over (n = 27,385), 65-74 years (n = 43,839), and 55-64 years (n = 61,016). RESULTS Data revealed the proportions of mucinous and apocrine carcinoma were higher in older patients, and they more frequently had clinical stage II and III cancer. Their ER-positive rates were higher, in contrast to the lower HER2-positive, breast-conserving surgery (BCS), post-BCS irradiation, and adjuvant chemotherapy rates. Almost half of the older patients who underwent chemotherapy received CMF or oral 5FU, during hormone therapy, Tamoxifen was administered more frequently. The overall survival rate decreased with age, but the breast cancer-specific survival (BCSS) at 5 years remained similar. The rate of other cause of death in the oldest group was about a half, and more than double that in those aged 55-64 years. CONCLUSIONS We showed clinical data of older breast cancer patients in Japan. Their disease was more advanced at the time of diagnosis, post-BCS irradiation and primary systemic chemotherapy were omitted more frequently, and overall, BCSS was similar among age categories, although the rate of other causes of death was higher.
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Abstract
PURPOSE OF REVIEW Breast cancer incidence and mortality increase with age. Older patients (≥ 70) are often excluded from studies. Due to multiple factors, it is unclear whether this population is best-treated using standard guidelines. Here, we review surgical management in older women with breast cancer. RECENT FINDINGS Geriatric assessments can guide treatment recommendations and aid in predicting survival and quality of life. Surgery remains a principal component of breast cancer treatment in older patients, though differences exist compared with younger women, including higher mastectomy rates and evidence-based support of omission of post-lumpectomy radiation or axillary dissection in subsets of patients. In those forgoing surgical management, there is increased use of endocrine therapy. Hospice is also a valuable element of end-of-life care. Physicians should utilize geriatric assessment to make treatment recommendations for older breast cancer patients, including omission of radiation therapy, alterations to standard surgeries, or enrollment in hospice care.
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Ward SE, Holmes GR, Ring A, Richards PD, Morgan JL, Broggio JW, Collins K, Reed MWR, Wyld L. Adjuvant Chemotherapy for Breast Cancer in Older Women: An Analysis of Retrospective English Cancer Registration Data. Clin Oncol (R Coll Radiol) 2019; 31:444-452. [PMID: 31122807 DOI: 10.1016/j.clon.2019.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 02/13/2019] [Accepted: 02/20/2019] [Indexed: 10/26/2022]
Abstract
AIMS Adjuvant chemotherapy is recommended as a treatment for women with high recurrence risk early breast cancer. Older women are less likely to receive chemotherapy than younger women. This study investigated the impact of chemotherapy on breast cancer-specific survival in women aged 70 + years using English registry data. MATERIALS AND METHODS Cancer registration data were obtained from two English regions from 2002 to 2012 (n = 29 728). The impact of patient-level characteristics on the probability of receiving adjuvant chemotherapy was explored using logistic regression. Survival modelling was undertaken to show the effect of chemotherapy and age/health status on breast cancer-specific survival. Missing data were handled using multiple imputation. RESULTS In total, 11 735 surgically treated early breast cancer patients were identified. Use of adjuvant chemotherapy has increased over time. Younger age at diagnosis, increased nodal involvement, tumour size and grade, oestrogen receptor-negative or human epidermal growth factor receptor 2-positive disease were all associated with increased probability of receiving chemotherapy. Chemotherapy was associated with a significant reduction in the hazard of breast cancer-specific mortality in women with high risk cancer, after adjusting for patient-level characteristics (hazard ratio 0.74, 95% confidence interval 0.67-0.81). DISCUSSION Chemotherapy is associated with an improved breast cancer-specific survival in older women with early breast cancer at high risk of recurrence . Lower rates of chemotherapy use in older women may, therefore, contribute to inferior cancer outcomes. Decisions on potential benefits for individual patients should be made on the basis of life expectancy, treatment tolerance and patient preference.
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Affiliation(s)
- S E Ward
- Department of Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - G R Holmes
- Department of Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - A Ring
- Breast Unit, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - P D Richards
- Department of Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - J L Morgan
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
| | - J W Broggio
- National Cancer Registration and Analysis Service, Public Heath England, Birmingham, UK; Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - K Collins
- Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - M W R Reed
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - L Wyld
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
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Omission of surgery in older women with early breast cancer has an adverse impact on breast cancer-specific survival. Br J Surg 2018; 105:1454-1463. [DOI: 10.1002/bjs.10885] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 01/03/2018] [Accepted: 04/03/2018] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Primary endocrine therapy is used as an alternative to surgery in up to 40 per cent of women with early breast cancer aged over 70 years in the UK. This study investigated the impact of surgery versus primary endocrine therapy on breast cancer-specific survival (BCSS) in older women.
Methods
Cancer registration data for 2002–2010 were obtained from two English regions. A retrospective analysis was performed for women with oestrogen receptor (ER)-positive disease, using statistical modelling to show the effect of treatment (surgery or primary endocrine therapy) and age and health status on BCSS. Missing data were handled using multiple imputation.
Results
Cancer registration data on 23 961 women were retrieved. After data preprocessing, 18 730 of 23 849 women (78·5 per cent) were identified as having ER-positive disease; of these, 10 087 (53·9 per cent) had surgery and 8643 (46·1 per cent) had primary endocrine therapy. BCSS was worse in the primary endocrine therapy group than in the surgical group (5-year BCSS rate 69·4 and 89·9 per cent respectively). This was true for all strata considered, although the difference was less in the cohort with the greatest degree of co-morbidity. For older, frailer patients the hazard of breast cancer death had less relative impact on overall survival.
Conclusion
BCSS in older women with ER-positive disease is worse if surgery is omitted. This treatment choice may contribute to inferior cancer outcomes. Selection for surgery on the basis of predicted life expectancy may permit choice of women for whom surgery confers little benefit.
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The use of surgery in the treatment of ER+ early stage breast cancer in England: Variation by time, age and patient characteristics. Eur J Surg Oncol 2016; 42:489-96. [DOI: 10.1016/j.ejso.2015.12.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/11/2015] [Accepted: 12/16/2015] [Indexed: 12/14/2022] Open
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Parks RM, Rostoft S, Ommundsen N, Cheung KL. Peri-Operative Management of Older Adults with Cancer-The Roles of the Surgeon and Geriatrician. Cancers (Basel) 2015; 7:1605-21. [PMID: 26295261 PMCID: PMC4586786 DOI: 10.3390/cancers7030853] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/16/2015] [Accepted: 08/05/2015] [Indexed: 12/23/2022] Open
Abstract
Optimal surgical management of older adults with cancer starts pre-operatively. The surgeon plays a key role in the appropriate selection of patients and procedures, optimisation of their functional status prior to surgery, and provision of more intensive care for those who are at high risk of post-operative complications. The literature, mainly based on retrospective, non-randomised studies, suggests that factors such as age, co-morbidities, pre-operative cognitive function and intensity of the surgical procedure all appear to contribute to the development of post-operative complications. Several studies have shown that a pre-operative geriatric assessment predicts post-operative mortality and morbidity as well as survival in older surgical cancer patients. Geriatricians are used to working in multidisciplinary teams that assess older patients and make individual treatment plans. However, the role of the geriatrician in the surgical oncology setting is not well established. A geriatrician could be a valuable contribution to the treatment team both in the pre-operative stage (patient assessment and pre-operative optimisation) and the post-operative stage (patient assessment and treatment of medical complications as well as discharge planning).
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Affiliation(s)
- Ruth Mary Parks
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby DE 22 3DT, UK.
| | - Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital, Oslo 0424, Norway.
| | - Nina Ommundsen
- Department of Geriatric Medicine, Akershus University Hospital, Po box 1000, Lørenskog 1478, Norway.
| | - Kwok-Leung Cheung
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby DE 22 3DT, UK.
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Clinically cN0 breast cancer in elderly: What surgery? Int J Surg 2014; 12 Suppl 2:S130-S134. [DOI: 10.1016/j.ijsu.2014.08.364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/15/2014] [Indexed: 12/31/2022]
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Syed BM, Parks RM, Cheung KL. Management of operable primary breast cancer in older women. WOMENS HEALTH 2014; 10:405-22. [PMID: 25259901 DOI: 10.2217/whe.14.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A considerable number of breast cancer diagnoses are made in older women. Differing physiological needs of older patients and biology of tumors compared with younger patients may alter treatment options between surgery and nonsurgical primary approaches. Adjuvant therapies may benefit these patients; however, concerns about toxicity and physical demands of treatment may affect patient choice regarding treatment. Furthermore, quality of life may be more important to the older individual than curative treatment alone. Growing evidence is emerging for employing Comprehensive Geriatric Assessment to determine other factors that may contribute to treatment decision-making in the older population. The way geriatric oncology is delivered varies, bringing the importance of the multidisciplinary team to the forefront of care delivery in this age group. Future research in this area should include combined consideration of tumor biology and geriatric needs.
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Affiliation(s)
- Binafsha M Syed
- Department of Surgery, Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan
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Hernandez RK, Quach D, Wade SW, Pirolli M, Quigley J, Narod SA, Liede A. Prevalence of women with early-stage breast cancer receiving active management using electronic health records from oncology clinics in the United States. Breast Cancer Res Treat 2014; 146:637-46. [PMID: 25053278 DOI: 10.1007/s10549-014-3052-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 06/27/2014] [Indexed: 01/10/2023]
Abstract
The purpose of this study was to estimate the prevalence of women receiving treatment or active surveillance for stage I-III breast cancer in the United States from 2009 to 2012, stratified by patient age and tumor characteristics. In each study year, electronic medical records were used to identify women aged ≥18 years with stage I-III breast cancer and treated or under active surveillance (≥4 visits) at an oncology clinic that contributes data to the Oncology Services Comprehensive Electronic Records database. Prevalence was projected to the national level overall and within strata (by tumor characteristics, year of breast cancer diagnosis, and age). We identified 5,219 female breast cancer patients (18 % <age 50; 58 % <age 65) representing 787,082 (95 % CI 778,012-796,153) women in the US in 2012. At diagnosis, 44 % had stage I, 42 % stage II, and 14 % stage III disease; 69 % had estrogen receptor (ER) and progesterone receptor (PR) expression-positive tumors; 19 % were ER- and PR-negative; and 14 % had triple-negative phenotype (ER-, PR-, and HER2-negative). Overall 56 % of patients received treatment in 2012, 22 % chemotherapy, 8 % biologic therapy, and 36 % endocrine therapy. Treatment prevalence was higher among younger patients and at more advanced disease stages. Approximately half of women with ER-negative, PR-positive, HER2-negative, or triple-negative tumors received chemotherapy. As a conclusion, in 2012, approximately 800,000 women in the US were under treatment or active surveillance for early-stage breast cancer. Treatment prevalence differed by patient age, disease stage, and tumor histology.
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Montroni I, Rocchi M, Santini D, Ceccarelli C, Ghignone F, Zattoni D, Nuvola G, Zanotti S, Ugolini G, Taffurelli M. Has breast cancer in the elderly remained the same over recent decades? A comparison of two groups of patients 70years or older treated for breast cancer twenty years apart. J Geriatr Oncol 2014; 5:260-5. [DOI: 10.1016/j.jgo.2014.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 09/13/2013] [Accepted: 02/25/2014] [Indexed: 01/21/2023]
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Soyder A, Ozbaş S, Koçak S. Locoregional Recurrence and Survival Rates after Breast-Conserving Surgery and Hormonal Therapy in 70-Year-Old or Older Patients with Stage I or IIA Breast Carcinoma. ACTA ACUST UNITED AC 2014; 8:134-7. [PMID: 24419104 DOI: 10.1159/000350776] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Data for treatment of elderly women (≥ 70 years) with estrogen receptor-positive early stage breast cancer are available. We have compared different treatment options to determine whether lumpectomy (LU) plus adjuvant hormonal therapy (HT) is as effective as combined LU, HT, and radiotherapy (RT). METHOD Medical records of elderly patients over 69 years of age who had been treated for T1N0M0 (stage I) and T2N0M0 (stage IIA) at 2 different medical centers between March 2004 and January 2011 were assessed, and 35 patients were included in this study. 21 of these patients underwent only breast-conserving surgery (BCS) and HT (Group 1: T1N0M0-Group 1a, n = 16; T2N0M0-Group 1b, n = 5) and the others either BCS, HT and RT (Group 2, n = 4) or BCS, chemotherapy (CT), HT and RT (Group 3, n = 10). Adjuvant HT for all the patients comprised aromatase inhibitors. RESULTS The mean follow-up period for Groups 1, 2 and 3 were 32.2, 31.3 and 20.4 months, respectively. No locoregional recurrence or cancer-specific mortality occurred in any of these patients; 1 patient from Group 1 died of a different cause. DISCUSSION The BCS+HT regimen seems to be an efficient treatment option for early stage breast cancer in selected 70-year-old and older patient groups.
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Affiliation(s)
- Aykut Soyder
- Department of Surgery, Adnan Menderes University School of Medicine, Aydin, Turkey
| | - Serdar Ozbaş
- Department of Surgery, Adnan Menderes University School of Medicine, Aydin, Turkey
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Swaminathan V, Spiliopoulos MK, Audisio RA. Choices in surgery for older women with breast cancer. Breast Care (Basel) 2012; 7:445-51. [PMID: 24715825 DOI: 10.1159/000345402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Breast cancer is a major cause of mortality worldwide. As the population ages and life expectancy increases, the burden of cancer on health services will increase. Older patients with breast cancer are becoming more suitable for surgery; tailored surgical techniques and increasing healthy life expectancy alongside improved assessment of patients are aiding this trend. Surgery is also becoming a favoured treatment of personal choice for older patient with breast cancer. Evidence shows that surgery is almost always feasible for the older patient with outcomes (survival, progression, and recurrence rates) comparable to younger groups and superior to non-surgical treatments. We aim to describe the current status of surgery for the older patient with breast cancer, showing it is an option that should not be denied. Surgery should always be considered regardless of age, after evaluation of co-morbidities.
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Affiliation(s)
| | | | - Riccardo A Audisio
- Consultant Breast Oncological Surgeon, St Helens Teaching Hospital, St Helens, UK
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Abstract
Care of the older woman with early breast cancer is of particular importance to both the oncologist and geriatrician because of both the prevalence of the disease in this population as well as the subtleties necessary in individualizing treatment decisions. In general, older women are able to tolerate many of the same modalities of treatment for early breast cancer as younger women, but special consideration must be given to future life expectancy, comorbidities, and other elements that might be identified using a CGA. Both short-term and long-term side effects of cancer therapies can be clinically important in the older woman, and appropriate screening and support for these toxicities are necessary.
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Affiliation(s)
- Ari VanderWalde
- Clinical Research Senior Medical Scientist, Global Development- Oncology, Amgen, Thousand Oaks, California
| | - Arti Hurria
- Associate Professor and Director of Cancer and Aging Program, Department of Medical Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
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Lambert PC, Holmberg L, Sandin F, Bray F, Linklater KM, Purushotham A, Robinson D, Møller H. Quantifying differences in breast cancer survival between England and Norway. Cancer Epidemiol 2011; 35:526-33. [PMID: 21606014 DOI: 10.1016/j.canep.2011.04.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 04/10/2011] [Accepted: 04/15/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Survival from breast cancer is lower in the UK than in some other European countries. We compared survival in England and Norway by age and time from diagnosis. METHODS We included 303,648 English and 24,919 Norwegian cases of breast cancer diagnosed 1996-2004 using flexible parametric relative survival models, enabling improved quantification of differences in survival. Crude probabilities were estimated to partition the probability of death due to all causes into that due to cancer and other causes and to estimate the number of "avoidable" deaths. RESULTS England had lower relative survival for all ages with the difference increasing with age. Much of the difference was due to higher excess mortality in England in the first few months after diagnosis. Older patients had a higher proportion of deaths due to other causes. At 5 years post diagnosis, a woman aged 85 in England had probabilities of 0.35 of dying of cancer and 0.32 of dying of other causes, whilst in Norway they were 0.26 and 0.35. By eight years the number of "avoidable" all-cause deaths in England was 1020 with the number of "avoidable" breast cancer related deaths 1488. CONCLUSION Lower breast cancer survival in England is mainly due to higher mortality in the first year after diagnosis. Crude probabilities aid our understanding of the impact of disease on individual patients and help assess different treatment options.
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Affiliation(s)
- Paul C Lambert
- Centre for Biostatistics and Genetic Epidemiology, Department of Health Sciences, 2nd Floor Adrian Building, University of Leicester, University Road, Leicester LE1 7RH, UK.
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Abstract
BACKGROUND Women aged ≥65 are generally underrepresented in early breast cancer studies. Therefore, the optimal management of this group of women remains less certain. METHODS A literature review of recently published trials, reviews, and practice guidelines outlining the surgical and adjuvant management of early breast cancer in older women was performed. RESULTS Surgery remains as the cornerstone treatment for early breast cancer in the elderly. Adjuvant radiation is generally considered if the projected lifespan is >5 years. Hormone receptor-positive disease is best treated with adjuvant endocrine treatment; aromatase inhibitors and tamoxifen are both options. Evidence for the use of adjuvant chemotherapy and trastuzumab for high-risk disease in the elderly is more limited. Polychemotherapy is still preferred in fit older women. Certain toxicities from systemic treatments can be more pronounced and should be carefully managed. Treatment with systemic agents should be individualized, with consideration of patient preference, performance status, comorbidities, and projected lifespan. Molecular tumor signatures may help better select patients for treatment in the future. CONCLUSIONS Age in itself should not be an absolute contraindication to any breast cancer therapy. Comprehensive, multidisciplinary assessment of elderly patients is imperative in evaluating eligibility for beneficial therapies.
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Affiliation(s)
- Sonal Gandhi
- Department of Medical Oncology, Sunnybrook Odette Cancer Centre, Toronto, Canada.
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