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  • Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

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    Old 06-08-2021, 06:04 AM   #1
    IADT3since2000
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    Exclamation Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    A number of medical research studies have documented the importance of experience for surgeons who perform radical prostatectomies. Results are better, often much better, when the surgeon has a lot of experience and does RPs frequently.

    Recently Dr. Matthew Cooperberg, MD, a highly regarded surgeon at the University of California, San Francisco (UCSF), a major center of excellence in prostate cancer care in the US, gave a talk on surgery at the 2nd Patient Conference on Prostate Cancer, sponsored by UCSF and the California Prostate Cancer Coalition. He made the shocking point that many prostatectomies are performed by surgeons who do these surgeons too infrequently to have the experience needed for high confidence in good outcomes. His slide showed the following:

    …Annual………………………% Surgeons……………..% Patients
    Caseload…………………………(933)………………………….Seen….

    …..1………………………………….26.9…………………………..3.8

    …..2………………………………….16.2…………………………..4.6

    …..3……………………………………9.4…………………………..4.0

    …..4……………………………………6.3…………………………..3.6

    …..5……………………………………7.1…………………..……..5.0

    …6-10………………………………16.9………………….…….18.4

    10 or Fewer……………………..82.9…………………...….39.3

    ..11-24………………………….…13.3…………………..…..28.2

    25 or More………………………..3.9…………………..…..32.4

    50 or More…………………………1.8…………………..…..22.8


    As is clear from this table, many patients have their RPs done by doctors who are short on experience, as the line for “10 or Fewer” RPs per year demonstrates: 82.9% of the surgeons in the study were in this group, and they accounted for nearly 40% of all RPs performed. The next line, for 11-24 RPs annual, indicates somewhat better experience, but is still short of top flight experience, and if you add the 28.2% of all RPs to the 39.3% for the clearly inexperienced surgeons, you get 67.5%, which is two thirds of all RPs performed by doctors with short or minimally adequate experience.


    The bottom line here: it is imperative to check the experience of any doctor you are considering for an RP.

    Ideally, an expert who is widely recognized is the best option. Reputation and a record of research publications can point to these experts. But many fine doctors do not publish research and may not be at major institutions. Local prostate cancer support groups often have local knowledge of who is good and who is not, though you have to assess the judgement of the participants in those groups. Helplines from organizations may also be helpful, as may online reviews. In my area, The Washingtonian Magazine publishes an annual list of doctors who are considered experts by their peers, and there are similar publications in other cities. There is also a non-profit service that rates doctors based on consumer feedback. Of course, friends who have had an RP are also good bases to touch. All these types of resources can aid in selecting a surgeon.

    ….Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    21 years as a survivor. Doing well. Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low and stable at <0.01; apparently cured (Current PSA as of 12/2/2020). (Current T 93 12/2/2020.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education. What I experienced is not a guarantee for all but shows what is possible.

     
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    Old 06-08-2021, 06:51 AM   #2
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    The common wisdom about choosing an RP surgeon includes having done more than 1000 procedures. You should also inquire about the surgeon's personal stats in three outcome areas: oncological, continence, and potency (erections), but rather than overall stats, ask about the outcomes for men with your prostate-cancer status (Gleason score and lesion location).

    Djin
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    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, negative frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
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    Old 06-08-2021, 10:09 AM   #3
    Terry G
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    I wonder what percentage of men that receive a prostate cancer diagnosis bother to get a second opinion or bother to investigate radiation treatment options.
    __________________
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    Bx: Three of twelve cores adenocarcinoma Gleason 6 (3+3) all on left side, no pni.
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    Old 06-08-2021, 01:26 PM   #4
    IADT3since2000
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    Hi Terry,

    Quote:
    Originally Posted by Terry G View Post
    I wonder what percentage of men that receive a prostate cancer diagnosis bother to get a second opinion or bother to investigate radiation treatment options.
    That’s an interesting question. I often chuckle when I hear patients ask if they should get "second" opinions because I myself saw at least nine doctors – urologists, radiation oncologists, a dermatologist with local knowledge and a medical oncologist before settling on primary ADT in an effort to hold the fort until radiation technology improved, which I did for thirteen years. (I saw more doctors prior to my apparently successful attempt at curative radiation in 2013.)

    There has been relevant research providing clues to what proportion of patients get second opinions. Here’s what I found after a brief search, with the last study looking like the most reliable.
    .
    One 2016 study of newly diagnosed localized prostate cancer in the Philadelphia area were surveyed with the question whether they had gotten a second opinion from a urologist; 40% replied they had. A free link to the complete paper is:https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.30412. I wish they had also included second opinions from medical oncologists and radiation oncologists.

    A small 2017 study (47 patients), with an abstract and link to a free copy of the complete paper at https://pubmed.ncbi.nlm.nih.gov/28379829/, found that “Three profiles of patients emerged for choosing specialists: active (21.3%), partially active (53.2%), and passive (25.5%). Active patients conducted substantial research when choosing a diagnosing urologist and a treating specialist: they searched online, consulted other men with prostate cancer, and/or visited multiple specialists for opinions. Partially active patients took only 1 additional step to find a treating specialist on their own after receiving a referral from their diagnosing urologist. Passive patients relied exclusively on referrals from their primary care physicians (PCPs) and diagnosing urologists.”

    A very large – 85,088 patients - 2010 study, https://pubmed.ncbi.nlm.nih.gov/20212180/ with link to free complete copy, found that “Overall, 42 309 men (50%) were seen exclusively by urologists, 37 540 (44%) by urologists and radiation oncologists, 2329 (3%) by urologists and medical oncologists, and 2910 (3%) by all 3 specialists.” Basically, considering all levels of risk, this study indicates about a 50/50 split between those patients getting just one and those patients getting more than one opinion.

    Thanks for raising this question.

    ….Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    21 years as a survivor. Doing well. Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low and stable at <0.01; apparently cured (Current PSA as of 12/2/2020). (Current T 93 12/2/2020.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education. What I experienced is not a guarantee for all but shows what is possible.

     
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    Old 06-08-2021, 01:51 PM   #5
    duckinator
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    I strongly considered RP and a primary concern was the experience of the person with his hands running the knives. The "team" was important but if the surgeon was highly experienced, you would assume the team would be too. My UR in backwater Missouri has done 1,200 RALPs, currently doing 150 per year. The next higher volume guy in state has done 2,000 but was a three hour drive. I'd rather have a doctor with over 1,000 RALPs in a smaller medical system than a newbie in Mayo.

    However I ultimately chose SBRT with a RO & "team" that has done 250 of them on PCa. Would be interesting to know if a similar study has been done on RO's.
    __________________
    PSA at 4.2 10/2019
    Diagnosed PCa 11/21/2019 small volume 3+3 thus AS

    2021 - PSA 4.72
    3TmpMRI then fusion biopsy
    3+4 in a 7mm lesion , 3+4 nearby, and 3+3 on other side.

    Started SBRT 6/2/2021

     
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    Old 06-08-2021, 06:00 PM   #6
    Terry G
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    Jim…Thanks for the data on second opinions. I’m surprised at the data. I would have guessed it to be lower. One thing for sure is the treatment choice decision is a complicated one.
    __________________
    Rising PSA:
    11/13 1.95; 9/15 3.28; 10/16 5.94
    TRUS 1/17
    Bx: Three of twelve cores adenocarcinoma Gleason 6 (3+3) all on left side, no pni.
    DOB 7/21/47; good health; age 69 @ Dx
    Treated 6/17 SBRT @ Cleveland Clinic by Dr. Tendulkar
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    Old 06-08-2021, 08:34 PM   #7
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    An anecdotal observation. I participate in many PCa support groups, and have had my share of "discussions" with other opinionated folks about treatments. Two conclusions (1) the only people who have ever challenged the concept of active surveillance are men who had surgery, and never considered any other treatment; and (2) The most, umm, "vigorous" defenses of their treatment are solely from men who only consulted with urologists before choosing surgery. IMHO, they are inordinately sensitive to any data that suggests another type of treatment might have been a better choice. Just my opinion, FWIW.
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    Seven biopsies from 2009 to 2021. Three were were positive with 5% Gleason(3+3) found.

     
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    Old 06-09-2021, 11:51 AM   #8
    Gary I
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    Quote:
    Originally Posted by duckinator View Post
    ..... I ultimately chose SBRT with a RO & "team" that has done 250 of them on PCa. Would be interesting to know if a similar study has been done on RO's.
    Good choice on SBRT.

    Great question on RO experiences with prostate cancer experiences and successes. Most RO's are generalists, and getting hard prostate treatment data from them, their planners, or staffs...is near impossible, in my experience. Frankly, I suspect they don't track it closely.

    Choose wisely my brothers, and take our biased opinions for exactly what they're worth.
    __________________
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    Second 3T MRI 1/17
    RALP 7/17, G3+4, Organ confined
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    PSA 0.32 to .54 over next 4 months
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    Old 06-09-2021, 12:50 PM   #9
    duckinator
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    My process was first decide on a treatment, then I had to decide on who to have do it. Both very important decisions.

    Of course that was after I decided I needed to treat my PCa.
    __________________
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    Diagnosed PCa 11/21/2019 small volume 3+3 thus AS

    2021 - PSA 4.72
    3TmpMRI then fusion biopsy
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    Old 06-10-2021, 05:05 AM   #10
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    My thinking was simple. If there's a good chance I can be "cured" first with surgery I would try. Also, I wanted to know if the cancer was more than revealed in the biopsy. And, my family is long lived.

    And, I have a bias against radiation and ADT if avoidable.

     
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    Old 06-10-2021, 05:34 AM   #11
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    Quote:
    Originally Posted by Prostatefree View Post
    My thinking was simple. If there's a good chance I can be "cured" first with surgery I would try. Also, I wanted to know if the cancer was more than revealed in the biopsy. And, my family is long lived.

    And, I have a bias against radiation and ADT if avoidable.

    From what I hear, NOBODY likes ADT. Lately. it seems to be recommended by radiologists for unfavorable intermediate cases and higher.

    But, there is a man on a ** group who advocates ADT with RP, He is Gleason 9, and was in a program where he had ADT both before and after surgery. Highly recommends that course for newly diagnosed higher risk men. He is in his 40's.

    Wow! Looks like more and more treatments are involving ADT. The increase in survival versus the decrease in QOL is whole other discussion.
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    Seven biopsies from 2009 to 2021. Three were were positive with 5% Gleason(3+3) found.

     
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    Old 06-10-2021, 08:27 AM   #12
    Prostatefree
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    Yes. My experience is anecdotal. My brother went the surgery route and had to follow up with ADT and radiation. Of the three, the ADT was the most unpleasant in his experience.

    I was, and am, fully prepared for radiation and ADT if I need it. This isn't about preferences, but survival with the best possible outcome and mininally invasive.

    One of the distinctions may be an impression that radiation and ADT or less invasive than surgery. I'm not convinced.

    As surgeons become more skilled with the robot and new doctors grow up with the expectation and training for robot assisted surgury in general stats will improve. They haven't been as dramatic as the improvements in the technology around radiation, but it doesn't mean it isn't happening.

    In the end, hopefully, none of these treatments will be the final answer to cancer.
    __________________
    Born 1953; family w/PCa-grandfather, 3 brothers;
    7-12-04 PSA 1.9; 7-10-06 PSA 2.0; 8-30-07 PSA 3.2; 12-1-11 PSA 5.7; 5-16-12 PSA 4.76; 12-11-12 PSA 5.2; 3-7-16 PSA 7.2;
    3-14-16 TRUS biopsy, PCa 1%-60% across 8 of 12 samples, G3+3;
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    Old 06-10-2021, 11:28 AM   #13
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    My UR specializes in Prostate Surgery and BPH Surgery [HoLEP] as well as Prostate and Bladder Cancer. He is under 40 years old but has performed over 500 HoLEP procedures. Experience does give the perspective patient more confidence.
    He also works in conjunction with the Lead RT MD at one of the local Cancer Centers. After he received my Biopsy results he spent 30 minutes with my wife and I explaining the results and ALL available treatment options. Not once did he attempt to push me into a RP although he is a surgeon.
    My suggestion for any newly diagnosed prostate cancer patient is to run as fast as you can away from any MD / UR that tries to PUSH you into one particular treatment. My UR gave me a book on PCa and also gave us plenty of time to let him know our treatment decision or get a second opinion so that we could proceed with treatment.
    My UR has resumed custody of my Cancer Care after IMRT and his office is where I get my Lupron shots.
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    Old 06-10-2021, 11:40 AM   #14
    IADT3since2000
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    Hi Prostatefree. You wrote:
    Quote:
    Originally Posted by Prostatefree View Post
    Yes. My experience is anecdotal. My brother went the surgery route and had to follow up with ADT and radiation. Of the three, the ADT was the most unpleasant in his experience....
    I'm curious whether your brother was aware of countermeasures against the side effects of ADT. Do you know if he used countermeasures?

    We've had guys come to our UsToo PC support/education group and complain about bad times on ADT, but it turns out they were not advised about countermeasures by their urologist and just suffered the side effects in ignorance.

    ….Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    21 years as a survivor. Doing well. Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low and stable at <0.01; apparently cured (Current PSA as of 12/2/2020). (Current T 93 12/2/2020.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education. What I experienced is not a guarantee for all but shows what is possible.

     
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    Old 06-10-2021, 02:32 PM   #15
    Gary I
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    Re: Many Radical Prostatectomy (RP) Surgeons Are Short on Experience

    Quote:
    Originally Posted by IADT3since2000 View Post

    I'm curious whether your brother was aware of countermeasures against the side effects of ADT. Do you know if he used countermeasures?

    We've had guys come to our UsToo PC support/education group and complain about bad times on ADT, but it turns out they were not advised about countermeasures by their urologist and just suffered the side effects in ignorance.

    ….Jim
    Jim, it's the radiologist, not the urologist, usually employing ADT, so he should be the one discussing the myriad potential short and long term side effects. In my experience that unfortunately, doesn't happen often.

    Please share with us the details of the ADT "countermeasures" that you mentioned. Thanks.
    __________________
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    Second 3T MRI 1/17
    RALP 7/17, G3+4, Organ confined
    pT2 pNO pMn/a Grade Group 2
    PSA 0.32 to .54 over next 4 months
    DCFPyl PET & ercMRI @NCI - 11/17
    One inch tumor still in prostate bed
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    SRT, 2ADT, IMGT 70.2 Gy, complete 5/18
    PSA 0.066 1/20, .059 6/20, .077 9/20, .099 11/20,.075 1/21 .079 4/21

     
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