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Mai M, Goldman J, Appiah D, Abdulrahman R, Kidwell J, Shi Z. Timing of Surgery and Social Determinants of Health Related to Pathologic Complete Response after Total Neoadjuvant Therapy for Rectal Adenocarcinoma: Retrospective Study of National Cancer Database. Curr Oncol 2024; 31:1291-1301. [PMID: 38534930 PMCID: PMC10969721 DOI: 10.3390/curroncol31030097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 05/26/2024] Open
Abstract
Total neoadjuvant therapy (TNT) for rectal adenocarcinoma (RAC) involves multi-agent chemotherapy and radiation before definitive surgery. Previous studies of the rest period (time between radiation and surgery) and pathologic complete response (pCR) have produced mixed results. The objective of this study was to evaluate the relationship between the rest period and pCR. This study utilized the National Cancer Database (NCDB) to retrospectively analyze 5997 stage-appropriate RAC cases treated with TNT from 2016 to 2020. The overall pCR rate was 18.6%, with most patients undergoing induction chemotherapy followed by long-course chemoradiation (81.5%). Multivariable logistic regression models revealed a significant non-linear relationship between the rest period and pCR (p = 0.033), with optimal odds at 14.7-15.9 weeks post radiation (odds ratio: 1.49, 95% confidence interval: 1.13-1.98) when compared to 4.0 weeks. Medicaid, distance to the treatment facility, and community education were associated with decreased odds of pCR. Findings highlight the importance of a 15-16-week post-radiation surgery window for achieving pCR in RAC treated with TNT and socioeconomic factors influencing pCR rates. Findings also emphasize the need for clinical trials to incorporate detailed analyses of the rest period and social determinant of health to better guide clinical practice.
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Affiliation(s)
- Megan Mai
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Jodi Goldman
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Duke Appiah
- Department of Public Health, School of Population and Public Health, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Ramzi Abdulrahman
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Radiation Oncology Clinic, University Medical Center Cancer Center, Lubbock, TX 79430, USA
| | - John Kidwell
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Colorectal Surgery Clinic, University Medical Center Cancer Center, Lubbock, TX 79430, USA
| | - Zheng Shi
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Radiation Oncology Clinic, University Medical Center Cancer Center, Lubbock, TX 79430, USA
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Del Rosario M, Chang J, Ziogas A, Clair K, Bristow RE, Tanjasiri SP, Zell JA. Differential Effects of Race, Socioeconomic Status, and Insurance on Disease-Specific Survival in Rectal Cancer. Dis Colon Rectum 2023; 66:1263-1272. [PMID: 35849491 PMCID: PMC10548716 DOI: 10.1097/dcr.0000000000002341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND National Comprehensive Cancer Network guideline adherence improves cancer outcomes. In rectal cancer, guideline adherence is distributed differently by race/ethnicity, socioeconomic status, and insurance. OBJECTIVE This study aimed to determine the independent effects of race/ethnicity, socioeconomic status, and insurance status on rectal cancer survival after accounting for differences in guideline adherence. DESIGN This was a retrospective study. SETTINGS The study was conducted using the California Cancer Registry. PATIENTS This study included patients aged 18 to 79 years diagnosed with rectal adenocarcinoma between January 1, 2004, and December 31, 2017, with follow-up through November 30, 2018. Investigators determined whether patients received guideline-adherent care. MAIN OUTCOME MEASURES ORs and 95% CIs were used for logistic regression to analyze patients receiving guideline-adherent care. Disease-specific survival analysis was calculated using Cox regression models. RESULTS A total of 30,118 patients were examined. Factors associated with higher odds of guideline adherence included Asian and Hispanic race/ethnicity, managed care insurance, and high socioeconomic status. Asians (HR, 0.80; 95% CI, 0.72-0.88; p < 0.001) and Hispanics (HR, 0.91; 95% CI, 0.83-0.99; p = 0.0279) had better disease-specific survival in the nonadherent group. Race/ethnicity were not factors associated with disease-specific survival in the guideline adherent group. Medicaid disease-specific survival was worse in both the nonadherent group (HR, 1.56; 95% CI, 1.40-1.73; p < 0.0001) and the guideline-adherent group (HR, 1.18; 95% CI, 1.08-1.30; p = 0.0005). Disease-specific survival of the lowest socioeconomic status was worse in both the nonadherent group (HR, 1.42; 95% CI, 1.27-1.59) and the guideline-adherent group (HR, 1.20; 95% CI, 1.08-1.34). LIMITATIONS Limitations included unmeasured confounders and the retrospective nature of the review. CONCLUSIONS Race, socioeconomic status, and insurance are associated with guideline adherence in rectal cancer. Race/ethnicity was not associated with differences in disease-specific survival in the guideline-adherent group. Medicaid and lowest socioeconomic status had worse disease-specific survival in both the guideline nonadherent group and the guideline-adherent group. See Video Abstract at http://links.lww.com/DCR/B954 . EFECTOS DIFERENCIALES DE LA RAZA, EL NIVEL SOCIOECONMICO COBERTURA SOBRE LA SUPERVIVENCIA ESPECFICA DE LA ENFERMEDAD EN EL CNCER DE RECTO ANTECEDENTES: El cumplimiento de las guías de la National Comprehensive Cancer Network mejora los resultados del cáncer. En el cáncer de recto, el cumplimiento de las guías se distribuye de manera diferente según la raza/origen étnico, nivel socioeconómico y el cobertura médica.OBJETIVO: Determinar los efectos independientes de la raza/origen étnico, el nivel socioeconómico y el estado de cobertura médica en la supervivencia del cáncer de recto después de tener en cuenta las diferencias en el cumplimiento de las guías.DISEÑO: Este fue un estudio retrospectivo.ENTORNO CLINICO: El estudio se realizó utilizando el Registro de Cáncer de California.PACIENTES: Pacientes de 18 a 79 años diagnosticados con adenocarcinoma rectal entre el 1 de enero de 2004 y el 31 de diciembre de 2017 con seguimiento hasta el 30 de noviembre de 2018. Los investigadores determinaron si los pacientes recibieron atención siguiendo las guías.PRINCIPALES MEDIDAS DE RESULTADO: Se utilizaron razones de probabilidad e intervalos de confianza del 95 % para la regresión logística para analizar a los pacientes que recibían atención con adherencia a las guías. El análisis de supervivencia específico de la enfermedad se calculó utilizando modelos de regresión de Cox.RESULTADOS: Se analizaron un total de 30.118 pacientes. Los factores asociados con mayores probabilidades de cumplimiento de las guías incluyeron raza/etnicidad asiática e hispana, seguro de atención administrada y nivel socioeconómico alto. Los asiáticos e hispanos tuvieron una mejor supervivencia específica de la enfermedad en el grupo no adherente HR 0,80 (95 % CI 0,72 - 0,88, p < 0,001) y HR 0,91 (95 % CI 0,83 - 0,99, p = 0,0279). La raza o el origen étnico no fueron factores asociados con la supervivencia específica de la enfermedad en el grupo que cumplió con las guías. La supervivencia específica de la enfermedad de Medicaid fue peor tanto en el grupo no adherente HR 1,56 (IC del 95 % 1,40 - 1,73, p < 0,0001) como en el grupo adherente a las guías HR 1,18 (IC del 95 % 1,08 - 1,30, p = 0,0005). La supervivencia específica de la enfermedad del nivel socioeconómico más bajo fue peor tanto en el grupo no adherente HR 1,42 (IC del 95 %: 1,27 a 1,59) como en el grupo adherente a las guías HR 1,20 (IC del 95 %: 1,08 a 1,34).LIMITACIONES: Las limitaciones incluyeron factores de confusión no medidos y la naturaleza retrospectiva de la revisión.CONCLUSIONES: La raza, el nivel socioeconómico y cobertura médica están asociados con la adherencia a las guías en el cáncer de recto. La raza/etnicidad no se asoció con diferencias en la supervivencia específica de la enfermedad en el grupo que cumplió con las guías. Medicaid y el nivel socioeconómico más bajo tuvieron peor supervivencia específica de la enfermedad tanto en el grupo que no cumplió con las guías como en los grupos que cumplieron. Consulte Video Resumen en http://links.lww.com/DCR/B954 . (Traducción- Dr. Francisco M. Abarca-Rendon).
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Affiliation(s)
- Michael Del Rosario
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, California
| | - Jenny Chang
- Department of Medicine, University of California, Irvine, Irvine, California
| | - Argyrios Ziogas
- Department of Medicine, University of California, Irvine, Irvine, California
| | - Kiran Clair
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, California
| | - Robert E. Bristow
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, California
| | - Sora P. Tanjasiri
- Department of Medicine, University of California, Irvine, Irvine, California
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Irvine, California
| | - Jason A. Zell
- Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Irvine, California
- Department of Medicine, University of California, Irvine, Irvine, California
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Irvine, California
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Lee KC, Zhao B, Pianka K, Liu S, Eisenstein S, Ramamoorthy S, Lopez NE. Current trends in nonoperative management for rectal adenocarcinoma: An unequal playing field? J Surg Oncol 2022; 126:1504-1511. [PMID: 36056914 DOI: 10.1002/jso.27082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/28/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Increasing evidence suggests patient-oriented benefits of nonoperative management (NOM) for rectal cancer. However, vigilant surveillance requires excellent access to care. We sought to examine patient, socioeconomic, and facility-level factors associated with NOM over time. METHODS Using the National Cancer Database (2006-2017), we examined patients with Stage II-III rectal adenocarcinoma, who received neoadjuvant chemoradiation and received NOM versus surgery. Factors associated with NOM were assessed using multivariable logistic regression with backward stepwise selection. RESULTS There were 59,196 surgical and 8520 NOM patients identified. NOM use increased from 12.9% to 15.9% between 2006 and 2017. Patients who were Black (adjusted odds ratio [aOR]: 1.36, 95% confidence interval [CI]: 1.26-1.47), treated at community cancer centers (aOR: 1.22, 95% CI: 1.12-1.30), without insurance (aOR: 1.87, 95% CI: 1.68-2.09), and with less education (aOR: 1.53, 95% CI: 1.42-1.65) exhibited higher odds of NOM. Patients treated at high-volume centers (aOR: 0.79, 95% CI: 0.74-0.84) and those who traveled >25.6 miles for care (aOR: 0.59, 95% CI: 0.55-0.64) had lower odds of NOM. CONCLUSIONS Vulnerable groups who traditionally have difficulty accessing comprehensive cancer care were more likely to receive NOM, suggesting that healthcare disparities may be driving utilization. More research is needed to understand NOM decision-making in rectal cancer treatment.
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Affiliation(s)
- Katherine C Lee
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Beiqun Zhao
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Kurt Pianka
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Shanglei Liu
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Samuel Eisenstein
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Sonia Ramamoorthy
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
| | - Nicole E Lopez
- Department of Surgery, University of California, San Diego, La Jolla, California, USA
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Silva T, Kadakia N, Aribo C, Gochi A, Kim GY, Solomon N, Molkara A, Molina DC, Plasencia A, Lum SS. Compliance With Surgical Oncology Specialty Care at a Safety Net Facility. Am Surg 2021; 87:1545-1550. [PMID: 34130523 DOI: 10.1177/00031348211024975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Social determinants of health challenge in at-risk patients seen in safety net facilities. STUDY DESIGN We performed a retrospective review of surgical oncology specialty clinic referrals at a safety net institution evaluating referral compliance and times to first appointment and initiation of definitive treatment. Main outcomes measured included completion of initial visit, initiation of definitive treatment, time from referral to first appointment, and time from first appointment to initiation of definitive treatment. RESULTS Of 189 new referrals, English was not spoken by 52.4% and 69.4% were Hispanic. Patients presented without insurance in 39.2% of cases. Electronic patient portal was accessed by 31.6% of patients. Of all new referrals, 55.0% arrived for initial consultation and 53.4% initiated definitive treatment. Malignant diagnosis (P < .0001) and lack of insurance (P = .01) were associated with completing initial consultation. Initiation of definitive treatment was associated with not speaking English (P = .03), malignant diagnosis (P < .0001), and lack of insurance (P = .03). Times to first appointment and initiation of definitive treatment were not significantly affected by race/ethnicity, language, insurance, treatment recommended, or electronic patient portal access. CONCLUSION Access to surgical oncology care for at-risk patients at a safety net facility is not adversely affected by lack of insurance, primary spoken language, or race/ethnicity. However, a significant proportion of all patients fail to complete the initial consultation and definitive treatment. Lessons learned from safety net facilities may help to inform disparities in health care found elsewhere.
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Affiliation(s)
- Trevor Silva
- Riverside University Health System, Moreno Valley, CA, USA
| | - Nikita Kadakia
- Department of Surgery, School of Medicine, University of California, Riverside, CA, USA
| | - Chade Aribo
- Department of Surgery, School of Medicine, University of California, Riverside, CA, USA
| | - Andrea Gochi
- Department of Surgery, School of Medicine, University of California, Riverside, CA, USA
| | - Gi Yoon Kim
- Riverside University Health System, Moreno Valley, CA, USA
| | - Naveen Solomon
- Riverside University Health System, Moreno Valley, CA, USA.,Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Afshin Molkara
- Riverside University Health System, Moreno Valley, CA, USA.,Department of Surgery, School of Medicine, University of California, Riverside, CA, USA
| | - David C Molina
- Riverside University Health System, Moreno Valley, CA, USA.,Department of Surgery, School of Medicine, University of California, Riverside, CA, USA.,Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Alexis Plasencia
- Riverside University Health System, Moreno Valley, CA, USA.,Department of Surgery, School of Medicine, University of California, Riverside, CA, USA.,Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Sharon S Lum
- Riverside University Health System, Moreno Valley, CA, USA.,Department of Surgery, School of Medicine, University of California, Riverside, CA, USA.,Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
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de Jager E, Levine AA, Udyavar NR, Burstin HR, Bhulani N, Hoyt DB, Ko CY, Weissman JS, Britt LD, Haider AH, Maggard-Gibbons MA. Disparities in Surgical Access: A Systematic Literature Review, Conceptual Model, and Evidence Map. J Am Coll Surg 2020; 228:276-298. [PMID: 30803548 DOI: 10.1016/j.jamcollsurg.2018.12.028] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 01/17/2023]
Affiliation(s)
- Elzerie de Jager
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA; College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Adele A Levine
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - N Rhea Udyavar
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | | | - Nizar Bhulani
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | | | - Clifford Y Ko
- American College of Surgeons, Chicago, IL; Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - L D Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, MA
| | - Melinda A Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA.
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Perez NP, Pernat CA, Chang DC. Surgical Disparities: Beyond Non-Modifiable Patient Factors. Health Serv Res 2020. [DOI: 10.1007/978-3-030-28357-5_5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Rice SR, Vyfhuis MAL, Scilla KA, Burrows WM, Bhooshan N, Suntharalingam M, Edelman MJ, Feliciano J, Badiyan SN, Simone CB, Bentzen SM, Feigenberg SJ, Mohindra P. Insurance Status is an Independent Predictor of Overall Survival in Patients With Stage III Non-small-cell Lung Cancer Treated With Curative Intent. Clin Lung Cancer 2019; 21:e130-e141. [PMID: 31708388 DOI: 10.1016/j.cllc.2019.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/23/2019] [Accepted: 08/28/2019] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Population studies suggest an impact of insurance status on oncologic outcomes. We sought to explore this in a large single-institution cohort of patients with non-small-cell lung cancer (NSCLC). MATERIALS AND METHODS We retrospectively analyzed 342 consecutive patients (January 2000 to December 2013) curatively treated for stage III NSCLC. Patients were categorized by insurance status as uninsured (U), Medicare/Medicaid + Veterans Affairs (M/M + VA), or Private (P). The χ2 test was utilized to compare categorical variables. The Kaplan-Meier approach and the Cox proportional hazard models were used to analyze overall survival (OS) and freedom from recurrence (FFR). RESULTS Compared with M/M + VA patients, P insurance patients were more likely to be younger (P < .001), married (P < .001), Caucasian (P = .001), reside in higher median income zip codes (P < .001), have higher performance status (P < .001), and undergo consolidation chemotherapy (P < .001) and trimodality therapy (P < .001). Diagnosis to treatment was delayed > 30 days in U (67.3%), M/M + VA (68.1%), and P (52.6%) patients (P = .017). Compared with the M/M + VA and U cohorts, P insurance patients had improved OS (median/5-year: 30.7 months/34.2%, 19 months/17%, and 16.9 months/3.8%; P < .001) and FFR (median/5-year: 18.4 months/27.3%, 15.2 months/23.2%, and 11.4 months/4.8%; P = .012), respectively. On multivariate analysis, insurance status was an independent predictor for OS (P = .017) but not FFR. CONCLUSION Compared with U or M/M + VA patients, P insurance patients with stage III NSCLC were more likely to be optimally diagnosed and treated, resulting in a doubling of median OS for P versus U patients. Improved access to affordable health insurance is critical to combat inequities in access to care and has potential for improvements in cancer outcomes.
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Affiliation(s)
- Stephanie R Rice
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Melissa A L Vyfhuis
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Katherine A Scilla
- Department of Medicine, Division of Hematology/Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Whitney M Burrows
- Department of Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Neha Bhooshan
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Mohan Suntharalingam
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Martin J Edelman
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Josephine Feliciano
- Department of Medicine, Division of Hematology/Oncology, Johns Hopkins Hospital, Baltimore, MD
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | | | - Soren M Bentzen
- Department of Epidemiology and Biostatistics, University of Maryland School of Medicine, Baltimore, MD
| | - Steven J Feigenberg
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD.
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