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Talking with male patients about cancer screening
Catherine E. Dubé, EdD; Barbara K. Fuller, MPH; Margot Jackson, MADr. Dubé is Senior Lecturer, Brown University, Providence, RI; Ms. Fuller is Project Coordinator, Brown Medical School; Ms. Jackson is a graduate student at the University of California, Los Angeles. The authors have indicated no relationships to disclose relating to the content of this article.Cancer-screening discussions can be complex, involving multiple options and much controversy. The use of shared decision making and patient education can address men's informational needs and improve adherence.
Supported by a grant from the National Cancer Institute, the authors of this article have been working for the past 5 years to improve communication between men and their health care providers about cancer screening. During this time, we have collaborated with faculty from the medical schools at Brown and Dartmouth universities, and we have organized faculty development workshops at six additional schools. We conducted focus groups with men about communication with their providers, and we have conducted an observational study of "master performer" clinical communication behaviors for men's cancer screening. The details of these two studies are described in other articles.1,2 In our work, we have discovered that many health care providers have not seriously reflected upon the special needs of male patients. We have also learned that clinicians hold certain stereotypes that may run counter to men's actual feelings and beliefs and that these stereotypes can interfere with effective clinical communication. Is it possible that male patients are medically underserved compared with their female counterparts? Men have a shorter life expectancy than women, suffer more severe chronic conditions, and have higher mortality rates at all ages and for all leading causes of death.3,4 They have more limited contact with the health care system, and they are less likely to have a regular health care provider than are women.5 Among men who do visit a physician, many receive no counseling about health behaviors like smoking, alcohol use, diet, and exercise (see "The importance of preventive health care.")5
Clinical communication between providers and male patients has also been shown to be less participatory than communication between providers and female patients,6 particularly when providers are male.7 Men do not disclose as much personal information as women,8,9 they smile less,10,11 they retain hierarchical status in communication (whereas women try to minimize status differences), and they may interpret and express symptoms differently than do women.9 Men tend to report less pain9,12-15 and are less likely than women to be treated for their pain.16,17 Men often feel uncomfortable talking about their health concerns until a serious problem has developed.18 Under stressful conditions, men may display aggressive or independent behaviors, which may be disconcerting for clinicians. Clinicians may hold certain assumptions about male patients that are not well founded. Clinicians may believe, for example, that men are immodest and unlikely to feel embarrassment during genital exams,19 don't care about their health, are emotionally insensitive, and will seek medical care only if pressed to do so by a woman in their life. In our focus group research, however, we discovered that men were surprisingly modest about physical exposure in clinical settings, concerned about embarrassing exams, and interested in their health. We also learned that they desired closer personal relationships with their health care providers. Concern for modesty and privacy should be afforded to male patients, particularly in the context of potentially embarrassing physical exam procedures. Communication principles and practices that are commonly used to address the needs of women patients with sensitivity can also be used when treating men. Explanations should be provided of invasive or sensitive exam procedures, as should warnings about pain or other sensations that may be experienced in uncomfortable genital or rectal exams. Attention to relationship building is also important, even in the face of potentially dismissive or resistant responses by male patients. Efforts to be empathic, respectful, and understanding of male patients may not yield the same satisfying and appreciative response often seen in female patients, but many men value these behaviors in clinicians. Finally, clinicians may need to adjust information-gathering techniques because of the reluctance of some male patients to appear vulnerable or to reveal personal information. By engaging in an interactive relationship with their male patients, providers are in a position to demystify the medical setting, thereby encouraging men to schedule regular preventive checkups, to practice a healthy lifestyle, to seek help when they have a medical concern, and to discuss their concerns before they become serious medical problems. Colorectal cancer screeningThe U.S. Preventive Services Task Force (USPSTF) strongly recommends colorectal cancer screening starting at age 50 years for men and women who are at average risk and starting at younger ages for those at higher risk because of a family history of polyps or colorectal cancer or a personal history of ulcerative colitis.20 Yet no single screening strategy is endorsed. There are several options for colorectal cancer screening, including fecal occult blood testing (FOBT), flexible sigmoidoscopy (alone or in combination with FOBT), colonoscopy, and double-contrast barium enema (USPSTF guideline). According to the CDC, the recommended intervals for these screening options are as follows: • FOBT annually • Sigmoidoscopy every 5 years • Barium enema every 5 years • Colonoscopy every 10 years.21 The USPSTF recommends that clinicians talk with patients about the benefits and potential harms of each option before selecting a screening strategy, with the ultimate choice of the best screening strategy resting on patient preferences, adherence, medical contraindications, and resources for testing and follow-up.20 Colorectal cancer–screening rates for men and women remain low, with only 45% of men and 41% of women aged 50 years or older being screened.21 The age-adjusted incidence rate of colorectal cancer is nearly 50% higher for men than for women,22 and men may require more encouragement and instruction than women to participate in colorectal cancer screening.14 FOBT is a problematic screening option because it has low rates of adherence.23,24 In population-based studies, return rates of FOBT kits are as low as 13% to 15%.25 Other colorectal cancer screening strategies also suffer from low adherence. Sigmoidoscopy adherence, for example, ranges from 6% in community-based screening programs to 47% in selected populations or patients who have relatives with colorectal cancer.20,26 For colonoscopy, little information on adherence is available, but barriers to adherence include the discomfort and inconvenience of preparing for the test; the need for sedation and recovery time that requires transportation to the testing center and time off from work; fears about discomfort during the procedure; the risk of bowel perforation; and, for uninsured patients, the cost. One strategy to improve adherence is to involve the patient in the screening decision-making process.27 Because of the multiple options for colorectal cancer screening, both patients and clinicians may have difficulty choosing the best strategy.28 This uncertainty may result in a complicated and time-consuming decision-making process. Because patient participation in decision making improves adherence,29 clinicians are advised to take a collaborative approach and provide information on guidelines, screening options, and the clinician's perspectives on screening. Providers should also encourage patients to reflect on their own values and preferences, explore solutions and negotiate strategies, and develop a mutually agreeable plan. Once a decision has been made, clinicians should provide patients with detailed information on how to proceed with the plan and what to expect. Patients may not be aware of how to properly prepare and return an FOBT card, for example. Similarly, if a patient is scheduled for an endoscopic procedure, clear guidelines should be given on the necessary preparatory and procedural steps. To further improve adherence, facilitators and barriers to screening should be explored and solutions to problems interfering with screening plans developed or negotiated. A monitoring and follow-up system will help to identify nonadherent patients so that clinicians can intervene to renegotiate the screening plan or to otherwise aid in follow-through. Colorectal cancer screening is potentially painful, embarrassing, or repulsive to many patients. By normalizing screening behaviors, emphasizing the importance of preventive care for men, listening to and addressing men's concerns, presenting themselves as the patient's ally through partnership statements, preparing patients for the screening test, and ensuring that adherence problems are flagged and addressed, clinicians will be in a better position to improve colorectal cancer–screening rates and ultimately reduce colorectal cancer deaths among their male patients. Prostate cancer screeningProstate cancer–screening recommendations and guidelines remain controversial, with some groups recommending against screening and others advising that routine screening be offered to all men. Conflicting viewpoints stem from the characteristics of the common screening procedures—the prostate-specific antigen (PSA) test and the digital rectal exam (DRE). Sensitivity and specificity are problematic for both tests, and both have a high risk of false-negative results (leaving cancer undetected) and false-positive results (leading to unnecessary and costly diagnostic follow-up that carries its own risk of complications). Further, the natural history of prostate cancer is still unclear, meaning that some cancers detected by screening may be clinically unimportant; the efficacy of available treatments for localized prostate cancer, with their concomitant potential harms and complications, is also a topic of debate.30 However, guidelines do agree on the age at which the screening decision becomes salient: Men aged 50 years or older may consider screening if their life expectancy is 10 or more years, while high-risk men may begin screening at age 45 years. The screening methods most commonly considered are the PSA test and the DRE. The American Urological Association (AUA) and the American Cancer Society (ACS) are in favor of offering annual screening with the PSA test and the DRE. However, the AUA recognizes that not all men older than 50 years are appropriate candidates for screening and that screening decisions should be individualized. Both organizations recommend a discussion of the benefits and risks of PSA testing before the test is ordered.31,32 The American College of Physicians (ACP) does not recommend routine screening for all men. Instead, the ACP recommends that clinicians discuss screening with their patients, describe the potential benefits and known harms of screening, diagnosis, and treatment, and reflect upon the patient's concerns before individualizing a decision whether or not to screen.33 The USPSTF, citing lack of sufficient evidence, does not make a specific recommendation. It does leave the door open for clinicians to consider screening patients for "other reasons," but not without an informative discussion between clinician and patient in which they address gaps in the evidence and explore patients' personal preferences and risk factors.34 Finally, the American College of Preventive Medicine (ACPM) recommends against routine population screening with the DRE and the PSA test.35 Rather, ACPM guidelines suggest providing information about gaps in evidence and the harms and benefits of screening to all male patients aged 50 years and older. This organization promotes the idea that men should make their own screening choices based on their personal preferences and with the help of their physician.34 Just as organizations differ in their stand on screening for prostate cancer, they also provide conflicting advice on counseling patients about the screening decision. The AUA and ACS recommendations reflect an informed consent model, in which patents consent to a plan of action set forth by a provider. The ACP recommendation promotes a shared decision-making process. The ACPM promotes an autonomous decision on the part of the patient. Despite diversity of opinion, most guidelines agree that clinicians must inform male patients about the potential harms, benefits, limitations, and consequences of prostate cancer screening. Some also call for the presentation and assessment of related scientific evidence. This is a tall order for clinicians with limited patient-contact time and for patients who may lack scientific knowledge. We recommend that the decision to undergo screening for prostate cancer be a shared one. This model allows the patient to decide how active a role he would like to take in decision making, and it encourages collaborative dialogue between clinicians and patients. Because the scientific evidence about prostate cancer–screening efficacy is complex and difficult to assess, clinicians should process the evidence and consolidate it into a coherent message that is easily understood by patients. We have found that complicated or convoluted discussions about the scientific evidence without a clear clinician recommendation leave patients frustrated and confused.1 We recommend, therefore, that clinicians act as advisers and that they provide clear clinical opinions about screening for each patient, that they listen to patients' concerns and perspectives, and that a mutually agreeable plan be negotiated between patients and their providers. Shared decision making is a dialogue within the provider-patient relationship with complementary role expectations and behavior on the part of both clinician and patient.36 Active participation, collaboration, and partnership between the participants are key. The clinician also serves as facilitator, actively enhancing the patient's consideration of his beliefs, values, and preferences related to prostate cancer–screening choice. Clinicians can also offer decision aids such as videotapes or patient education pamphlets to help patients understand the issues and reflect upon their preferences. Steps in the shared decision-making process include the following: • Express a desire to partner with the patient to make the best screening decision together • Elicit and respond to the patient's desired role in decision making • Discuss the patient's individual risk • Provide information about evidence related to screening options, harms, and benefits • Elicit the patient's values and preferences • Negotiate a mutually agreeable plan • Make plans for follow-up. The prostate cancer–screening discussion is challenging and time consuming. We have found that it is difficult to conduct an effective and comprehensive prostate cancer–screening discussion in less than 5 minutes. Many clinicians avoid such discussions altogether.37 With healthy older men at a well-patient visit, however, time spent discussing cancer screening may be well justified since it may be among the most important items on the problem list. Testicular cancerFor early detection of testicular cancer, the most important tasks are an effective clinical exam and patient education about self-examination. This process is simple to perform and to teach, and the population at risk for testicular cancer is young, which means that early detection could result in many years of life saved. Further, testicular exams also provide an opportunity to discuss important topics like sexuality, sexually transmitted diseases, prevention, and self-care with young male patients who generally have limited contact with the health care system. However, screening recommendations for testicular cancer vary. The USPSTF recommends against routine clinical or self-examination, even for men at high risk, citing lack of evidence that screening improves health outcomes.38 The ACS, in contrast, recommends these exams for all men as part of a routine cancer-related checkup,39 and the Bright Futures guideline advises that examination of the genitals (for problems including testicular cancer) be performed on all adolescent males.40 The Institute for Clinical Systems Improvement recommends clinical testicular exams only for those at high risk.41 The American Medical Association and the AUA support education in self-examination methods for early detection of testicular cancer.42,43 Should a clinician choose to screen for testicular cancer using a clinical testicular exam, communication about the exam before performing it can reduce anxiety and embarrassment and provide an opportunity to normalize conversation about sexual problems, sexual organs, and other sensitive topics. Establishing a trusting relationship with a younger male patient before any exam is crucial. Adolescent patients can be preoccupied with body image44 and are prone to embarrassment and shame in the medical encounter.45 If the patient is uncomfortable, the provider should consider having a chaperone in the room. Introduction and normalization of the testicular exam can be accomplished by comparing it to a breast exam for women—a routine exam that can help ensure that any problems will be caught early. A discussion of testicular cancer in regard to public role models may aid the clinician in relating to younger male patients, since they will often identify with Lance Armstrong and other public figures who have had experience with testicular cancer. Providers should be sure to reassure patients about their actual risk status because testicular cancer occurs rarely in healthy young men. Before and during the clinical exam, procedures should be thoroughly explained. In our focus groups with younger men, we learned that they preferred detailed explanations of exam procedures, including what to expect, what the clinician is doing and why, descriptions of anatomical structures, and what is normal and what is not. Taking an appropriate amount of time to conduct the exam was also important to these younger men. Teaching patients how to conduct a testicular self-exam can be efficiently accomplished during the clinical exam. Demonstrating the procedure with verbal explanation and allowing the patient to mimic the maneuvers allows providers to simultaneously conduct an exam and teach patients the appropriate technique. Explanations of anatomical terms should be free of jargon, easily understood by patients, and illustrated before or after the exam using models or pictures. Conversation during the clinical testicular exam should be interactive, professional, respectful, and nonjudgmental. After the exam is completed and the patient has dressed, exam findings can be discussed and questions elicited and answered before transition to other sensitive topics. If testicular self-examination is recommended to patients, they should leave the office aware of how often they should perform the exam (eg, monthly), where they should perform it (eg, in the shower), what findings to worry about (eg, lumps that are round and hard like a knuckle), and what to do if they have questions or concerns. ConclusionsUnderstanding male communication and behaviors has become even more important with women entering the health professions at ever increasing numbers. Stereotypes held by practicing clinicians and handed down to trainees need to be challenged and adjusted to provide more effective care to men. Since men are less likely to be connected with the health care system than women, special efforts should be made to encourage appropriate preventive care, including age-appropriate cancer screening and early detection strategies (see Table 1). With conflicting and contradictory cancer-screening guidelines, clinicians and their male patients risk confusion, but effective communication strategies can help allay this confusion and improve adherence.
Over the course of our project, the authors have learned that practitioners are distressed about the lack of consensus in men's cancer-screening guidelines, particularly with regard to prostate cancer screening. With limited time available to evaluate the scientific evidence, limited clinical contact time, and guidelines suggesting that the evidence be reviewed with patients, health care providers are justifiably frustrated. Patients who present for routine medical care also express frustration when faced with cancer-screening decisions that they did not anticipate and do not have the training or skills to make.1 Yet until more clarity is offered about prostate cancer–screening strategies, the problem will remain. In the meantime, employing effective communication strategies will help with both addressing cancer screening and establishing good relationships with male patients. For access to the complete curriculum on Clinical Communication for Male Cancer Screening, go to www.brown.edu/Research/ICHP/mcshome.shtml .
REFERENCES 1. Dubé CE, Fuller BK. A qualitative study of communication skills for male cancer screening discussions. J Cancer Educ. Winter 2003;18:182-187. 2. Dubé CE, Fuller BK, Rosen RK, et al. Men's experiences of physical exams and cancer screening tests: a qualitative study. Prev Med. In press. 3. Centers for Disease Control and Prevention, National Center for Health Statistics. Table 27. Life expectancy at birth, at 65 years of age, and at 75 years of age, according to race and sex: United States, selected years 1900-2001. Health, United States, 2003. Available at: http://www.cdc.gov/nchs/data/hus/tables/2003/03hus027.pdf . Accessed October 21, 2004. 4. Courtenay WH. Constructions of masculinity and their influence on men's well-being: a theory of gender and health. Soc Sci Med. 2000;50:1385-1401. 5. Sandman D, Simantov E, An C. Out of Touch: American Men and the Health Care System. Commonwealth Fund Men's and Women's Health Survey Findings. New York, NY: The Commonwealth Fund; March 2000. 6. Kaplan SH, Gandek B, Greenfield S, et al. Patient and visit characteristics related to physicians' participatory decision-making style. Results from the Medical Outcomes Study. Med Care. 1995;33:1176-1187. 7. Roter DL, Hall JA. Gender differences in patient-physician communication. In: Gallant SJ, Keita GP, Royak-Schaler R, eds. Health Care for Women: Psychological, Social and Behavioral Influences. Washington, DC: American Psychological Assoc; 1997:57-72. 8. Gray J. Men Are from Mars, Women Are from Venus: A Practical Guide for Improving Communication and Getting What You Want in Your Relationships. New York, NY: HarperCollins; 1992. 9. Teutsch C. Patient-doctor communication. Med Clin North Am. 2003;87:1115-1145. 10. Kiss A. Does gender have an influence on the patient-physician communication? J Men's Health & Gender. May 2004;1:77-82. 11. LaFrance M, Hecht MA, Paluck EL. The contingent smile: a meta-analysis of sex differences in smiling. Psychol Bull. March 2003;129:305-334. 12. Pinn VW. Sex and gender factors in medical studies: implications for health and clinical practice. JAMA. 2003;289:397-400. 13. Sun LS. Gender differences in pain sensitivity and responses to analgesia. J Gend Specif Med. September 1998;1:28-30. 14. Myers CD, Riley JL III, Robinson ME. Psychosocial contributions to sex-correlated differences in pain. Clin J Pain. July-August 2003;19:225-232. 15. Rollman GB. Introduction: sex makes a difference: experimental and clinical pain responses. Clin J Pain. July-August 2003;19:204-207. 16. Bertakis KD, Azari R, Callahan EJ. Patient pain in primary care: factors that influence physician diagnosis. Ann Fam Med. May-June 2004;2:224-230. 17. Raftery KA, Smith-Coggins R, Chen AH. Gender-associated differences in emergency department pain management. Ann Emerg Med. 1995;26:414-421. 18. Banks I. No man's land: men, illness, and the NHS. BMJ. 2001;323:1058-1060. 19. Elta GH. Women are different from men. Gastrointest Endosc. August 2002;56: 308,309. 20. U.S. Preventive Services Task Force. Screening for Colorectal Cancer: Recommendations and Rationale. Rockville, Md: Agency for Healthcare Research and Quality; July 2002. Available at: http://www.ahrq.gov/clinic/3rduspstf/colorectal/colorr.htm . Accessed October 21, 2004. 21. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control. 2003 program fact sheet: colorectal cancer: the importance of prevention and early detection. Screening for colorectal cancer. Available at: http://www.cdc.gov/cancer/colorctl/colorect.htm . Accessed October 21, 2004. 22. National Cancer Institute. Cancer incidence in the United States (SEER), 1987-91: 10 most common cancers by sex among whites and blacks. Available at: http://seer.cancer.gov/publications/raterisk/rates12.html. Accessed October 21, 2004. 23. Richardson JL, Danley K, Mondrus GT, et al. Adherence to screening examinations for colorectal cancer after diagnosis in a first-degree relative. Prev Med. March 1995;24:166-170. 24. Sandler RS, DeVellis BM, Blalock SJ, Holland KL. Participation of high-risk subjects in colon cancer screening. Cancer. 1989;63:2211-2215. 25. Myers RE, Trock BJ, Lerman C, et al. Adherence to colorectal cancer screening in an HMO population. Prev Med. 1990;19:502-514. 26. Vernon SW. Participation in colorectal cancer screening: a review. J Natl Cancer Inst. 1997;89:1406-1422. 27. Woolf SH. The best screening test for colorectal cancer—a personal choice. N Engl J Med. 2000;343:1641-1643. 28. Redelmeier DA, Shafir E. Medical decision making in situations that offer multiple alternatives. JAMA. 1995;273:302-305. 29. Thakur NM, Perkel RL. Prevention in adulthood: forging a doctor-patient partnership. Prim Care. 2002;29:571-582. 30. Harris R, Lohr KN. Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:917-929. 31. American Urological Association. Prostate-specific antigen (PSA) best practice policy. Oncology (Huntingt). February 2000;14:267-280 passim. 32 American Cancer Society. ACS cancer detection guidelines: cancer-related checkup. Available at: http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp?sitearea=PED . Accessed October 21, 2004. 33. American College of Physicians. Screening for prostate cancer. Ann Intern Med. 1997;126:480–484. 34. U.S. Preventive Services Task Force. Screening for Prostate Cancer: Recommendations and Rationale. Rockville, Md: Agency for Healthcare Research and Quality; 2002. Available at: http://www.ahrq.gov/clinic/3rduspstf/prostatescr/prostaterr.htm . Accessed October 21, 2004. 35. Ferrini R, Woolf SH. Screening for prostate cancer in American men: American College of Preventive Medicine practice policy statement. Available at: http://www.acpm.org/prostate.htm . Accessed October 21, 2004. 36. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44:681-692. 37. Dunn AS, Shridharani KV, Lou W, et al. Physician-patient discussions of controversial cancer screening tests. Am J Prev Med. February 2001;20:130-134. 38. U.S. Preventive Services Task Force. Screening for Testicular Cancer: Recommendation Statement. Rockville, Md: Agency for Healthcare Research and Quality; February 2004. Available at: http://www.ahrq.gov/clinic/3rduspstf/testicular/testiculrs.htm . Accessed October 21, 2004. 39. American Cancer Society. Testicular cancer. Available at: http://documents.cancer. org/121.00/121.00.pdf. Accessed October 21, 2004. 40. Green M, Palfrey JS, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 2nd ed, rev. Arlington, Va: National Center For Education in Maternal and Child Health, Georgetown University; 2002. 41. Institute for Clinical Systems Improvement (ICSI). Preventive Services for Children and Adolescents. Bloomington, Minn: ICSI; 2003. 42. American Medical Association. H-55.989 testicular cancer self-examination (Res. 28, I-87; Reaffirmed: Sunset Report, I-97). Available at: http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-55.989.HTM . Accessed October 21, 2004. 43. American Urological Association. Urological services. Testicular cancer self-examination. Available at: http://www.auanet.org/about/policy/services.cfm . Accessed October 21, 2004. 44. Felice ME, Maehr J. Fourteen to sixteen years: mid-adolescence—the dating game. In: Dixon SD, Stein MT, eds. Encounters with Children: Pediatric Behavior and Development. 3rd ed. St Louis, Mo: Mosby; 2000:452. 45. Lazare A. Shame and humiliation in the medical encounter. Arch Intern Med. 1987;147:1653-1658. 46. American Cancer Society. ACS guidelines for the early detection of colon cancer. Available at: http://www.cancer.org/colonmd/pdfs/guidelines.pdf . Accessed October 21, 2004. 47. American College of Preventive Medicine. Clinical preventive services. Available at: http://www.acpm.org/clinical.htm#Colorectal%20Cancer . Accessed October 21, 2004. 48. American Medical Association. H-55.981 carcinoma of the colon and rectum. Available at: http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/H-55.981.HTM . Accessed October 21, 2004. 49. Institute for Clinical Systems Improvement (ICSI). Colorectal cancer screening. Available at: http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=159 . Accessed October 21, 2004. 50. American Medical Association. Featured CSA report: screening and early detection of prostate cancer. Available at: http://www.ama-assn.org/ama/pub/article/2036-4458.html#recommendations . Accessed October 21, 2004. 51. Institute for Clinical Systems Improvement (ICSI). Prostate specific antigen as a screening test for prostate cancer. Available at: http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=298 . Accessed October 21, 2004.
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