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Old 11-29-2009, 01:31 AM   #1
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Dealing With the Initial Shock - What Should I Do Next?

I am still a bit shocked. After I had my annual physical a few days ago (I'm in my early 50s), my internist informed me that my PSA was 3.3. That was the first time I ever heard that my PSA was elevated, and I have no clinical symptoms, and the rest of my blood work is normal. My internist is a very experienced and conservative physician. After commenting that my DRE was normal, he said that I should see a urologist, just in case. I saw a urologist the next day. The urologist performed a DRE and said that one side of my prostate felt a bit firmer than normal. He told me to get a new PSA test, both free and total, which I did this past Friday. The urologist also said that regardless of what my new PSA test demonstrates, I should have a prostate biopsy. I am scheduled for a biopsy next week, but I don't feel that I am armed with sufficient information to decide whether I should do it now.

Unfortuantely, I do not have sufficient historical PSA data to know how fast my PSA got to 3.3. I do have my first ever PSA test result, which was in 1998 and read 0.81. I have had a few other PSA tests over the past 10 years, but my previous doctor's office tells me they can't locate the records. . .

Should I go through the biopsy and worry later, if necessary, or should I consider taking any other steps before I undergo a biopsy? For example, I just read about the PSA3Plus test - should I have that test first? Should I see another urologist to get a second opinion? Any other advice?

I want to move fast, but prudently. Unfortunately, I do not feel that I have adequate infromation to analyze whether my urologist is jumping the gun with recommending a biopsy this quickly. I would really appreciate any advice on what I should learn and do next.

Many thanks!

 
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Old 11-29-2009, 05:53 AM   #2
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Re: Dealing With the Initial Shock - What Should I Do Next?

I'm far less expert than some others on this forum. However, I can mention a few items that might help. The free PSA results may help you decide. If the free PSA to total PSA ratio is larger than 25%, that is a "good" result and less indicative of cancer. If it is less than 15%, it is more indicative of cancer. Between 15 and 25 is a grey area. It's possible the PSA rise might be due to infection, but without more PSA history you're relying on the urologist's judgement to rule this out. I'm not very familiar with PCAPlus; heard of it but never had one. Other more advanced and expensive diagnostic tests include MRI/MRIS and color doppler ultrasound, but again I have not had these. As I understand it, none of the diagnostics are really definitive- i.e. can't rule out or rule in cancer. I have had two biopsies and, while uncomfortable for 20 minutes or so, they are not really painful, although they do produce some blood in urine and ejaculate for some time afterwards. I think the standard biopsy is now at least 12 cores. If it were me, considering the rise in PSA, your age and the urologist's mention of the DRE, I would probably go ahead with the biopsy.

 
Old 11-29-2009, 05:38 PM   #3
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Re: Dealing With the Initial Shock - What Should I Do Next?

Quote:
Originally Posted by Rider18 View Post
... The urologist performed a DRE and said that one side of my prostate felt a bit firmer than normal. He told me to get a new PSA test, both free and total, which I did this past Friday. The urologist also said that regardless of what my new PSA test demonstrates, I should have a prostate biopsy. I am scheduled for a biopsy next week, but I don't feel that I am armed with sufficient information to decide whether I should do it now.
....
Should I go through the biopsy and worry later, if necessary, or should I consider taking any other steps before I undergo a biopsy? ...

I want to move fast, but prudently. Unfortunately, I do not feel that I have adequate infromation to analyze whether my urologist is jumping the gun with recommending a biopsy this quickly. I would really appreciate any advice on what I should learn and do next.
Holler1 gave some good advice. Unless you have another issue with your urologist, I don't think that seeing another will tell you much more-- as you know, it's only the biopsy that can confirm whether cancer is present (and even then, it's possible to miss it, since the biopsy is a sampling- although you can discuss getting more cores than 12, but that's not a bad place to start).

If you had sexual activity within 2-3 days of your PSA test, or if your doctor performed a DRE prior to the taking of blood for the test, your PSA reading could be higher than otherwise. So for subsequent PSA tests, keep this in mind. I'd say you can wait 3 months and repeat the PSA tests if you want to put off a biopsy, but maybe you'll know something when you get the results from your latest tests. The fact that one of the doctors felt some firmness on one side of the prostate is one thing that might say the biopsy is prudent sooner rather than later.

There are many books on the subject of prostate cancer, and often there is some good discussion about screening and PSA tests and biopsies- so it wouldn't hurt to get one or two just for your education. There is a very good chance that you do not have prostate cancer, but getting educated is always good. One general book that comes to mind is by Patrick Walsh, Guide to Surviving Prostate Cancer.

The good news in all this for you, once you get over the shock of what may or may not be the diagnosis, is that if you do need treatment for prostate cancer, there are many different choices. And catching this early is key. (I
was 64 when diagnosed and eventually chose proton beam radiation since it seemed to offer a similar cure rate to other treatments, but with markedly fewer side effects since it is a highly targeted form of radiation that spares nearby tissue for the most part- but this is getting way ahead of where you are right now.)

Please keep asking questions, as this board has some excellent participants.

 
Old 11-29-2009, 08:09 PM   #4
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Re: Dealing With the Initial Shock - What Should I Do Next?

Holler1 & Daff - Many thanks for the helpful responses!

 
Old 11-30-2009, 03:15 PM   #5
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Re: Dealing With the Initial Shock - What Should I Do Next?

Hi Rider18,

Welcome to the board! I'm sure you would rather have had no need to come to it , a sentiment we all share, but we're a good group! I've read through your post #4 and already viewed the fine advice offered by holler1 and daff. I'll add a few points in green.


Quote:
Originally Posted by Rider18 View Post
I am still a bit shocked.

Welcome to the club, but only as an associate member. Can't promise any official membership for those not formally diagnosed. Sorry about that. But going through that initially stunning encounter with the doctor is one of the initiation rites.

After I had my annual physical a few days ago (I'm in my early 50s), my internist informed me that my PSA was 3.3. That was the first time I ever heard that my PSA was elevated, and I have no clinical symptoms, and the rest of my blood work is normal. My internist is a very experienced and conservative physician. After commenting that my DRE was normal, he said that I should see a urologist, just in case. I saw a urologist the next day. The urologist performed a DRE and said that one side of my prostate felt a bit firmer than normal.

As you may know, in the "old days" - meaning, actually, just a few years ago, knowledge is advancing rapidly in this field - most doctors were not that concerned until a man's PSA hit 4, and many did not take age into account. It's good that your doctor has an up-to-date way of looking at PSA. It is possible, even with your negative exam and blood tests for infection, that infection or inflammation is contributing to the increase in PSA, possibly also some mild benign enlargement, possibly all mixed with some cancer. It would also be good to know the urologists estimate of the size of your prostate. Among other things, that gives you the second number you need to calculate the "PSA density," at least tentatively. The ultrsound used for the biopsy should enable the doctor to determine a more precise volume and density.

He told me to get a new PSA test, both free and total, which I did this past Friday. The urologist also said that regardless of what my new PSA test demonstrates, I should have a prostate biopsy.

His advice strikes me as wise practice. The results will add significant information even if they do not affect the biopsy decision.

I am scheduled for a biopsy next week, but I don't feel that I am armed with sufficient information to decide whether I should do it now.

As holler1 and daff have indicated, we laymen usually feel that the doctors will want to do a biopsy in cases like yours because of the DRE, and that is a sound reason, even if the PSA is quite favorable, and yours is a bit elevated. The one question here is whether the doctor doing the DRE did a good job resulting in a valid DRE. Because he was a urologist, the chances are strong that he knew what to do and what to observe. In other words, his estimate based on the DRE was probably valid. My layman's impression is that it's somewhat reassuring that the primary care doctor did not feel your prostate was abnormal based on his DRE. That suggests that, if there is something going on, it is not massive. Some of us, unfortunately, unlike you, have strong indications of cancer from the DRE at the outset.

Unfortuantely, I do not have sufficient historical PSA data to know how fast my PSA got to 3.3. I do have my first ever PSA test result, which was in 1998 and read 0.81. I have had a few other PSA tests over the past 10 years, but my previous doctor's office tells me they can't locate the records. . .

For now, prior to the biopsy, you might want to accept that answer, but, if the biopsy does show cancer, it would be worth being assertive in trying again to get the dates and scores for your earlier (and the date for the latest) PSA tests. Those could provide meaningful clues, especially whether your PSA had risen by more than 2.0 in the past year, which is actually quite worth knowing. You could point that out to the staff, or better, to the most senior person on the staff, and to the doctor himself if you do not get the results. You could request firmly that the doctor contact the lab that ran the test to check their records. I suspect the doctor ordering the test, or the lab that ran it, has some legal obligation to keep the records for a fairly long period of time.

Should I go through the biopsy and worry later, if necessary, or should I consider taking any other steps before I undergo a biopsy? For example, I just read about the PSA3Plus test - should I have that test first? Should I see another urologist to get a second opinion? Any other advice?

Holler1 and daff have already covered this ground, but here's one more point. There's a special kind of biopsy, known as a color Doppler ultrasound (CDU) biopsy, that provides more key information than a standard biopsy, even one sampling 12 cores. It's main feature is that the color Doppler feature allows the doctor doing the biopsy to visualize new blood vessel formation that tumors need and use to grow. That color feature allows the doctor to get a good idea of the shape, location and size of the tumor, in addition to the usual information. It is awkward for most of us to get a CDU biopsy because there are only a few sites in the country with the expertise and special, high-end equipment to do the job. (Not just any CDU will do.) However, one of the national experts, Dr. Duke Bahn, MD, practices in Ventura, California, sort of in the LA area, and might be convenient for you. If it were me facing your situation, I would want him to do a CDU biopsy. He could also confirm the DRE before the biopsy. If you are interested, PCRI (the Prostate Cancer Research Institute), a non-profit organization headquartered on Century Blvd near LAX, has publications about CDU biopsy. If you don't get such a biopsy, talk to the doctor to make sure he intends to take at least 10 core samples.

I want to move fast, but prudently.

Good for you - that's the right attitude. "Take your time in a hurry." - Wyatt Earp on gun fighting

Unfortunately, I do not feel that I have adequate infromation to analyze whether my urologist is jumping the gun with recommending a biopsy this quickly. I would really appreciate any advice on what I should learn and do next.

My take is that he is well within standard sound practice, base on what you have posted. As far as getting oriented, even just to learn about what's involved in figuring out whether or not a patient has cancer, I stronly recommend this book: "A Primer on Prostate Cancer - The Empowered Patient's Guide."



Many thanks!
Please feel free to ask followup questions to the board. You are very likely to have new questions as you learn.

But for now, good luck and take care.

Jim

 
Old 12-03-2009, 05:38 PM   #6
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Re: Dealing With the Initial Shock - What Should I Do Next?

Rider18:

Just saw your post and want to provide a little bit of my history as it sounds similar to yours. This might be too late as it sounded like you were planning a biopsy this week. In either case this might be helpful ...

When I was in my early 50's 4-5 years ago I had a PSA jump to the 5's and my prostate was enlarged (found via routine DRE). My internist recommended I see a urologist and he confirmed the findings. He recommended a biopsy and I decided to think about it. After a couple of weeks I had a phone conversation with my urologist and we both agreed that since this was the first time the PSA had jumped up that we could watch it, but he wanted to see me every 6 months for a PSA and an exam.

I followed that until last January. From the first PSA to the one in January, the PSA jumped around but never got back to 5 and also never back down to the 2s. It was only after 3 tests (18 months) when the PSA went up each time (again, not a lot as it was only in the low 4s) that we decided a biopsy was called for. Also, during this entire time my prostate was enlarged. I want to emphasize that each time the doctor said it was enlarged but it felt normal (and that might be the difference in your case as you said your doctor felt something).

My first biopsy (12 samples) did not rule out cancer, but instead came back with what they call High Grade PIN. This is like the PSA exam - not a definite marker for CA but another indicator that says something is not normal. A second biopsy was scheduled in June and that one "hit the spot". They found PC in 10% of 1 of the cores. In my case it was very early and since they found it via PSA with no lumps it had a very low score.

As for what you should do - that is a personal decision. If you feel you are going to worry a lot then I would get the biopsy now. If you feel you are not ready then I would strongly recommend you see your urologist every 6 months.

Please let us know how things turn out.

MrMike

 
Old 12-03-2009, 11:10 PM   #7
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Re: Dealing With the Initial Shock - What Should I Do Next?

Jim,

I can't express how grateful I am for your thorough response. I know it takes time and careful thought, which makes it even more valuable and appreciated. And being an associate member is just fine with me!

I have received my latest test results. My new PSA reading dropped to 2.33 and my free PSA is at about 19%. This time, I was abstaining and went to the same lab. So, I hope that this result is more accurate. The urologist's assistant called me and said that the doctor decided to cancel my biopsy this week. However, he wants me to re-test in about 3 months and, otherwise, he did not need me to do anything else. When I informed my internist regarding this, he agreed re the biopsy cancellation and, in response to me questioning the low level of free PSA, said that free PSA readings are not as reliable when total PSA is below 3.0. I guess, all this sounds like a good development. However, somehow, I have an uneasy feeling. Although I was was shocked with the initial test results and prospects, I was getting myself mentally ready for the biopsy and, deep down, I knew I needed to be ready that I would be diagnosed with PC. Now, I feel like I'll be on pins and needles until March. It's the unknown and lack of clarity that is bugging me, but, I guess, I'll just have to deal with it.

Meanwhile, based on all I have read thus far, I think you may be right that I probably have some combination of inflammation and early PC. I will definitely read what you suggested about CDU. Also, I already got more assertive with the prior medical group, and they are trying to obtain my test results for the past 8 years from two labs. I hope to get at least something in the next few days.

I do have a couple of questions:

1. In light of the new PSA reading, would it make sense for me to do a CDU test now, or should I wait until after the March PSA test?

2. It is clear to me that I need to do what I can to try and improve my prostate health. There is so much information and recommendations out there - foods (e.g., pumpkin seeds), food supplements, vitamins, etc. Any advice in this department?

3. Finally, is there any known correlation between any specific physical exercises and prostate health.

Once again, many thanks!

 
Old 12-03-2009, 11:23 PM   #8
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Re: Dealing With the Initial Shock - What Should I Do Next?

Mike,

Thank you very much for your response. I just described my developments in a previous message to Jim. I will be doing a lot of reading in the coming days and weeks. Unless I learn of something that I should do in the very near term (e.g., a CDU test), I plan to wait until the next PSA test.

Thanks again!

 
Old 12-04-2009, 08:11 PM   #9
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Re: Dealing With the Initial Shock - What Should I Do Next?

Hi again Rider 18,

Wow! Great PSA result! (And the free PSA result is not bad either.) Just for now, I think some good champagne is in order. I'll insert some thoughts in green in an excerpt of your response to me.


Quote:
Originally Posted by Rider18 View Post
Jim,

I can't express how grateful I am for your thorough response. I know it takes time and careful thought, which makes it even more valuable and appreciated. And being an associate member is just fine with me!

You're welcome, but I have to say your membership application is not looking so great. Sorry about that!

I have received my latest test results. My new PSA reading dropped to 2.33 and my free PSA is at about 19%. This time, I was abstaining and went to the same lab. So, I hope that this result is more accurate.

You may have heard there has been a move in the past few years to lower the PSA trigger point from the old 4.0 to 2.5. (In fact, the American Urological Association puts emphasis on the overall set of circumstances instead of a specific trigger.) But your new result is clearly below that lower trigger.

The urologist's assistant called me and said that the doctor decided to cancel my biopsy this week.

He's probably cancelling because your latest PSA is below 2.5 and the PSA velocity clearly does not exceed 2.0 (see below for explanation) in the context of a free PSA result that is not that bad plus a DRE that he might think is iffy as a basis for concern. My layman's impression is that cancelling for now, but with followup soon, is the best course.

However, he wants me to re-test in about 3 months and, otherwise, he did not need me to do anything else.

That followup is important. Among other things, it will help illuminate whether there is any upward trend. It would be reassuring to see virtually no change or even a decrease next time. Cancer causes a tell-tale, steady exponential upward trend in PSA, though sometimes that is masked by other influences, such as infection, BPH, recent sex, a different lab and so on.

When I informed my internist regarding this, he agreed re the biopsy cancellation and, in response to me questioning the low level of free PSA, said that free PSA readings are not as reliable when total PSA is below 3.0. I guess, all this sounds like a good development.

Definitely!

However, somehow, I have an uneasy feeling. Although I was was shocked with the initial test results and prospects, I was getting myself mentally ready for the biopsy and, deep down, I knew I needed to be ready that I would be diagnosed with PC. Now, I feel like I'll be on pins and needles until March. It's the unknown and lack of clarity that is bugging me, but, I guess, I'll just have to deal with it.

Based on what had happened, I did not expect that drop of a point in PSA, and I'm sure your doctor didn't either. But that's real! Still, those of us on the board are quite familiar with the anxiety you describe. Goes with the territory.

Meanwhile, based on all I have read thus far, I think you may be right that I probably have some combination of inflammation and early PC.

Based on the decline or more accurate reading this time (can't be sure which or both), I think there is a greater likelihood that you are free of cancer. But there's still enough basis to be sure to followup frequently for a while.

I will definitely read what you suggested about CDU. Also, I already got more assertive with the prior medical group, and they are trying to obtain my test results for the past 8 years from two labs. I hope to get at least something in the next few days.

That's great! However, an additional benefit from your latest test is that it is only 1.52 higher than the PSA of .81 you had way back in 1998. That means the velocity in the past year cannot be more than 2.0, and that is the key threshold of concern! That >2.0 velocity was a possibility with your PSA at 3.3, but that has now been favorably resolved! (Have another gulp of champagne!) Still it's good to know the velocity should you turn out to have prostate cancer, as the lower the velocity, the better. Should you need to know more about this, the key work was done by a team led by Dr. Anthony D'Amico, and there is an old thread about it on the board.

I do have a couple of questions:

1. In light of the new PSA reading, would it make sense for me to do a CDU test now, or should I wait until after the March PSA test?

In my now fairly savvy layman's opinion, it makes sense to wait. Hopefully no kind of biopsy will be deemed necessary.

2. It is clear to me that I need to do what I can to try and improve my prostate health. There is so much information and recommendations out there - foods (e.g., pumpkin seeds), food supplements, vitamins, etc. Any advice in this department?

Yes - that would be an excellent thing to do. I wrote an old thread about this to provide some leads: "Nutrition & lifestyle tactics - books, resources and a quick summary," started on 3/6/2008. There are other threads also on the board about preventive tactics.

3. Finally, is there any known correlation between any specific physical exercises and prostate health.

A lot of research has been and is being done. Exercise makes a clear difference in coping with some of the side effects, and there is indirect evidence that aerobic and strength exercise help in preventing or lowering the risks of the disease. If you are a glutton for punishment, go to www.pubmed.gov and search for " exercise AND prostate cancer ". I just did that and got 372 hits!

Consider the following excerpt of the abstract from hit #8 (as of tonight - will change as newer studies are added to the database), with my comments in green:

J Urol. 2009 Nov;182(5):2226-31. Epub 2009 Sep 16.

Exercise and prostate cancer risk in a cohort of veterans undergoing prostate needle biopsy.
Antonelli JA, Jones LW, Bañez LL, Thomas JA, Anderson K, Taylor LA, Gerber L, Anderson T, Hoyo C, Grant D, Freedland SJ.

Dr. Freedland had previously done some impressive research at Johns Hopkins before moving to Duke.

Duke Prostate Center, Division of Urologic Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
...
PURPOSE: Epidemiological and molecular evidence suggest potential associations between exercise and prostate cancer risk reduction. We further characterized this relationship by examining exercise and cancer risk among men undergoing prostate needle biopsy. MATERIALS AND METHODS: A total of 190 men who underwent prostate biopsy at the Durham Veterans Affairs Medical Center completed a questionnaire on current exercise behavior. Participants were asked average frequency of mild, moderate and strenuous intensity exercise in a typical week, as well as average duration as assessed by the Godin Leisure Time Exercise Questionnaire. Total current exercise was calculated in terms of metabolic equivalent task hours per week. Primary outcome measures were prostate biopsy result and Gleason sum. RESULTS: After adjusting for age, race, body mass index, prostate specific antigen, digital rectal examination, family history, previous prostate biopsy and comorbidity score, men who reported 9 or more metabolic equivalent task hours per week of exercise were significantly less likely to have cancer on biopsy (OR 0.35, CI 0.17-0.75, p = 0.007)
["OR" means "Odds Ratio," so those exercising 9 or more hours were only 35% as likely to have cancer show up in the biopsy, a really impressive reduction; the "true" number is in the range from 17% to 75% with 35% being the most likely statsitically]. Furthermore, among men with malignant biopsy results, reporting moderate exercise (3 to 8.9 metabolic equivalent task hours weekly) was associated with a lower risk of high grade disease (Gleason 7 or greater, OR 0.14, CI 0.02-0.94, p = 0.04) [Again, a highly impressive OR, only 14% as likely to have high grade disease, but the statistical confidence is not overly strong, though favorable.]. CONCLUSIONS: To our knowledge these results provide the first evidence of an association between exercise and prostate cancer risk as well as grade at diagnosis in men scheduled to undergo prostate biopsy. [To my knowledge too. This is impressive stuff, and I sure hope it holds up as other researchers weigh in.] Specifically moderate exercise was associated with a lower risk of prostate cancer and in men with cancer, lower grade disease. Further investigation using an objective measure of exercise in a larger sample size is required to confirm these findings. Yes, we really need to look at more than 190 men to increase confidence, but this is a solid and worthy start.]


Once again, many thanks!
You're welcome.

Take care,

Jim

Last edited by IADT3since2000; 12-05-2009 at 06:36 AM. Reason: Spelling - changed "5o" to "to".

 
Old 12-04-2009, 09:01 PM   #10
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Re: Dealing With the Initial Shock - What Should I Do Next?

Rider18,
I'm glad to hear of your good PSA result, and I too believe you are on a prudent course of action. I just want to add a personal note that may be reassuring. Considering the difference in age (I'm 67) your situation seems a little like mine. My PSA history is in my sig, and is significantly higher than yours overall, but similarly to yours it shows ups and downs for which I have no good explanation. My free PSA is also in a similar range to yours, just above the low range. The reassuring part is that I have had two biopsies in the last two years and both were negative. Obviously everyone's case is unique, but my sense is that negative diagnoses in this kind of situation are not uncommon. I've been living with this uncertainty or worry for a couple of years now, and while it is acute when a test is coming up, it is less worrisome most of the time, and of course is much much less than it would be with a positive diagnosis. I have also been reading and learning about CDU and MRI/MRIS with the hope that one of these (or some other test) may turn out to be the diagnostic tool that will supplement and eventually displace the needle biopsy, although it appears that goal is years away. Best of luck.

 
Old 12-05-2009, 11:11 AM   #11
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Re: Dealing With the Initial Shock - What Should I Do Next?

Great News !!

You case sounds very similar to mine and your course of action is what I did. Had regular (every 6 months) checkups with my Urologist. I am also glad to hear that you are going to use the same lab for the PSA. Both my urologist and surgeon recommended that as well. As for the PSA it is not an exact science. One of the surgeons that I saw, (he happened to be one of the doctors that did many of the original studies on the PSA) told me the highs are not important. He looks at the lows and gets concerned when the lows "march up". So going to the same lab and keeping a record going forward will be the key to early detection of any problem.

You may also have BPH (Enlarged Prostate). My prostate remained enlarged for 4 years. I do not know the relationship of BPH to PC but that is something you can discuss with your urologist down the road.

Best of luck and in some way I hope you will not have any need to contact us again down the road :-)

MrMike

 
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