Respectful Insolence

Oddly enough, I’m more tired this morning than I was on Friday.

That’s the sort of thing that happens when I actually do as much work over the weekend as I often do on two typical weekdays. The reason is that I’ve suddenly found myself with an unexpected promotion, and–oh, by the way–there’s stuff that needs to be done on Monday. Consequently, my originally intended topic for Monday will have to wait until Tuesday or Wednesday, mainly because it might require a bit of thought. That’s OK. It’ll wait. Besides, it’ll be much more useful and educational if I have a little time to think about it. Who knows? Maybe I can do a post as useful and interesting as the one I did about Steve Jobs a couple of months ago.

Besides, the resident woo-friendly antivaccinationist “columnist” at the Chicago Tribune, Julie Deardorff, didn’t disappoint yesterday. In fact, I had been beginning to wonder if perhaps she had started to turn away from the dark side, as I hadn’t seen anything really credulous from her in a while. Granted, that could just be because I haven’t been monitoring her the way I used to a while back. I don’t know. But yesterday she rose to heights to which she has seldom aspired before–or, perhaps I should say she sank to depths to which she has seldom sunk before–as she decided to do an article on how you can supposedly treat cancer with “natural” diets. True to form, she falls for every bit of woo that comes her way. Equally true to form, she falls for the oldest “cancer testimonial” bit in the book, one that I’ve written about multiple times before, including very recently and far, far back in the depths of time, all the way at the very dawn of this blog.

Why am I not surprised?

Ms. Deardorff begins:

David Servan-Schreiber was 31 when he was diagnosed with a walnut-size brain tumor and given 6 months to live. After surgery and chemotherapy, the young neuroscientist asked his oncologist if he should change his diet.

“Eat whatever you like,” his doctor told him. “It won’t make much of a difference.”

Servan-Schreiber thought otherwise. For the next 15 years, he threw himself into researching the body’s natural defenses; today he believes dietary and other lifestyle changes are powerful and underutilized cancer-fighting tools.

“Cancer lies dormant in all of us,” he wrote in his new book, “Anticancer: A New Way of Life” (Viking, $25.95). “But our bodies are also equipped with a number of mechanisms that detect and keep such [defective] cells in check.”

That’s true enough, as far as it goes, but looking at the claims it looks as though they go too far. Dr. Servan-Screiber is clearly a highly intelligent man, but he wouldn’t be the first person whom serious disease led down the path of dubious conclusions. Moreover, what saved his life is almost certainly not the dietary manipulations and other woo in his book, but good old-fashioned surgery and radiation therapy. In other words, he’s almost certainly an outlier. There’s nothing magical about that, and like many outliers who happened to have tried “alternative” treatments in addition to conventional treatments, he attributes his survival largely to the woo rather than the conventional treatment. Without reading the book, it’s hard for me to say how valid his conclusions are, but from the description by Deardorff, they sound overblown at best and highly dubious at worst:

Cancer rears its ugly head when things get out of balance, Servan-Schreiber said in an interview. And that can happen if the bad guys that promote the growth of cancer cells (tobacco, excessive alcohol, excessive sugar, hydrogenated fats, environmental pollutants) outnumber the good guys that support our natural defenses (cancer-fighting phytochemicals found in fruits, vegetables, herbs and teas; physical activity; and stress management techniques).

But conventional treatment, while indispensable, focuses on a single target: destroying cancer cells. Doctors rarely address the other side: teaching patients how to fortify themselves using nutrition, exercise and stress management techniques to create an inhospitable environment for cancer.

There’s no doubt that diet is a risk factor for certain types of cancer, but it’s also not a risk factor for others. For example, there clearly are dietary factors that can increase or decrease the risk of developing colon cancer. Alcohol, for instance, is a risk factor for certain cancers, such as pharyngeal (throat), laryngeal (voice box), esophageal, liver, and breast, and possibly colorectal. There is evidence linking intake of fruit and vegetables to lowered cancer risk. Putting it all together, though, a lot of the risks due to diet tend to come more from being obese, which increases the risk of some cancers, rather than the actual diet itself. From my perspective, eating a healthy, well-balanced diet is more important than any one food or nutrient. There is also some evidence that, for example, vitamin D might lower the risk of some cancers, but it’s not clear that that risk reduction doesn’t come at a price, given that vitamin D does not appear to reduce the overall risk of death from cancer in the general population.

There’s also little doubt that at least moderate exercise also decreases the risk of cancer. Indeed, I’ve even written about such studies before in the past. Exercise is also good to do just in general for cardiovascular health. None of this is rocket science or outside the mainstream. But inevitably, when someone like Dr. Servan-Schrieber decides that lifestyle is a cancer-fighting tool, he’s right to a point but takes it far beyond what evidence supports. In most cases, the alteration in cancer risk is relatively small in most cases, at least in comparison to the claims made for it. For example, there’s no evidence that diet is able to prevent cancer recurrence, at least not enough to justify this sort of statement:

“Cancer is all about residual cells left behind in the body,” said Dr. Keith Block, medical director of the Block Center for Integrative Cancer Treatment in Evanston, where nutrition and lifestyle modifications are an essential part of all treatment plans. “When you ignore the environment where cancer lives, the disease in those residual cells comes back to haunt at a more aggressive level. It’s irresponsible to send patients home without strategies and interventions to reduce the risk of recurrence.”

What often happens, however, is that patients are told to eat whatever they want–even though research has shown the traditional Western diet can promote cancer growth–as long as they take in enough calories. When Susie Sondag of Chicago was diagnosed with breast cancer in 1999 at age 29, her doctors told her to eat meat and starch and to take the high-calorie supplement Ensure to counteract any weight loss.

“My response was ‘thanks for sharing,’” said Sondag, who instead changed to a raw and vegetarian diet.

Actually, there was nothing that her doctors said that was wrong, and no evidence that a raw vegetarian diet would have made any difference. Of course, the reason that data doesn’t show what Ms. Deardorff wants is because it’s obviously the evil big pharma conspiracy at work:

If garlic, broccoli, green tea or jogging could be patented, things might be different. Large, high-quality clinical trials would be held and oncologists would write out an anti-cancer grocery list. But although there’s a great deal of scientific evidence showing an effect of foods on cancer growth, no one wants to fund the large, controlled trials because no profits can be made.

Let’s see. A quick search of PubMed for “cancer and exercise” revealed 4,665 articles, while a search for “cancer and diet” revealed 24,912 articles. Heck, there are 474 articles on “cancer and broccoli” alone and 1,150 on “cancer and green tea.” Searching Clinicaltrials.gov shows 29 studies looking at cancer and green tea, six studies of broccoli and cancer, including one looking at preventing lung cancer in smokers with broccoli sprout extract, and 168 studies looking at cancer and exercise. That’s why it irritates the hell out of me to hear the claim that no one studies this stuff. As for large “controlled” trials, for for a lot of this stuff, it’s very difficult to do truly controlled trials. Retrospective evidence is sometimes the best we can manage.

I have to admit, looking at Dr. Servan-Schrieber’s book and his website, I was curious exactly what kind of cancer he had. I couldn’t find it on his website or in the Amazon blurbs, which I found rather strange. If I were writing such a memoir, I’d say exactly what kind of brain cancer it was right off the bat and I’d point it out in every interview. Still, what’s maddening about him is that he mixes the sensible with the dubious. Here’s the sensible:

With respect to conventional treatment, I think every patient should have at least two different opinions from two different oncologists. Every doctor I know who has cancer seeks at least two different opinions, more often three or four. It’s normal to explore what are all the options available because there are so many.

Actually, going much beyond two or three opinions, except in the case of rare tumors, is more likely to confuse than enlighten, but in general the above is sensible. Here’s the questionable:

But doctors such as Servan-Schreiber and Block say that no one ever regretted trying, especially when there are no negative side effects to eating garlic, leeks and scallions. They also warn that false hopelessness is far worse than false hope. Because even fatalism has been scientifically proven to affect a cancer patient’s outcome.

Unfortunately, “Secret”-style wishful thinking aside, fatalism has not been “scientifically proven” to affect a cancer patient’s outcome. In fact, the latest research suggests that attitude does not affect a cancer patient’s chances of surviving his or her cancer. That’s not to say that having a positive attitude doesn’t have numerous other benefits, but improving the odds of survival is not among them. Dr. Servan-Schrieber has even gone so far as to write a book entitled Instinct to Heal, which advocates what he calls the “new emotion medicine” and methods that, he claims, can “cure stress, anxiety, and depression without drugs or psychotherapy.” These methods include clear woo such as heart coherence, eye movement desensitization and reprocessing, and even what he calls the control of qi through acupuncture. All of these are, of course, supported primarily by anecdotes.

It doesn’t surprise me that Julie Deardorff would lap up whatever someone like Dr. Servan-Schrieber dishes out, be it sensible and science-based or woo. Unfortunately, she can’t tell the difference. Of course, why should she? After all, an MD/PhD like Dr. Servan-Schrieber apparently can no longer tell the difference himself, something that I, as a fellow MD/PhD, find very sad.

Comments

  1. #1 T. Bruce McNeely
    September 22, 2008

    …especially when there are no negative side effects to eating garlic, leeks and scallions

    Your spouse or partner might disagree.

  2. #2 Dave Ruddell
    September 22, 2008

    What gets me is the whole idea that if something can’t be patented, ‘they’ can’t make money off of it. There are quite a number of generic drug companies that make tidy profits. As for Big Pharma, I think Bayer does fairly well selling their own brand of ASA, as does Wyeth with Advil, despite the fact that store brands are much cheaper. Maybe there’s another reason why they aren’t interested in trying to sell some of these woo-based cures?

  3. #3 The Perky Skeptic
    September 22, 2008

    What is it, I ask fruitlessly, that makes people credit woo instead of chemo or radiation??? I know, I know– the woo is the one thing they feel in control of in the midst of this disease that takes away their control. But still! I wish we could find a way to direct the language of scientific medical therapy in a way that makes patients feel empowered. “I am going to chemo!!! My chemo is kicking this cancer’s ASS!!! I am taking positive steps to help my doctors irradiate the hell out of this tumor!!! GO ME!!!”

  4. #4 Marc
    September 22, 2008

    Question:

    Has anybody ever done a study of outliers (especially positive outcome outliers) in relation to their level of therapy and their use or nonuse of woo/complimentary medicine/whatever?

    For instance, I think it’s reasonably well established that application of woo, statistically speaking, doesn’t help the average cancer patient. However, let’s look at the edges. Does woo significantly increase the odds that a very sick patient will exceed their short-term life expectancy?

    This is of more than theoretical interest to me as a family member of mine was just diagnosed with Stage 4 bladder cancer (although at this point calling it “bladder cancer” is vaguely reminiscent of the “He stumpt his TOE” speech in The Adventures of Huckleberry Finn.) While they are using all feasible conventional treatments, frankly, if woo is more effective in extremely-poor-prognosis patients than in the general course, I would start mailing them boxes of goat-glands.

    M

  5. #5 cptchaos
    September 22, 2008

    “What is it, I ask fruitlessly, that makes people credit woo instead of chemo or radiation???”

    Well. I think, to one part it is the physicians that practise science bases medicine themselves. They just know that they are not in control of many situations. With their scientific mindset they don’t credit every success to them self. They are aware that to some degree luck matters as well.
    So those woo-masters have some advantage to persuade themselves and others that they are in control and can heal. In spite of the fact that they can’t and often perform worse than the sceptic physicians.

    An other problem is, that most people think that, competent people have an attitude of “I can solve every problem in my area of expertise”. But the contrary is true. People who think they understand everything in an area, usually know so little about it that they are unaware of the problems in it. Not to mention their inability to know their limits.
    Real experts know of so many problems, that they tend to feel quite limited in their abilities.

  6. #6 Scott
    September 22, 2008

    Does woo significantly increase the odds that a very sick patient will exceed their short-term life expectancy?

    Why in the world would it, given that it doesn’t work in general? Are you speculating that the placebo effect might be particularly effective in cases with a particularly poor prognosis? If so, it would probably be more relevant and useful to look for such an effect of placebos in general, as opposed to woo specifically.

    Best wishes to your family member – I hope he turns out to be an outlier too.

  7. #7 Calli Arcale
    September 22, 2008

    This reminds me of an article in the Star Tribune recently: http://www.startribune.com/lifestyle/health/28701254.html?elr=KArksUUUU

    It’s about a doctor who is promoting vitamin D as very nearly a panacea. The Strib did a rather credulous piece on it. While I agree that a lot of people could certainly do with getting outside a lot more, I’m skeptical of the cancer-curing claim, and even more so of the autism claim made in the article. You might want to take a look at that one, Orac. It might deserve some Respectful Insolence.

  8. #8 Prometheus
    September 22, 2008

    This appears to be another example of the “lucky veteran” fallacy.

    Let me explain:

    Anyone who has spent time around combat veterans will have run into the person who credits his (or her) survival to some talisman or another – a bible (or other holy book), a “lucky rabbit’s foot” (from a decidedly unlucky rabbit), a religious medalion, or even a “lucky rubber band”. These folks are convinced that this talisman was the “cause” of their survival.

    What is not talked about is how many soldiers in combat had such talismans and died anyway. We don’t hear the stories of the “unlucky” veterans because they are dead. Maybe they would have a different view of how “lucky” these talismans are.

    Now, imagine that you’re dealing with a situation where instead of a few percent (on average) of people are killed, the mortality rate is 90+% after a few years. In this situation, the survivors (the “lucky veterans”) are rare. Having seen their “comrades” dying in droves, they are even more likely to attribute their “miraculous” survival to something they did that (they believe) their “fallen comrades” did not.

    The catch is that there is no way for the survivor to know that the “talisman” they credit for the survival wasn’t used by some – or even most – of their “fallen comrades”. In fact, many of the people who died of the exact same tumor type may have tried the same dietary “interventions” and died anyway.

    I suspect, however, that even if Dr. Servan-Schreiber knew that people had died of the same type of tumor despite using his dietary “therapies” it wouldn’t change his mind. The human mind is very adept at overcoming such minor inconveniences as contradictory data. He would probably say something like:

    “It worked for me – it can work for you!”

    or

    “It can’t hurt and it might help!”

    Purveyors of false hope rarely see the downside of what they are “selling”.

    Prometheus

  9. #9 I am so wise
    September 22, 2008

    Actually, if garlic did fight cancer, there would be a way to patent it. Make a more effective, safer GMO version of it and then patent it. Lots of cures with a basis in nature have been patented.

    Also, why does nobody in the pro-woo/bullshit crowd ever question the monetary and prestige motivations of their people?

  10. #10 Calli Arcale
    September 22, 2008

    They don’t question the monetary/prestige motivations of their own people because their people have told them that they’re in it to help people, and not for money or prestige.

    In other words, because “their people” are very good salesmen.

  11. #11 Dangerous Bacon
    September 22, 2008

    Apart from all the typical woo, strawmen (physicians don’t ever advise people on changing lifestyle factors/diet in the prevention or treatment of cancer, they just want to “kill cancer cells”) and other idiocy, the phrase that jumped out at me was the part about Servan-Schreiber being “given six months to live”.

    Maybe I’m missing something here, but I’ve never heard any of the oncologists on our hospital staff talk about setting a deadline like this for any patients, and I suspect that Orac has never done this either. What most of us would like to know when facing a cancer diagnosis is what the usual course of the disease is, the likelihood of success for any interventions and yes, how long people at our stage of illness typically survive. It’s far different from being dogmatically told that “you’ve got six months to live”. That’s a convenient invention for those who want to portray physicians as heartless and a way to show that “see, I beat those bastards with nothing more than garlic and celery juice!”.

    The only situations where you are “given” X amount of time to live is in bad fiction and the columns of ignorant woo-promoters.

  12. #12 SC
    September 22, 2008

    Thanks, Prometheus – some good sampling-on-the-dependent-variable questions for my midterm! :)

  13. #13 Dawn
    September 23, 2008

    Orac, in your opinion, what exactly is responsible for the explosion in cancer cases?

  14. #14 Orac
    September 23, 2008

    What “explosion” in cancer cases? Please be specific.

  15. #15 Dawn
    September 23, 2008

    Well, in “Grandma’s day”, cancer was a rare thing…now, look at the number of cases today. In your professional opinion, what do you attribute that to?

  16. #16 Scott
    September 23, 2008

    “Explosion of cancer cases?” Looking at the most recent statistics on the ACS website (http://www.cancer.org/downloads/STT/CAFF2007PWSecured.pdf pages 2 & 3) doesn’t suggest any large increase in anything other than lung cancer (with the obvious explanation there) for 1930-2003. Admittedly those are plots of deaths rather than cases, but if there was a big enough jump in cases to justify the term “explosion” I would’ve expected to see *something*.

    I’d be interested to hear an explanation of the difference there.

  17. #17 Calli Arcale
    September 23, 2008

    Cancer was common in my grandma’s day. I’m not sure how old you are, Dawn, but perhaps you are old enough that cancer was less common in your grandma’s day. There was a simple reason for that, though — death rates due to other illnesses were much higher. We live measurably longer today, and that alone will produce a higher cancer rate, since many cancers are associated with old age. There has also been a significant increase in access to medical care, which will also increase diagnosis rate. (It doesn’t affect the actual rate of cancer; just the rate at which people find out about it.)

    Our longevity in the modern age is not just responsible for an increase in cancer diagnoses. It’s also responsible for a massive demographic shift that is going to significantly change how our society functions. Social security and Medicare face mounting financial challenges as there are more and more people living well past retirement age, while the birth rate declines. Housing is changing to address this; the city of Bloomington here in Minnesota is facing challenges with its aging population as it considers zoning variance applications for new or expanded high density senior living facilities (everything from apartment buildings to assisted living to nursing homes). It’s a real phenomenon, a real challenge, and quite possibly the greatest success of the 20th Century. I gotta say, if you’re gonna have a problem with your society, this is a good problem to have. ;-)

  18. #18 Orac
    September 23, 2008

    Dawn should go to this site:

    http://seer.cancer.gov/faststats/selections.php?series=data

    Select the types of data desired and graph it. Graphing all cancer types, for instance, produced a fairly flat line over the last thirty years. There has not been an “explosion” of any kind of cancer over the last 80 years other than smoking-related cancers, which now thankfully are finally starting to decline a bit now that smoking cessation programs are taking effect.

  19. #19 Ranson
    September 23, 2008

    Orac, Orac, Orac…

    Those are government numbers. We can’t trust them. Not without the secret hard copies that actually challenge the data as presented to the public.

  20. #20 Terrie
    September 23, 2008

    Dawn, the “explosion” in cancer is caused by seatbelts. The death rate for humans has consistently remained 100%, but as we have reduced the risk of death from one factor (auto accidents, in this case), it results in an increase in all other factors. So, wearing your seatbelt increases your risk of cancer. Wearing your seatbelt ALSO increases your chances of dying due to a Canadian Goose having a heart attack in mid-flight and landing on your head, breaking your neck.

  21. #21 Mary Parsons
    September 23, 2008

    Why do people think that the precursor of Cancer Research UK was established in 1902 if cancer is such a modern phenomenon? Similarly, I should think, for US cancer organisations.

    London had cancer hospitals in the nineteenth century. The Free Cancer Hospital was founded in 1851 – it later became the Royal Marsden.

    If cancer wasn’t common in previous generations then why did so many patent nostrums claim to cure it?

  22. #22 Mary Parsons
    September 23, 2008

    Royal Marsden link.

    History of the Imperial Cancer Research Fund 1902-1986.

    Sorry – lost the links for previous comment.

  23. #23 Bee
    September 23, 2008

    A well-known fifteenth century Scottish doctor (more of an herbalist, most likely) is known to have said that cancer was the scourge of his family, as many had died of it.

    That would be just the cancers visibly recognizable as such. Cancer is not a suddenly prevalent modern disease.

  24. #24 Militant Agnostic
    September 24, 2008

    I think that as we age cancer appears to become more prevalent as the number of people we know who have benn affecte by it inevitably increases – another example of how our observational biases lead to faulty conclusions.

  25. #25 snerd
    September 24, 2008

    Orac, clearly Dawn is talking about explosive cancer. Looking at her previous statement that cancer is caused by an acidic body, I believe she is developing a bold new theory that human organs are accumulating picric acid. It explains so much!

  26. #26 LibraryGryffon
    September 24, 2008

    Slightly OT, but I’ve been hearing a radio ad recently for the Cancer Project (http://www.cancerproject.org), voiced by Lisa Edelstein from House, whose main aim seems to be to get us to put our kids on vegetarian diets to reduce obesity and its attendant cancer risks. However I thought that vegetarianism, especially the vegan version, was contraindicated (at least in very young children) if you want your child to get all the nutrients they need for proper growth. Cancer Project has recipes, and links to a sight called NutritionMD which seem to be strictly vegan – no milk or egg use at all.

    I’m not sure that this would count as woo. But it does seem more like militant vegans promoting their agenda with scare tactics.

  27. #27 LibraryGryffon
    September 24, 2008

    I really do know the proper homonym — “site”, not “sight”.

  28. #28 Keenacat
    September 24, 2008

    The idea that vegetarianism automatically reduces obesity is, well, naive at best. French fries and a big, fat piece of cheese pizza are fully suitable for vegetarians, same goes for sugar, most oils, nuts (tremendous amounts of calories!!) and the like.
    Meet german comedian Dirk Bach, who is a vegetarian and has been supporting PETA for years:
    http://www.musicalzentrale.de/uploads_features/DirkInterview.jpg

  29. #29 lurker
    September 24, 2008

    G’day, I’m a cancer patient myself and my onco directed me here a few months back after I had yet another of my whinges about how, once they hear you have cancer, every man and his dog seem to have their own “woo” anecdote to share with you.

    I was getting to the point where I threatened that the next person who forwarded me an article on how if I would just turn vegan / detox / eat more garlic / meditate / pray / shun chemo / sleep upside down in a cave (okay I made that last one up), I could “cure” myself – that next person’s PC would be facing the mother of all DOS attacks.

    Now I just reply to their emails with the URL to your website here. Maybe not quite as satisfying, but they still get the hint eventually and *maybe* even learn something.

    Cheers, mate.

  30. #30 Prometheus
    September 25, 2008

    Dawn asks:

    “Well, in “Grandma’s day”, cancer was a rare thing…now, look at the number of cases today. In your professional opinion, what do you attribute that to?”

    Well, in my grandma’s day (she was born in the late 1800′s), cancer wasn’t such a problem because it generally only happened to “old people” – people who had managed to beat the odds and live long enough to finally develop cancer. Much more of a concern to adults in her “day” was the possibility to dying from things like childbirth, diphtheria, typhoid fever, polio, infections, trauma and heart disease.

    Even in my parents’ “day”, adults were much more likely to be carried off by heart disease and car crashes than by cancer. However, even then there were young adults and children who died of cancer, like a friend of my mother who died at the age of 37 from a breast cancer or the classmate of my father who died from leukemia at the age of 10.

    Who knows how many of the adults “back in the day” who died from heart disease in their 50′s and 60′s (many exacerbated by smoking) would have developed cancer had they been allowed to live that long.

    If you want to look for a cause of the “explosion” of cancer, you need look no further than modern medicine. By reducing the death toll from infectious diseases, childbirth, infection and heart disease, it “paved the way” for the “explosion” of cancer (not to mention Alzheimer’s disease). You could also point a finger at “the government” for mandating seatbelts (and their use) as well as safer cars, safer highways and better pre-hospital medical care

    Yes, they are all co-conspirators in the “explosion” of cancer.

    Sad to say, but each and every human eventually dies of something (even the people who eat only organic free-range vegetables and never ingest “chemicals”). If you reduce the deaths from one group of diseases, the death rate from other diseases must increase to compensate.

    The causes of death are a poor way to look at the health of a community, since – as has been mentioned a number of times – everybody dies from something, eventually. A better gauge of the “health” of the population is to look at the life expectancy, which has been continuously rising even in the US.

    Even though so many of the “alternative” medicine gurus assure us that the US population is the sickest it has ever been, we perversely keep living longer and longer.

    What do we know that they (the “alties”) don’t?

    Prometheus

  31. #31 notmercury
    September 25, 2008

    I really do know the proper homonym — “site”, not “sight”.

    *sigh* More ad homonym.

  32. #32 Marilyn Mann
    October 7, 2008

    This is a little off-topic, although that has never stopped me before. Members of my family have heterozygous familial hypercholesterolemia (heFH), an autosomal dominant genetic disorder that causes very high LDL-cholesterol. If untreated, 60 percent of people with FH die prematurely. Some cardiovascular geneticists in the Netherlands did a study where they traced some FH families back into the 19th century and compared the mortality in those families to the mortality in the general population. They found that in the 19th century mortality in the FH families was not higher than mortality in the general population. They don’t know the reason, but there are a couple of theories. One is that lifestyles in the 19th century were less conducive to the development of heart disease. Another is that high LDL may have some protective effect, making people with FH less likely to die of infectious disease.

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