Rethink Pink and Screening Mammography

Laura Esserman MD Rethinking Screening MAMMOGRAPHYRethink Pink October Breast Cancer Month

by Jeffrey Dach MD

A Closer Look at Screening Mammography

Dr Laura Esserman of the University of California startled the medical community with an article questioning screening mammography published in the Journal of the American Medical Association (JAMA ).   (Above header image courtesy of UCSF and Dr. Laura Esserman)

Dr Laura Esserman reviewed 20 years of breast cancer data.  Her conclusion is not favorable:

“Mammography screening for breast cancer has significant drawbacks, and expected survival benefits have not materialized. “

“While the incidence of early stage breast cancer has decreased due to mammography, the incidence rates for the killer cancers, (the advanced cancers) have remained stable.  While it is true that overall mortality rates have declined slightly, this is attributed to better treatment rather than increased detection.” Dr Laura Esserman.

Let’s take a look at the Data Charts Dr Esserman used for her article, Rethinking Screening for Breast Cancer and Prostate Cancer Laura Esserman, MD, (JAMA. 2009;302(15):1685-1692.)

esserman chart JAMA breast cancer The above chart shows the critical information in Dr Esserman’s JAMA article.  The Pink line is TOTAL breast cancer incidence annually.  Note increase beginning in 1983 with introduction of mammography screening.  Below the pink line, we see three more lines: this is the breakdown of the total incidence into localized, regional and metastatic cases.  The turquoise line is localized cancer. The Light purple line is regional cancer and the black line (lowest) is metastatic cancer.  The killer cancers are the regional and metastatic cases.  Note that these numbers have remained stable with little change in spite of detection of massive numbers of localized cases

Here  is another chart looking at incidence and mortality from breast cancer annually (below) (all cases):
CAAC 2006 Breast Cancer Mortality IncidenceSource for above two charts:
Figure 3 and Figure 4 combined, FIGURE 3 (upper pink line) Annual Age-adjusted Cancer Incidence Rates among Females for Breast Cancer, United States, 1975– 2005. FIGURE 4 (lower pink line) Annual Age-adjusted Cancer Death Rates among Females for Breast Cancers, United States, 1930–2005.

The upper pink line (red arrow) is the incidence of breast cancer since 1976. Notice the dramatic increased detection of cases in the early 1980’s with introduction of screening mamography.  The lower pink line (green arrow) is the annual mortality rate for breast cancer from 1930 to 2006. Note this is stable at about 30 cases per 100,000 women, and declines over the last section (green arrow) to about 25 cases per 100,000.  Dr Esserman suggests this rather modest decline in mortality (green arrow) is not due to increased detection with mammography, rather it is due to improvement in treatment.

 Annual Breast Cancer Mortality – Where’s the Benefit?

While the incidence of early stage breast cancer has decreased by 2.8% per year since 2001, incidence rates of advanced (distant-stage) disease have remained stable.  In 2009, 192,370 women will be diagnosed with breast cancer and 40,170 women will die of breast cancer.  Mammography has increased the detection of very early stage cancer, called DCIS, with 60,000 cases of DCIS detected annually.

Esserman’s 2009 Observations were made in 2002 by Barnett Kramer 

MammogramSeven years ago, Dr. Barnett Kramer, director of the Office of Disease Prevention at the National Institutes of Health, was interviewed in a 2002 article in the New York Times, in which said:

“The number of women with breast cancers with the worst prognosis, those that spread to other organs, had been fairly constant in the years before mammography was introduced, and that trend did not change after the introduction of mammography…If screening worked perfectly, every cancer found early would correspond to one fewer cancer found later. That did not happen. Mammography, instead has resulted in a huge new population of women with early stage cancer but without a corresponding decline in the numbers of women with advanced cancer.”

Weighing the Pluses and Minuses of Screening Mammography

Dr Gilbert Welch in his BMJ editorial, says the following about mammography screening for breast cancer:

•1 in 1,000 women annually screened for 10 years will avoid dying from breast cancer.
•2 to 10 women will be over-diagnosed and treated needlessly
•10 to 15 women will be told they have breast cancer earlier than they would otherwise have been told, but this will not affect their prognosis.
•100 to 500 women will have at least one “false alarm” (about half of these women will undergo a biopsy)

Mammography Finds the DCIS Lesions

Annual incidence insitu DCIS breastcancerLeft chart shows annual incidence of DCIS (ductal carcinoma in situ). Note huge increase in 1983 (green arrow) with introduction of screening mammography.

Finding the Reservoir of DCIS

Mammography screening finds the small indolent cancers called DCIS that represent a reservoir of silent disease in up to 18% of the population (at autopsy).  This leads to overdiagnosis and overtreatment.  For the invasive cancers found in 1-2% of the population (at autopsy series), screening detection is of little help, with little change in the number of advanced cancer cases, and about 40,000 deaths every year.  Source above left image: SEER Cancer Statistics Review 1975-2006

Dr. Gilbert Welch sums it up with the following sage advice: “doctors who recommend less-aggressive mammography (less frequently, waiting until you are age 50, or stopping it when you are older) or are less quick to biopsy may not be bad doctors but good ones.”

Just Stop Calling It Cancer – DCIS

DCIS Ductal Carcinomain Situ Breast Cancer Screening mammogramOne glaring problem with screening mammography is the detection of DCIS at a rate of 60,000 case per year.  DCIS is ductal carcinoma in situ, a pathology diagnosis which carries a very good prognosis, a 98% – 5 year survival with no treatment.   In spite of the rather benign natural history of DCIS, mainstream medicine treats these lesions aggressively with surgery and radiation.  Recently, the NIH has called for a change in terminology, asking pathologists to stop calling it “cancer”.

Left Image : typical appearance of DCIS with punctate calcifications on mammogram (arrow). Courtesy Wikimedia Commons.

Here is the NIH consensus statement:  “Because of the noninvasive nature of DCIS, coupled with its favorable prognosis, strong consideration should be given to elimination of the use of the anxiety-producing term “carcinoma” from the description of DCIS. “

A Large Reservoir of Silent Disease – For All Three

All three types of cancer, breast, thyroid and prostate have a large reservoir of indolent or biologically insignificant disease that remains silent during the patient’s lifetime.  We know this from autopsy studies. One autopsy study of 110 women from Finland using specimen radiographs of thin sections found breast cancer in 20% of the cases. (2 % had invasive cancer, and 18% of the 110 cases had In-Situ Cancer).

Spontaneous Remission of Breast Cancer ?

PinkRibbonBreastCancerAwarenessMonthOne screening study reported by Welch in the Annals of Internal Medicine actually concluded that many small breast cancers spontaneously regress.  Gina Kolata wrote a New York Times piece about it.  Actually, spontaneous regression of breast cancer has been reported many times in the medical literature.  Sir William Osler, a legendary and revered doctor reported 14 cases himself.

See this 1901 report: The Medical Aspects of Carcinoma of the Breast, with a Note on the Spontaneous Disappearance of Secondary Growths, OSLER W., American Medicine: April 6 1901; 17-19; 63-66.

Perhaps breast cancer remission was more common during his lifetime.  I personally have seen a case of spontaneous regression of breast cancer documented by follow up MRI scan.  Left Image: Breast Cancer Awareness Month with Pink Ribbons. Courtesy of WIkimedia Commons.

The real challenge is for medical science to investigate spontanous regression, and once understood, use it induce a cure in the cancer patient, thereby winning the war against cancer.  Perhaps a mouse model discovered in 2003 showing spontaneous regression of advanced cancer in genetically determined mice could help make some progress with this research.  This would be a good subject for an NIH grant.

Diagnosis is Not Screening

We must be careful about the difference between screening, and diagnosis.  Screening pertains to mass screening of a healthy population.  We had found this leads to overdiagnosis and overtreatment.  Diagnosis pertains to evaluation and workup of a symptomatic patient, which is what the doctor does every day.  PSA testing, mammography and ultrasound remain excellent diagnostic tools for workup and evaluation of the symptomatic patient.

How to Prevent Breast Cancer

1) Vitamin D Supplementation.
2) Iodine Supplementation (Iodoral)
3) Natural Progesterone
4) Avoid carcinogenic chemicals, xenoestrogens, pesticides, etc.

Update 2017: Ann Intern Med. 2017.
Breast Cancer Screening in Denmark: A Cohort Study of Tumor Size and Overdiagnosis.   From Nordic Cochrane Centre, Copenhagen, Denmark, and University of Oslo and Norwegian Institute of Public Health, Oslo, Norway. Drs. Jørgensen, Gøtzsche,  Kalager,  Zahl.

Breast cancer screening was not associated with a reduction in the incidence of advanced cancer. It is likely that 1 in every 3 invasive tumors and cases of DCIS diagnosed in women offered screening represent overdiagnosis (incidence increase of 48.3%).

Update 3/10/15:

Breast cancer screening was not associated with a reduction in the incidence of advanced cancer. It is likely that 1 in every 3 invasive tumors and cases of DCIS diagnosed in women offered screening represent overdiagnosis (incidence increase of 48.3%).

Abolishing Mammography Screening Programs? A View from the Swiss Medical Board by Nikola Biller-Andorno, M.D., Ph.D., and Peter Jüni, M.D.  N Engl J Med 2014; 370:1965-1967

Vast Study Casts Doubts on Value of Mammograms  By GINA KOLATAFEB. 11, 2014 New York Times.

Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial
BMJ 2014; 348  . Conclusion:  Annual mammography in women aged 40-59 does not reduce mortality from breast cancer beyond that of physical examination or usual care when adjuvant therapy for breast cancer is freely available. Overall, 22% (106/484) of screen detected invasive breast cancers were over-diagnosed, representing one over-diagnosed breast cancer for every 424 women who received mammography screening in the trial.

Update 2015: Laura Esserman in the New York Times:  A Breast Cancer Surgeon Who Keeps Challenging the Status Quo SEPT. 28, 2015 By KATIE HAFNER New York Times

Esserman, Laura, and Christina Yau. “Rethinking the Standard for Ductal Carcinoma In Situ Treatment.” JAMA oncology (2015).

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Jeffrey Dach MD

Links and References

Rethinking Screening for Breast Cancer and Prostate Cancer.  Laura Esserman, MD, MBA; Yiwey Shieh, AB; Ian Thompson, MD JAMA. 2009;302(15):1685-1692.

After 20 years of screening for breast and prostate cancer, several observations can be made. First, the incidence of these cancers increased after the introduction of screening but has never returned to prescreening levels. Second, the increase in the relative fraction of early stage cancers has increased. Third, the incidence of regional cancers has not decreased at a commensurate rate. One possible explanation is that screening may be increasing the burden of low-risk cancers without significantly reducing the burden of more aggressively growing cancers and therefore not resulting in the anticipated reduction in cancer mortality. To reduce morbidity and mortality from prostate cancer and breast cancer, new approaches for screening, early detection, and prevention for both diseases should be considered.

Stop Calling it Cancer
Conclusions: Clearly, the diagnosis and management of DCIS is highly complex with many unanswered questions, including the fundamental natural history of untreated disease. Because of the noninvasive nature of DCIS, coupled with its favorable prognosis, strong consideration should be given to elimination of the use of the anxiety-producing term “carcinoma” from the description of DCIS. The outcomes in women treated with available therapies are excellent. Thus, the primary question for future research must focus on the accurate identification of patient subsets diagnosed with DCIS, including those persons who may be managed with less therapeutic intervention without sacrificing the excellent outcomes presently achieved. Essential in this quest will be the development and validation of accurate risk-stratification methods based on a comprehensive understanding of the clinical, pathologic, and biologic factors associated with DCIS.
Analysis Questions Breast and Prostate Cancer Screening
By Peggy Peck, Executive Editor, MedPage Today October 21, 2009
Thursday, 22 October 2009. Rethinking strategies for breast and prostate cancer screening. Twenty years of screening for breast and prostate cancer—the most diagnosed cancers for women and men—have not brought the anticipated decline in deaths from these diseases, argue experts in an opinion piece published Wednesday in the Journal of the American Medical Association

Gilbert Welch MD

H. Gilbert Welch, MD, MPH  Professor of Medicine and Community and Family Medicine, Dartmouth Medical School; Co-Director of the White River Junction Outcomes Group

Research Interests: Dr. Welch is a general internist whose research focuses on the problems created by medicine’s efforts to detect disease early: physicians test too often, treat too aggressively and tell too many people that they are sick. Most of his work has focused on overdiagnosis in cancer screening: in particular, screening for melanoma, cervical, breast and prostate cancer. His recent book, “Should I be tested for cancer? Maybe not and here’s why” (UC Press 2004)

How Two Studies on Cancer Screening Led to Two Results – New York Times  March 13, 2007
Campaign Myth: Prevention as Cure-All By H. GILBERT WELCH, M.D October 6, 2008
9 July 2009, BMJ 2009;339:b1425 Editorials. Gilbert Welch MD. Overdiagnosis and mammography screening. The question is no longer whether, but how often, it occurs.

Huffington Post  Helen Cordes

Rethink Pink NOW! Saner Solutions to Breast Cancer, Part 2

Spontaneous Remission of Breast Cancer
The Natural History of Invasive Breast Cancers Detected by Screening Mammography
Per-Henrik Zahl, MD, PhD; Jan Mæhlen, MD, PhD; H. Gilbert Welch, MD, MPH
Arch Intern Med. 2008;168(21):2311-2316.
Study Suggests Some Cancers May Go Away By GINA KOLATA November 24, 2008

Others, Miscellaneous Rethinking Cancer Screening Dr Wang

The Oncologist, Vol. 12, No. 11, 1276-1287, November 2007;
Current Treatment and Clinical Trial Developments for Ductal Carcinoma In Situ of the Breast.  Judy C. Bougheya, Ricardo J. Gonzalezb, Everett Bonnerc, Henry M. Kuererb

autopsy studies show silent reservoir of breast cancer
Using Autopsy Series To Estimate the Disease “Reservoir” for Ductal Carcinoma in Situ of the Breast: How Much More Breast Cancer Can We Find?  H. Gilbert Welch, MD, MPH, and William C. Black, MD ANnals of Internal Med 1 December 1997 | Volume 127 Issue 11 | Pages 1023-1028. The reported incidence of DCIS has increased more than fourfold since 1980 [7]; this type of cancer now accounts for nearly half of mammographically detected cases of cancer [8, 9]. Whereas the two series with the highest prevalence (both of which were performed by the same investigators) were the most assiduous: The investigators examined 95 and 275 specimens per breast after being guided by radiographs of each 5-mm section.
Br J Cancer. 1987 December; 56(6): 814–819.  PMCID: PMC2002422
Breast cancer and atypia among young and middle-aged women: a study of 110 medicolegal autopsies. M. Nielsen, J. L. Thomsen, S. Primdahl, U. Dyreborg, and J. A. Andersen Department of Pathology, Frederiksberg Hospital, Copenhagen, Denmark.
In 110 consecutive, medicolegal autopsies of young and middle-aged women (range 20-54 years) the breasts were examined by an extensive histopathologic method and by correlative specimen radiography. Malignancy was found in 22 women (20%) of which only one was known to have had clinical invasive breast cancer (IBC). At autopsy 2 women had IBC (2%), the remaining in situ carcinoma (in situ BC) of microfocal type (18%), i.e. 15 (14%) intraductal carcinomas (DCIS), 4 (3%) lobular carcinoma in situ (LCIS) and one (1%) both DCIS and LCIS.

Incidence and Mortality Stats

Click to access F861009_final%209-08-09.pdf

Breast Cancer Facts and Figures 2009,2010 American Cancer Society
breast cancer facts and figures 2009 ACS. Stage: Figure 5b (page 7) presents incidence trends by race and stage at diagnosis. The incidence of regional-stage disease increased during 1994-2001 and has since decreased on average by 2.8% per year. Incidence rates of distant-stage disease have remained stable.
It is estimated that 192,370 women will be diagnosed with and 40,170 women will die of cancer of the breast in 2009.

The following information is based on NCI’s SEER Cancer Statistics Review2X Close
Breast Section ( )

Incidence & Mortality
Breast Cancer Mortality Rates Continue to Decline. According to a report issued by the American Cancer Society, breast cancer death rates in the United States continue to decline by more than 2% per year. This and other breast cancer statistics were published in Breast Cancer Facts & Figures 2009-2010.

Breast cancer mortality rates began to decline in the U.S. in 1990, and the most recent statistics suggest that this decline is continuing. Nevertheless, an estimated 40,170 women will die of breast cancer in 2009
CA Cancer J Clin 2009; 59:225-249 Cancer Statistics, 2009 Ahmedin Jemal, DVM, PhD1, Rebecca Siegel, MPH2, Elizabeth Ward, PhD3, Yongping Hao, PhD4, Jiaquan Xu, MD5 and Michael J. Thun, MD, MS6

TABLE 8 Trends in the Recorded Number of Deaths from Selected Cancers by Sex, United States, 1990–2006
1990  43,391 deaths from breast cancer
2006  40,821 deaths from breast cancer
Source: US Mortality Data, 1990 to 2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2009.
It is estimated that 192,370 women will be diagnosed with and 40,170 women will die of cancer of the breast in 2009. Table I-1 (

Naomi Freundlich

Saving Women From Breast Cancer: Are Mammograms Really the Answer?By Naomi Freundlich, Health Beat. Posted October 21, 2009.

“For every 2,000 women [age 50-69] invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy women who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer patients and will be treated unnecessarily. It is thus not clear whether screening does more good than harm.

H. Gilbert Welch, professor of medicine at Dartmouth Institute for Health Policy and Clinical Research, writing in an editorial in the British Medical Journal looks at the “credits” and “debits” a 50-year-old woman considering yearly mammography should consider (figures are per 1000 women):

•1 in 1,000 women annually screened for 10 years will avoid dying from breast cancer.
•2 to 10 women will be over-diagnosed and treated needlessly
•10 to 15 women will be told they have breast cancer earlier than they would otherwise have been told, but this will not affect their prognosis.
•100 to 500 women will have at least one “false alarm” (about half of these women will undergo a biopsy)

Welch adds, “Mammography is one of medicine’s ‘close calls’– a delicate balance between benefits and harms—where different people in the same situation might reasonably make different choices. Mammography undoubtedly helps some women but hurts others. No right answer exists, instead it is a personal choice.”
February 19, 2009. Breast cancer screening peril. Negative consequences of the breast screening programme. Peter C. Gøtzsche and his colleagues from the independent Nordic Cochrane Centre. They describe a synthesis of published papers that quantify the benefits and harms of screening using absolute rather than relative numbers that make it easier to comprehend. They conclude as follows: if 2,000 women are screened regularly for ten years, one will benefit from the screening, as she will avoid dying from breast cancer. At the same time, ten healthy women will, as a consequence, become “cancer patients” and will be treated unnecessarily.

The Truth About Breast Cancer is Not Pretty and it’s not Pink Posted October 1, 2009
Comments on Mammography Leading to Over-Diagnosis and Over-Treatment (Dr. Eric Winer, October 2009)

CONFRONTING CANCER; Breast Cancer: Mammography Finds More Tumors. Then the Debate Begins. By Gina Kolata Published: Tuesday, April 9, 2002
Wednesday, October 21, 2009
ACS Throws Women Under the Bus. The American Cancer Society has lobbed a deadly volley over the bow of SS Cancerland…
Making Personal Decisions  about X-ray Screening Tests, Such as Mammography and CT of the Lung,  Colon, Heart, or the Entire Body.  John W. Gofman, M.D., Ph.D., Professor Emeritus of Molecular & Cell Biology, University of California at Berkeley. Egan O’Connor, Executive Director and Editor, CNR. ”

Spontaneous Remission Regression of Cancer Spontaneous Remission database of medically reported cases of spontaneous remission in the world, with more than 3,500 references from more than 800 journals in 20 different languages.

The Medical Aspects of Carcinoma of the Breast, with a Note on the Spontaneous Disappearance of Secondary Growths OSLER W American Medicine: April 6 1901; 17-19; 63-66 Extracted Summary

The consulting physician sees mammary cancer at two stages of its progress. Dreading the surgeon, and hoping against hope, a number of women prefer to come to him at the first detection of a tumor. But these form a small fraction of the cases. A large majority are the unhappy victims of the internal metastases after operation. For some years I have been interested in this class of cases, and have collected material bearing upon the question of these late, and more strictly medical, manifestations of the disease.In this paper, fourteen cases of carcinoma of the breast are reported in which there were secondary growths and in some cases the secondary growths spontaneously disappeared.
‘Spontaneous regression’ debate erupts anew at ASCO symposium
By Kate Madden Yee staff writer October 12, 2009

Mouse Model of Spontaneous Regression
Proc Natl Acad Sci U S A. 2003 May 27; 100(11): 6682–6687.
The National Academy of Sciences. Immunology
Spontaneous regression of advanced cancer: Identification of a unique genetically determined, age-dependent trait in mice. Zheng Cui et al.

Jeffrey Dach MD

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Rethink Pink and Screening Mammography
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Rethink Pink and Screening Mammography
Rethink Pink and Screening Mammography
Jeffrey Dach MD
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About Jeffrey Dach MD

Medical Director of TrueMedMD, a Clinic in Davie Florida specializing in Bioidentical Hormones and Natural thyroid. Office address 7450 Griffin Road Suite 190, Davie, Florida 33314 telephone 954-792-4663

4 thoughts on “Rethink Pink and Screening Mammography

  1. Pingback: Laura Esserman Questions Screening Mammography - Jeffrey Dach MD

  2. Pingback: Rethinking Pink and Screening Mammography

  3. All of these troubling issues with mammography have been extensively covered in a new, independent investigation of mammograms (read “The Mammogram Myth: The Independent Investigation Of Mammography The Medical Profession Doesn’t Want You To Know About” by Rolf Hefti. Also see Undoubtedly, profits, system justification, and politics keep the real facts hidden from women.

  4. Physiologic medicament against breast cancer

    The low but
    consistent incidence rate of invasive breast cancer deriving from ductal in
    situ carcinoma (DCIS) justifies that the usual surgical and adjuvant therapy of
    high grade DCIS is not always capable of ensuring a tumor-free life, while low
    grade DCIS is perhaps superfluously over treated.

    estrogen receptor (ER)-signaling is the chief safeguard of genomic stability in
    strong interplay with DNA-controlling and repairing systems, such as BRCA-genes
    and their protein products []. Detection of DCIS by mammographic screening may be regarded as an
    early marker of disturbed hormonal, metabolic and DNA-stabilizer equilibrium,
    since the female breast is exquisitely sensitive to the defects of estrogen
    signaling []. The stronger the defect of cellular estrogen
    surveillance, the higher is the probability of DCIS development with high-risk

    Among young
    cases with active ovarian estrogen synthesis, the relatively higher risk of
    poorly differentiated DCIS may be attributed to the low incidence rate of more
    successfully suppressed ER-positive cancers rather than an excessive
    inclination to ER-negative tumors. Moreover, among dark-skinned American women,
    the higher risk of developing poorly differentiated DCIS and the higher breast
    cancer mortality rate as compared with white women are associated with estrogen
    deficiency and further hormonal defects. These endocrine disturbances may be
    explained by the incongruence between their excessive pigmentation and the poor
    light and sunshine exposure of North-America.


    In women, during
    aging, progressive weakening of estrogen signaling and the associated gene
    stabilizer mechanisms are dangerous systemic processes [], despite any usual, aggressive treatment of DCIS.
    In patients having increased risk of invasive breast cancer, natural estrogen
    substitution is the optimal risk-reducing therapy aiming the stabilization of
    gene regulatory processes and the apoptotic death of accidentally initiated
    tumor cells []. By contrast, antiestrogen treatment against tumor
    recurrence may be risky, being effective only in such genetically proficient
    women who are capable of strong, counteractive upregulation of estrogen
    signaling. Tumor growth may be provoked by de
    novo or acquired antiestrogen resistance being associated with the missing
    capacity of patients for the extreme upregulation of estrogen signaling or with
    the exhaustion of defensive counteractions by excessive antiestrogen
    administration [].

    In conclusion,
    in cases of DCIS which have been diagnosed, the most important preventive
    strategy against invasive breast cancer development is to
    combine lumpectomy with strict control and maintenance of estrogen signaling
    over a whole lifetime.

    Zsuzsanna Suba

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