Breast Cancer Research and Treatment

, Volume 169, Issue 1, pp 141–152 | Cite as

Surveillance for cancer recurrence in long-term young breast cancer survivors randomly selected from a statewide cancer registry

  • Tarsha Jones
  • Debra Duquette
  • Meghan Underhill
  • Chang Ming
  • Kari E. Mendelsohn-Victor
  • Beth Anderson
  • Kara J. Milliron
  • Glenn Copeland
  • Nancy K. Janz
  • Laurel L. Northouse
  • Sonia M. Duffy
  • Sofia D. Merajver
  • Maria C. Katapodi



This study examined clinical breast exam (CBE) and mammography surveillance in long-term young breast cancer survivors (YBCS) and identified barriers and facilitators to cancer surveillance practices.


Data collected with a self-administered survey from a statewide, randomly selected sample of YBCS diagnosed with invasive breast cancer or ductal carcinoma in situ younger than 45 years old, stratified by race (Black vs. White/Other). Multivariate logistic regression models identified predictors of annual CBEs and mammograms.


Among 859 YBCS (n = 340 Black; n = 519 White/Other; mean age = 51.0 ± 5.9; diagnosed 11.0 ± 4.0 years ago), the majority (> 85%) reported an annual CBE and a mammogram. Black YBCS in the study were more likely to report lower rates of annual mammography and more barriers accessing care compared to White/Other YBCS. Having a routine source of care, confidence to use healthcare services, perceived expectations from family members and healthcare providers to engage in cancer surveillance, and motivation to comply with these expectations were significant predictors of having annual CBEs and annual mammograms. Cost-related lack of access to care was a significant barrier to annual mammograms.


Routine source of post-treatment care facilitated breast cancer surveillance above national average rates. Persistent disparities regarding access to mammography surveillance were identified for Black YBCS, primarily due to lack of access to routine source of care and high out-of-pocket costs.


Public health action targeting cancer surveillance in YBCS should ensure routine source of post-treatment care and address cost-related barriers. Clinical Trials Registration Number: NCT01612338.


Mammography Clinical breast exam Out-of-pocket-cost Adherence State cancer registry 



Joan Such Lockhart, PhD, RN, CORLN, AOCN, CNE, ANEF, FAAN, and Sr. Rosemary Donley, PhD, APRN from Duquesne University School of Nursing, 600 Forbes Avenue, Pittsburgh, PA 15282, USA for providing support and guidance to Dr. Tarsha Jones while she completed her doctoral studies at Duquesne University School of Nursing. Jenna McLosky, CGC, Cancer Genomics Program—Michigan Department of Health and Human Services for patient and relative identification, recruitment, and assessment of eligibility.


Centers for Disease Control and Prevention, 5U48DP001901-03, PI: M.C. Katapodi. Robert Wood Johnson Foundation, Nurse Faculty Scholars Award 68039, PI: M.C. Katapodi.

Compliance with ethical standards

Conflict of interest

Tarsha Jones, Debra Duquette, Meghan Underhill, Kari E. Mendelsohn-Victor, Beth Anderson, Chang Ming, Kara J. Milliron, Glenn Copeland, Nancy K. Janz, Laurel L. Northouse, Sonia M. Duffy, Sofia D. Merajver, and Maria C. Katapodi declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    de Moor JS, Mariotto AB, Parry C, Alfano CM, Padgett L, Kent EE, Forsythe L, Scoppa S, Hachey M, Rowland JH (2013) Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care. Cancer Epidemiol Biomark Prev 22(4):561–570. CrossRefGoogle Scholar
  2. 2.
    King M-C, Levy-Lahad E, Lahad A (2014) Population-based screening for BRCA1 and BRCA2: 2014 Lasker Award. JAMA 312(11):1091–1092CrossRefPubMedGoogle Scholar
  3. 3.
    McCarthy AM, Yang J, Armstrong K (2015) Increasing disparities in breast cancer mortality from 1979 to 2010 for US black women aged 20 to 49 years. Am J Public Health 105(Suppl 3):S446–448. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Pal T, Vadaparampil ST (2012) Genetic risk assessments in individuals at high risk for inherited breast cancer in the breast oncology care setting. Cancer Control 19(4):255–266CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Rosenberg SM, Newman LA, Partridge AH (2015) Breast cancer in young women: rare disease or public health problem? JAMA Oncol 1(7):877–878CrossRefPubMedGoogle Scholar
  6. 6.
    Daly B, Olopade OI (2015) A perfect storm: how tumor biology, genomics, and health care delivery patterns collide to create a racial survival disparity in breast cancer and proposed interventions for change. CA Cancer J Clin 65(3):221–238. CrossRefPubMedGoogle Scholar
  7. 7.
    Danforth DN Jr (2013) Disparities in breast cancer outcomes between Caucasian and African American women: a model for describing the relationship of biological and nonbiological factors. Breast Cancer Res 15(3):208. CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Kumar P, Aggarwal R (2016) An overview of triple-negative breast cancer. Arch Gynecol Obstet 293(2):247–269CrossRefPubMedGoogle Scholar
  9. 9.
    Ademuyiwa FO, Gao F, Hao L, Morgensztern D, Aft RL, Ma CX, Ellis MJ (2015) US breast cancer mortality trends in young women according to race. Cancer 121(9):1469–1476. CrossRefPubMedGoogle Scholar
  10. 10.
    Runowicz CD, Leach CR, Henry NL, Henry KS, Mackey HT, Cowens-Alvarado RL, Cannady RS, Pratt-Chapman ML, Edge SB, Jacobs LA, Hurria A, Marks LB, LaMonte SJ, Warner E, Lyman GH, Ganz PA (2016) American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline. J Clin Oncol 34(6):611–635. CrossRefPubMedGoogle Scholar
  11. 11.
    Evans DG, Kesavan N, Lim Y, Gadde S, Hurley E, Massat NJ, Maxwell AJ, Ingham S, Eeles R, Leach MO, Howell A, Duffy SW (2014) MRI breast screening in high-risk women: cancer detection and survival analysis. Breast Cancer Res Treat 145(3):663–672. CrossRefPubMedGoogle Scholar
  12. 12.
    Tadros A, Arditi B, Weltz C, Port E, Margolies LR, Schmidt H (2017) Utility of surveillance MRI in women with a personal history of breast cancer. Clin Imaging 46:33–36. CrossRefPubMedGoogle Scholar
  13. 13.
    Buist DS, Bosco JL, Silliman RA, Gold HT, Field T, Yood MU, Quinn VP, Prout M, Lash TL (2013) Long-term surveillance mammography and mortality in older women with a history of early stage invasive breast cancer. Breast Cancer Res Treat 142(1):153–163. CrossRefPubMedGoogle Scholar
  14. 14.
    Field TS, Doubeni C, Fox MP, Buist DS, Wei F, Geiger AM, Quinn VP, Lash TL, Prout MN, Yood MU, Frost FJ, Silliman RA (2008) Under utilization of surveillance mammography among older breast cancer survivors. J Gen Intern Med 23(2):158–163. CrossRefPubMedGoogle Scholar
  15. 15.
    Keating NL, Landrum MB, Guadagnoli E, Winer EP, Ayanian JZ (2006) Factors related to underuse of surveillance mammography among breast cancer survivors. J Clin Oncol 24(1):85–94. CrossRefPubMedGoogle Scholar
  16. 16.
    Katz ML, Donohue KA, Alfano CM, Day JM, Herndon JE 2nd, Paskett ED (2009) Cancer surveillance behaviors and psychosocial factors among long-term survivors of breast cancer. Cancer and Leukemia Group B 79804. Cancer 115(3):480–488. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Sabatino SA, Thompson TD, Richardson LC, Miller J (2012) Health insurance and other factors associated with mammography surveillance among breast cancer survivors: results from a national survey. Med Care 50(3):270–276. CrossRefPubMedGoogle Scholar
  18. 18.
    Shelby RA, Scipio CD, Somers TJ, Soo MS, Weinfurt KP, Keefe FJ (2012) Prospective study of factors predicting adherence to surveillance mammography in women treated for breast cancer. J Clin Oncol 30(8):813–819. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Wirtz HS, Boudreau DM, Gralow JR, Barlow WE, Gray S, Bowles EJ, Buist DS (2014) Factors associated with long-term adherence to annual surveillance mammography among breast cancer survivors. Breast Cancer Res Treat 143(3):541–550. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Advani PS, Ying J, Theriault R, Melhem-Bertrand A, Moulder S, Bedrosian I, Tereffe W, Black S, Pini TM, Brewster AM (2014) Ethnic disparities in adherence to breast cancer survivorship surveillance care. Cancer 120(6):894–900. CrossRefPubMedGoogle Scholar
  21. 21.
    Institute of Medicine (2013) Addressing the challenges of an aging, population. Delivering high-quality cancer care: charting a new course for a system in crisis. National Academies Press, Washington, DC. Google Scholar
  22. 22.
    Howell D, Hack TF, Oliver TK, Chulak T, Mayo S, Aubin M, Chasen M, Earle CC, Friedman AJ, Green E, Jones GW, Jones JM, Parkinson M, Payeur N, Sabiston CM, Sinclair S (2012) Models of care for post-treatment follow-up of adult cancer survivors: a systematic review and quality appraisal of the evidence. J Cancer Surviv 6(4):359–371. CrossRefPubMedGoogle Scholar
  23. 23.
    Taymoori P, Moshki M, Roshani D (2014) Facilitator psychological constructs for mammography screening among Iranian women. Asian Pac J Cancer Prev 15(17):7309–7316CrossRefPubMedGoogle Scholar
  24. 24.
    Forbes CC, Blanchard CM, Mummery WK, Courneya K (2015) Prevalence and correlates of strength exercise among breast, prostate, and colorectal cancer survivors. Oncol Nurs Forum 42(2):118–127. CrossRefPubMedGoogle Scholar
  25. 25.
    Trinh L, Mutrie N, Campbell AM, Crawford JJ, Courneya KS (2014) Effects of supervised exercise on motivational outcomes in breast cancer survivors at 5-year follow-up. Eur J Oncol Nurs 18(6):557–563. CrossRefPubMedGoogle Scholar
  26. 26.
    Ajzen I (1991) The theory of planned behavior. Organ Behav Hum Decis Process 50(2):179–211. CrossRefGoogle Scholar
  27. 27.
    Katapodi MC, Facione NC, Miaskowski C, Dodd MJ, Waters C (2002) The influence of social support on breast cancer screening in a multicultural community sample. Oncol Nurs Forum 29(5):845–852. CrossRefPubMedGoogle Scholar
  28. 28.
    Katapodi MC, Northouse LL, Schafenacker AM, Duquette D, Duffy SA, Ronis DL, Anderson B, Janz NK, McLosky J, Milliron KJ, Merajver SD, Duong LM, Copeland G (2013) Using a state cancer registry to recruit young breast cancer survivors and high-risk relatives: protocol of a randomized trial testing the efficacy of a targeted versus a tailored intervention to increase breast cancer screening. BMC Cancer. PubMedPubMedCentralGoogle Scholar
  29. 29.
    Jones T, Lockhart JS, Mendelsohn-Victor KE, Duquette D, Northouse LL, Duffy SA, Donley R, Merajver SD, Milliron KJ, Roberts JS, Katapodi MC (2016) Use of cancer genetics services in African-American young breast cancer survivors. Am J Prev Med 51(4):427–436. CrossRefPubMedGoogle Scholar
  30. 30.
    Katapodi MC, Duquette D, Yang JJ, Mendelsohn-Victor KE, Anderson B, Nikolaidis C, Mancewicz E, Northouse LL, Duffy S, Ronis D, Milliron KJ, Probst-Hensch N, Merajver SD, Janz NK, Copeland G, Roberts SJ (2017) Recruiting families at risk for hereditary breast and ovarian cancer from a statewide cancer registry: a methodological study. Cancer Causes Control 28(3):191–201. CrossRefPubMedGoogle Scholar
  31. 31.
    Khatcheressian JL, Hurley P, Bantug E, Esserman LJ, Grunfeld E, Halberg F, Hantel A, Henry NL, Muss HB, Smith TJ, Vogel VG, Wolff AC, Somerfield MR, Davidson NE (2013) Breast cancer follow-up and management after primary treatment: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 31(7):961–965. CrossRefPubMedGoogle Scholar
  32. 32.
    Center for Disease Control and Prevention (2015) Mammography and Breast Cancer. Accessed 11 Feb 2017
  33. 33.
    Doubeni CA, Field TS, Ulcickas Yood M, Rolnick SJ, Quessenberry CP, Fouayzi H, Gurwitz JH, Wei F (2006) Patterns and predictors of mammography utilization among breast cancer survivors. Cancer 106(11):2482–2488. CrossRefPubMedGoogle Scholar
  34. 34.
    Risendal BC, Sedjo RL, Giuliano AR, Vadaparampil S, Jacobsen PB, Kilbourn K, Baron A, Byers T (2016) Surveillance and beliefs about follow-up care among long-term breast cancer survivors: a comparison of primary care and oncology providers. J Cancer Surviv 10(1):96–102. CrossRefPubMedGoogle Scholar
  35. 35.
    Mujahid MS, Janz NK, Hawley ST, Griggs JJ, Hamilton AS, Graff J, Katz SJ (2011) Racial/ethnic differences in job loss for women with breast cancer. J Cancer Surviv 5(1):102–111. CrossRefPubMedGoogle Scholar
  36. 36.
    Okoro CA, Zhao G, Fox JB, Eke PI, Greenlund KJ, Town M (2014) Surveillance for health care access and health services use, adults aged 18-64 years: Behavioral Risk Factor Surveillance System, United States. MMWR Surveill Summ 66(7):1–42. CrossRefGoogle Scholar
  37. 37.
    Ayanian JZ, Ehrlich GM, Grimes DR, Levy H (2017) Economic effects of medicaid expansion in Michigan. N Engl J Med 376(5):407–410CrossRefPubMedGoogle Scholar
  38. 38.
    Stark A, Stapp R, Raghunathan A, Yan X, Kirchner HL, Griggs J, Newman L, Chitale D, Dick A (2012) Disease-free probability after the first primary ductal carcinoma in situ of the breast: a comparison between African-American and White-American women. Breast Cancer Res Treat 131(2):561–570. CrossRefPubMedGoogle Scholar
  39. 39.
    Grimm LJ, Ghate SV, Hwang ES, Soo MS (2017) Imaging features of patients undergoing active surveillance for ductal carcinoma in situ. Acad Radiol 24(11):1364–1371. CrossRefPubMedGoogle Scholar
  40. 40.
    López ME, Kaplan CP, Nápoles AM, Livaudais JC, Hwang ES, Stewart SL, Bloom J, Karliner L (2013) Ductal carcinoma in situ (DCIS): posttreatment follow-up care among Latina and non-Latina White women. J Cancer Surviv 7(2):219–226. CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Gathirua-Mwangi WG, Monahan PO, Stump T, Rawl SM, Skinner CS, Champion VL (2016) Mammography adherence in African-American women: results of a randomized controlled trial. Ann Behav Med 50(1):70–78. CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Ellis KR, Janevic MR, Kershaw T, Caldwell CH, Janz NK, Northouse L (2017) The influence of dyadic symptom distress on threat appraisals and self-efficacy in advanced cancer and caregiving. Support Care Cancer 25(1):185–194. CrossRefPubMedGoogle Scholar
  43. 43.
    Northouse LL, Mood D, Kershaw T, Schafenacker A, Mellon S, Walker J, Galvin E, Decker V (2002) Quality of life of women with recurrent breast cancer and their family members. J Clin Oncol 20(19):4050–4064. CrossRefPubMedGoogle Scholar
  44. 44.
    Thompson HS, Littles M, Jacob S, Coker C (2006) Posttreatment breast cancer surveillance and follow-up care experiences of breast cancer survivors of African descent: an exploratory qualitative study. Cancer Nurs 29(6):478–487CrossRefPubMedGoogle Scholar
  45. 45.
    Haynes-Maslow L, Allicock M, Johnson LS (2016) Cancer support needs for African American breast cancer survivors and caregivers. J Cancer Educ 31(1):166–171. CrossRefPubMedGoogle Scholar
  46. 46.
    Palmer NR, Weaver KE, Hauser SP, Lawrence JA, Talton J, Case LD, Geiger AM (2015) Disparities in barriers to follow-up care between African American and White breast cancer survivors. Support Care Cancer 23(11):3201–3209. CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Saslow D, Boetes C, Burke W, Harms S, Leach MO, Lehman CD, Morris E, Pisano E, Schnall M, Sener S, Smith RA, Warner E, Yaffe M, Andrews KS, Russell CA (2007) American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 57(2):75–89CrossRefPubMedGoogle Scholar
  48. 48.
    Mainiero MB, Lourenco A, Mahoney MC, Newell MS, Bailey L, Barke LD, D’Orsi C, Harvey JA, Hayes MK, Huynh PT, Jokich PM, Lee SJ, Lehman CD, Mankoff DA, Nepute JA, Patel SB, Reynolds HE, Sutherland ML, Haffty BG (2016) ACR appropriateness criteria breast cancer screening. J Am Coll Radiol 13(11s):R45–r49. CrossRefPubMedGoogle Scholar
  49. 49.
    Lee CH, Dershaw DD, Kopans D, Evans P, Monsees B, Monticciolo D, Brenner RJ, Bassett L, Berg W, Feig S, Hendrick E, Mendelson E, D’Orsi C, Sickles E, Burhenne LW (2010) Breast cancer screening with imaging: recommendations from the Society of Breast Imaging and the ACR on the use of mammography, breast MRI, breast ultrasound, and other technologies for the detection of clinically occult breast cancer. J Am Coll Radiol 7(1):18–27. CrossRefPubMedGoogle Scholar
  50. 50.
    Morris EA, Liberman L, Ballon DJ, Robson M, Abramson AF, Heerdt A, Dershaw DD (2003) MRI of occult breast carcinoma in a high-risk population. AJR Am J Roentgenol 181(3):619–626. CrossRefPubMedGoogle Scholar
  51. 51.
    McBride CM, Emmons KM, Lipkus IM (2003) Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res 18(2):156–170CrossRefPubMedGoogle Scholar
  52. 52.
    Browder C, Eberth JM, Schooley B, Porter NR (2015) Mobile mammography: an evaluation of organizational, process, and information systems challenges. Healthcare (Amst) 3(1):49–55. CrossRefGoogle Scholar
  53. 53.
    Harrison RV, Janz NK, Wolfe RA, Tedeschi PJ, Chernew M, Stross JK, Huang X, McMahon LF Jr (2003) Personalized targeted mailing increases mammography among long-term noncompliant medicare beneficiaries: a randomized trial. Med Care 41(3):375–385. PubMedGoogle Scholar
  54. 54.
    Holt CL, Lee C, Wright K (2008) A spiritually based approach to breast cancer awareness: cognitive response analysis of communication effectiveness. Health Commun 23(1):13–22. CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Russell KM, Champion VL, Monahan PO, Millon-Underwood S, Zhao Q, Spacey N, Rush NL, Paskett ED (2010) Randomized trial of a lay health advisor and computer intervention to increase mammography screening in African American women. Cancer Epidemiol Biomark Prev 19(1):201–210. CrossRefGoogle Scholar
  56. 56.
    Greenlee H, Molmenti CL, Crew KD, Awad D, Kalinsky K, Brafman L, Fuentes D, Shi Z, Tsai WY, Neugut AI, Hershman DL (2016) Survivorship care plans and adherence to lifestyle recommendations among breast cancer survivors. J Cancer Surviv 10(6):956–963. CrossRefPubMedGoogle Scholar
  57. 57.
    Katapodi MC, Aouizerat BE (2005) Do women in the community recognize hereditary and sporadic breast cancer risk factors? Oncol Nurs Forum 32(3):617–623CrossRefPubMedGoogle Scholar
  58. 58.
    Wang C, Gonzalez R, Milliron KJ, Strecher VJ, Merajver SD (2005) Genetic counseling for BRCA1/2: a randomized controlled trial of two strategies to facilitate the education and counseling process. Am J Med Genet A 134A(1):66–73. CrossRefPubMedGoogle Scholar
  59. 59.
    Katapodi MC, Dodd MJ, Lee KA, Facione NC (2009) Underestimation of breast cancer risk: influence on screening behavior. Oncol Nurs Forum. PubMedGoogle Scholar
  60. 60.
    Katapodi MC, Northouse LL, Milliron KJ, Liu G, Merajver SD (2013) Individual and family characteristics associated with BRCA1/2 genetic testing in high-risk families. Psychooncology 22(6):1336–1343. CrossRefPubMedGoogle Scholar
  61. 61.
    Johnson Vickberg SM (2001) Fears about breast cancer recurrence. Cancer Pract 9(5):237–243. CrossRefPubMedGoogle Scholar
  62. 62.
    Vickberg SMJ (2003) The Concerns About Recurrence Scale (CARS): a systematic measure of women’s fears about the possibility of breast cancer recurrence. Ann Behav Med 25(1):16–24CrossRefPubMedGoogle Scholar
  63. 63.
    Rakowski W, Andersen MR, Stoddard AM, Urban N, Rimer BK, Lane DS, Fox SA, Costanza ME (1997) Confirmatory analysis of opinions regarding the pros and cons of mammography. Health Psychol 16(5):433–441CrossRefPubMedGoogle Scholar
  64. 64.
    Bandura A (1989) Human agency in social cognitive theory. Am Psychol 44(9):1175–1184CrossRefPubMedGoogle Scholar
  65. 65.
    Fletcher KA, Lewis FM, Haberman MR (2010) Cancer-related concerns of spouses of women with breast cancer. Psychooncology 19(10):1094–1101. CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Ajzen I, Fishbein M (1980) Understanding attitudes and predicting social behaviour. Prentice Hall, Englewood CliffsGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Tarsha Jones
    • 1
  • Debra Duquette
    • 2
  • Meghan Underhill
    • 3
  • Chang Ming
    • 4
  • Kari E. Mendelsohn-Victor
    • 5
  • Beth Anderson
    • 6
  • Kara J. Milliron
    • 7
  • Glenn Copeland
    • 8
  • Nancy K. Janz
    • 9
  • Laurel L. Northouse
    • 5
  • Sonia M. Duffy
    • 10
  • Sofia D. Merajver
    • 9
    • 11
  • Maria C. Katapodi
    • 4
    • 5
  1. 1.Florida Atlantic University Christine E. Lynn College of NursingBoca RatonUSA
  2. 2.Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  3. 3.The Phyllis F. Cantor Center for Research in Nursing & Patient Care Services, Dana-Farber Cancer InstituteHarvard Medical SchoolBostonUSA
  4. 4.Nursing Science, Faculty of MedicineUniversity of BaselBaselSwitzerland
  5. 5.University of Michigan School of NursingAnn ArborUSA
  6. 6.Michigan Department of Health and Human ServicesLansingUSA
  7. 7.University of Michigan Comprehensive Cancer CenterAnn ArborUSA
  8. 8.Michigan Cancer Surveillance ProgramLansingUSA
  9. 9.School of Public HealthUniversity of MichiganAnn ArborUSA
  10. 10.Ohio State University College of NursingColumbusUSA
  11. 11.School of MedicineUniversity of MichiganAnn ArborUSA

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