Important Tips from Cancer Prevention and Control Expert Dr. Elizabeth Platz

Focus on changing your lifestyle behaviors where we have evidence of a strong link. Often these lifestyle changes can also reduce your risk for other major chronic diseases, like heart disease and diabetes. You might as well get the most from your efforts, so choose healthy aging as your goal.

So, what are these lifestyle behaviors?

1. If you smoke, quit.

Did you know that in addition to lung, oral, and esophageal cancers, smoking also causes bladder, kidney, and pancreatic cancers? There are immediate and long-term benefits of quitting smoking. For example, a smoker’s risk of lung and other smoking-associated cancers decreases after quitting. In fact, by 10 years after quitting, the risk of lung cancer is half that of someone who keeps smoking.  Learn how to quit smoking

2. Maintain a healthy weight.

If you are overweight or obese, lose weight. Otherwise, maintain a healthy weight. To reduce your risk of cancer, try to keep your body mass index (BMI) between 18.5 and 25 and your waist circumference below 35 inches (for women) and 40 inches (for men). Calculate your BMI to see if you are within these ranges.

Did you know that excess body fatness causes breast cancer in post-menopausal women, endometrial cancer, colorectal, pancreatic, kidney, and esophageal cancers?

3. Increase your physical activity and reduce your sedentary time.

Adults should participate in at least 2.5 hours per week of moderate-intensity activity; that’s about 30 minutes each day, five days of the week. Plus don’t forget to do muscle-strengthening exercise too. Learn how to increase your physical activity.

Did you know that more physical activity is associated with a LOWER risk of colon cancer, breast cancer in post-menopausal women, and endometrial cancer?

Did you know that a fifth of Americans still smoke, that two-thirds of American adults are overweight or obese, and a fourth of American adults did not participate in any physical activities in the past month?

We know how hard it is to quit smoking, to lose weight, and to increase your physical activity. So think about engaging your family members and friends in your efforts to reduce cancer risk and to promote healthy aging. Everyone wins!

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***The following post was written by Dr. John Fetting at the Johns Hopkins Kimmel Cancer Center.

John Fetting

John Fetting, M.D.

After 30 years as a breast cancer medical oncologist, I have come to believe that we are too focused on trying to cure breast cancer and not focused enough on preventing it.  Until recently, treating breast cancer after it was diagnosed, and may have already spread, has been the best we could do. Despite substantial progress, cure is still uncertain and the road hard.  Along the way there is too much unnecessary trauma for too many.  Now that we have learned so much about the changes in breast cells which lead to cancer, we can prevent the trauma of breast cancer and its treatment.     

Consider how we try to cure breast cancer. We screen for breast cancer with mammography. We hope to diagnose breast cancer when it is non-invasive or, if it is invasive, when it is small so there has been little chance of spread. We remove the cancer surgically and treat the breast with radiation to eradicate the cancer in the breast. Then, if the cancer is invasive, we usually administer drug therapy, i.e. adjuvant therapy, in an attempt to kill any cancer cells which have left the breast.  Adjuvant therapy includes easy-to-take oral agents like tamoxifen, more toxic chemotherapy, and often both. There then follows what we hope will be a life without recurrence.  Have we made progress with this approach? Yes, we have.  Breast cancer mortality is coming down. Can we improve this treatment approach? We can and we will.  But we treat more patients with adjuvant therapy than need it and this treatment approach produces too much collateral damage for too many patients and their families.

How is this? The goal of breast cancer treatment is to prevent the establishment of cancer in other parts of the body, i.e. metastases. It is metastases which cause death. Metastases typically develop some years after the diagnosis and initial treatment of breast cancer. It is very unusual to find overt metastases at the time of initial diagnosis. But in some patients at the time of diagnosis there has been spread of small numbers of cancer cells to other body parts. These cells, called micrometastases, divide again and again over time and give rise to overt metastases in the years after diagnosis. The goal of adjuvant therapy is to kill these cells.  

A severe limitation of our current treatment approach is that we are not able to detect these micrometastases. We do not know which patients have cells elsewhere in their body and which do not. The best we can do is estimate the probability of metastases in the future based on features of the cancer, e.g. lymph node involvement, tumor size, then assume that this same fraction of patients harbor cells. For example, patients who do not have cancer in their underarm, i.e. axillary, lymph nodes have a 20- 30% risk of metastases over 10 years without any adjuvant therapy. This suggests that the same 20-30% of patients have cancer cells in other body parts at the time of diagnosis. It also means that 70-80% of patients with negative nodes will not develop metastases and do not have cells elsewhere at diagnosis. But which patients have cells and which do not? We are not able to distinguish. What do we do? Since a 20-30% risk of metastases is a serious threat, we treat the whole group. We treat the 20-30% who harbor cancer cells and the 70-80% who don’t. And treatment works. Treatment lowers the risk of metastasis in node-negative patients from 20-30% to 10-15% or lower. The problem with this approach is that 70-80% of patients are receiving treatment they don’t need. If treatment had no side effects, this overtreatment would not be so traumatic. But treatment has side effects. Most are short-lived but, rarely, side effects result in long term disability and death. What is most troubling about this approach is that survivors live with uncertainty about whether they will develop metastases. There is a shadow over their lives.

How can we improve?  The best way to prevent the trauma is to detect breast cancer before it can spread…..or before it is even breast cancer. A second way is to sharpen our ability to distinguish cancers which have given rise to micrometstases from those which have not.   At least then we will know who needs treatment and, very importantly, who does not.  We can reassure the many patients who do not have micrometastases, spare them treatment and its side effects, and give them back a future free of threat from breast cancer.    

The path forward is found in our ever-improving understanding of the genetic changes which cause breast cancer and enable it to spread. We are on the cusp of identifying genetic signatures of cells which are on the way to cancer. Once we know these signatures we can intervene with women who are at truly high risk. In much the same way we are poised to identify the genetic signature of cancer cells which have developed the ability to spread. We will be able to distinguish patients whose cancers have this micrometastatic signature from those which do not. We will then be able to focus our adjuvant treatments on those who truly need and spare those who do not.   

DNA is a double-stranded molecule built from just four nucleic acid building blocks:  guanine, cytosine, adenine, and thymine.  We each have an enormous amount of DNA which is packaged into our chromosomes. We have 46 chromosomes and inherit 23 from each of our parents. Our DNA is organized into segments called genes which drive all the important processes in our cells. Mutations in genes are changes in the nucleotides which can change the way our cells work. In some cases mutations can lead to cancer and to cancer which can spread.  Mutations in the nucleotides are not the only way a normal cell can become an invasive cancer. Another way of changing gene function is by chemically modifying the nucleotides so that the gene is no longer able to express itself. These chemical modifications are called epigenetic changes.            

For the 5-10% of breast cancers which are inherited, one mutation in an important gene, e.g. BRCA 1 or 2, is so deleterious that it is capable of producing breast cancer. But most breast cancers do not result from a single mutation inherited at birth.  Most breast cancers develop over a lifetime and result from mutations and epigenetic changes accumulated in many genes over many years.  Here is where things get difficult. Breast cancer cells develop many mutations and epigenetic changes. Some of these mutations and epigenetic changes are necessary for the development of the cancer. Others equip the cell to spread. Many others, however, are random and have nothing to do with cancer. Our task is to identify the changes which result in cancer and cancer which can spread. 

How do we do this?  One of the most important ways is to recruit large numbers of women whom we will follow over long periods of time. These groups are called cohorts and the studies are called cohort studies. For our efforts to distinguish cancers which have spread microscopically from those which have not, we will need large numbers of cancer patients who have been or will be followed for long periods of time. During that time some will have developed metastases; many will have not. We must then try to discover the genetic signature in their breast cancer tissue which identifies those who developed metastases. Once we have defined the genetic signature for metastasis we can focus adjuvant therapy on those with this signature and reassure those patients who do not.

In a very similar way we can identify the genetic signature which predicts the development of breast cancer in the first place. We will need to follow large numbers of women who do not have breast cancer   for long periods of time. Some women in the cohort will develop breast cancer; many will not. We need to sample the breast tissue of all these women periodically during follow-up and profile the genetic and epigenetic changes in the breast tissue. In this way we can identify the changes which precede and are necessary for the development of breast cancer.  Once we have identified these causative genetic and epigenetic changes, we can search for them in the breast tissue of other women in order to identify women at risk. Instead of women having screening mammograms to detect a suspicious mass or telltale calcifications, we may be able to sample breast tissue to identify women who have a high risk profile.

This effort to prevent the threat and trauma produced by breast cancer will require every bit as much of a commitment as the commitment to cure breast cancer.  We will need teams of researchers, an army of women participants, breast and breast cancer tissue, and financial support for the work.  We are ready now as never before to make real strides in preventing this life threatening disease and the trauma associated with our current unfocused efforts to cure it.

John Fetting, M.D.
Associate Director for Clinical Practice
Associate Professor
Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

Read a previous post by Dr. Fetting on Preventing Breast Cancer.

***Note: The John Fetting Award in Breast Cancer Prevention has been established to fund the most promising research in breast cancer prevention. Applications will be granted to the most promising work for a two-year period.  The John Fetting Award is led by breast cancer survivor and advocate Leslie Ries.  Her video documentary, Letters to My Daughters, chronicles her inspiring story and mission to help prevent breast cancer.

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Elissa Bantug

Elissa Bantug

Just as most patients have concerns and worries when treatment ends, many children also experience uncertainty and fear when a parent finishes treatment for breast cancer.  Children may be apprehensive and worry about mom’s long-term health.  They may also be sad or resentful at all of the changes at home.  It is very common for everyone in the household to want and expect their lives to return to a sense of normalcy as soon as possible following a family member’s treatment for cancer. 

Francis Lewis RN, MN, PhD, a behavioral scientist from the University of Washington, Seattle, warns that many parents devote too much time trying to teach children about cancer and not enough time listening to their thoughts and feelings: “Don’t be a biology teacher”, she urges gently   It’s important that children are given the opportunity to speak openly about how they are coping with all of the changes since cancer entered the family.  Schedules turned topsy-turvy, mom feeling terrible, others coming to the household to help with the caregiving can all be upsetting and disturb the normal routine. 

As a parent of young children and a cancer survivor, I recommend approaching communication with your children about your disease and recovery with honesty but care: they do not necessarily need to know all the details about your condition or prognosis.  At the same time, you do want to create space for them to ask scary or embarrassing questions, express their own concerns, and try to reduce any anxiety, confusion, anger, or fear they might be feeling.

Below are six tips to help the entire family through this transitional period:

  1. Healing takes time. It’s important to remember that when treatment ends, returning back to routines may take some time.  Recovery does not have a term limit, and the challenges that each patient faces to reacquire their own sense of normalcy (physically and emotionally) are different.  Specifically, this may mean that extra help is still needed with tasks such as childcare, cleaning, and meals in the weeks and months following treatment.
  2. Set clear expectations. Even the most intuitive and well-adjusted kids experience lots of emotions after a family member is treated for cancer.  Parents should talk openly about what can be expected directly following cancer treatment, and allow themselves time to recover.
  3. Find positive (and fun) fill-ins. When mom and dad are forced to miss routine family activities that children have grown accustomed to, this can be frustrating for everyone.  Whenever possible, try to make accommodations for children that they can look forward to--such as time with a visiting relative or a sleepover at a friend’s house. 
  4. Protect family time. Create a “new normal” that incorporates the patient’s energy level at that particular moment.  Fatigue is a very common side-effect after treatment and can vary from day to day.  This may mean that families find new ways to spend time with each other such as “movie night” at home, snuggle time with a book, or board games, instead of going out and doing more strenuous activities.
  5. Include everyone. It’s also important for children of cancer patients to feel included in the care plan.  Find age-appropriate ways for children to help out without over burdening them.  Endowing kids with responsibility not only helps them feel that they are helping mom heal; it also may help distract them from feelings of anger or resentment from disruption of important routines.  For example, families can have “backwards night” where the child reads the bedtime story instead of the parent. 
  6. Speak to a professional. Some children find it helpful to speak to a social worker or psychologist who is familiar with how cancer impacts children.  There are also many age-specific support groups, online websites, books, and camps for children who has a parent diagnosed with cancer.  Ask your cancer center for suggestions.

The good news is there are lots of research studies showing that children are resilient and do very well if they understand what is going on and what they can expect.  Finding age-appropriate explanations as well as ample time to listen may help children adjust to cancer and how it is affecting the entire family. Most importantly, talking openly in an age-appropriate manner and offering kids lots of reassurance is critical for helping the family move beyond cancer.

Cancer Survivorship Resources

Breast Cancer Survivorship Resources

 

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This is the final blog in a three-part series about Genome Sequencing and Predicting Cancer.

Valerie Mehl

Valerie Mehl

Just as every person is genetically unique, so is every cancer. While cancer is not usually written in the DNA we are born with, the story of each individual cancer is contained within the unique and different DNA of the cancer cell—the cancer genome. It reveals the genetic alterations specific to each person’s cancer, and these alterations can be targeted to detect cancers, monitor them, and treat them.

Within a few years, we anticipate that all cancer patients at the Kimmel Cancer Center will have their tumors sequenced to reveal their cancer genomes. It will not only help cancer experts determine which treatments may work for a particular patient, but just as importantly, which ones may not.  This is the focus of personalized cancer medicine, and we have just begun to realize its potential.

A Universal Test

As tumor cells divide, they develop their own blood supply to get the nutrients they need to nourish and grow, and as a result, pieces of the cancer’s DNA get carried into the bloodstream leaving telltale evidence of its existence.  Dr. Bert Vogelstein and team have developed a simple blood test that can detect DNA from cancer cells.  These tests have the potential to detect cancers very early, long before they can be seen on X-rays, CT scans, or through other types of diagnostic methods and long before they cause symptoms. Universal, precise, and specific, this test can pluck one cancer cell from a sea of a half million normal cells.  It can also help doctors determine if a cancer therapy is working by measuring the amount of cancer DNA in the blood.  If a treatment is working, the amount of DNA should decline.  If it goes up, it’s a sign that the treatment may not be killing the cancer.   Rising levels of cancer DNA could also alert doctors that a cancer has come back.

Dr. Vogelstein says such a test, used together with the prevention strategies we already referenced, could eventually make 75 percent of cancers curable. That is huge!

More about cancer genome sequencing and personalized cancer medicine.

Part One of Sequencing Our Genes: Is Cancer Written in our DNA?
Part Two of Sequencing Our Genes: What is Does and Doesn't Do

 

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Evan Lipson

Evan Lipson, M.D.

Leroy Sievers was a journalist who traveled the world covering wars, invasions and other conflicts. In 2005, he began a battle of his own against colon cancer. A producer for ABC’s Nightline, Leroy was a gifted communicator. During his illness he appeared in a Discovery Channel documentary with Ted Koppel and wrote a blog for National Public Radio called “My Cancer” - a project Leroy called the most meaningful of his career.

Laurie Singer, Leroy’s wife and caretaker, saw first hand how much the blog empowered Leroy and how intimately it connected him to the worldwide cancer community.

Click below to hear more.

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This is the second blog in a three-part series.

Valerie Mehl

Valerie Mehl

As technology that makes it possible to quickly sequence an individual’s whole genome becomes increasingly more available and affordable, people have begun to wonder about its ability to predict diseases a person is likely to develop.  If I had my whole genome sequenced, could it reveal whether or not I will develop cancer in the future?   This is among the questions leading cancer genetics expert Dr. Bert Vogelstein and colleagues set out to answer.

For their experiment, they turned to a database of 53,666 identical twins.  Why twins? Twins are natural clones, and as such, they share the same genome.  Generally speaking, if one follows one twin over a period of time to catalog all of the diseases he or she develops and then compares it to the other twin, measuring how often he or she developed the same diseases, one can calculate inherited genetic risk for these diseases.

What many overlook in whole genome sequencing, particularly as it relates to cancer, is not about what it reveals, but rather what it does not. 

Ovarian cancer is a perfect example.  Their study predicted that about two percent of women who would undergo whole genome sequencing would get a positive result and alert them to an inherited genetic risk for ovarian cancer.  On the other hand, 98 percent of women would get a negative test result. That doesn’t mean these women won’t get cancer—based on ovarian cancer incidence rates, we know that many of them will.  It just means that we cannot predict which ones will develop the cancer and which ones will not. 

We can look at this in another way.  There are 156 million women in the United States today.  Based on current ovarian cancer rates, we can estimate that about 2.2 million of them will develop ovarian cancer sometime in their lives.  Vogelstein and group say that whole genome sequencing could with much further research, in theory, identify about 500,000 of them.  Most of them—1.7 million of them—would have no sign of their impending cancers.

Where does that leave us then?

Our experts have said it many times, but it bears repeating.   The best way to manage cancer risk is through prevention and early detection.  It bears repeating yet again.  THE BEST WAY TO MANAGE CANCER RISK IS THROUGH PREVENTION AND EARLY DETECTION. 

So, let’s review.  Remember, people are rarely born with a cancer-causing genetic alteration.  Cancer is usually the result of accumulating edits made to the DNA of certain cells.  It would be a good idea, then, to eliminate from our lives, as much as possible, those things we know make these cancer-starting edits to cell DNA:

  • Quit smoking (better yet, don’t start).
  • Maintain a healthy weight and diet.
  • Limit alcohol consumption.
  • Exercise regularly.
  • Protect skin from the sun.
  • Reduce, if possible, medical exposures to radiation (X-rays, etc.).
  • Know your family history, and if you have an inherited cancer-related mutation or syndrome, talk to your doctor about preventive strategies.
  • Prevent on the job exposures to carcinogens such as asbestos.
  • Women, talk to your doctors about avoiding hormone replacement therapy at menopause as it increases breast cancer risk.
  • Get vaccinated against known cancer-causing viruses.  (The hepatitis B vaccine can prevent certain types of liver cancer.  The Gardasil vaccine prevents HPV (human papillomavirus) infection, a common sexually transmitted virus that causes the majority of cervical cancers and more than half of oral cancers.)

If we do just these things—applying the science we understand today to strengthen cancer prevention—we could reduce cancer incidence by a remarkable 54 percent, according to a recent study published in the March 2012, issue of Science Translational Medicine.

Part One of Sequencing Our Genes: Is Cancer Written in our DNA? 

Stay tuned for Part Three in Sequencing Our Genes, which will discuss the promise of sequencing tumor genomes.

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This is the first blog in a three-part series about Genome Sequencing and Predicting Cancer.

Valerie Mehl

Valerie Mehl

Technology called next generation sequencing can be used to reveal an individual’s complete and entire DNA (whole genome).  Right now, it costs about $5,000 to sequence an individual’s whole genome, but the price tag is decreasing rapidly. With its increasing affordability, many have suggested that it could be used to identify individuals who were likely to develop cancer in the future as well as those who would be safe from the disease.  But, will it?

Our whole genome is the DNA we’re born with. For some of us, that DNA contains the code for cancers that occur in our families.  These cancers are directly attributable to inherited genetic alterations. In this scenario, whole genome sequencing can be extremely beneficial in identifying the specific gene and mutation that is causing these familial cancers and potentially in determining how best to treat them.

However, most cancer is not related to an inherited genetic mutation. Most cancers develop in people with no hereditary predisposition. For the majority of the population, who were not born with a cancer-promoting alteration in their DNA, whole genome sequencing won’t predict whether they will get cancer. The reason is that our inherited DNA is not the final manuscript of our life and all of the health events we will face. Each of us plays an important part in editing and interpreting the script with the foods we eat, the air we breathe, and the habits we acquire. Other things, like random mistakes cells make as they divide, also play a role but are out of our control.

In fact, Kimmel Cancer Center cancer prevention and control expert Dr. Elizabeth Platz says that heredity accounts for only about one percent of cancers.  For most people, lifestyle behaviors are far more damaging.  While we can’t change heredity, fortunately,  we can change our behaviors. You may be surprised to learn that we already know how to prevent the majority of cancers. Diet, obesity, and lack of exercise, she says, contribute to 35 percent of cancers, and smoking is a factor in 30 percent of cancers.

Stay tuned to Part 2 of Sequencing Our Genes, which will cover what gene sequencing does and doesn't do.

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Michelle Potter

Michelle Potter

Right about now, parents are scrambling to enroll their kids in various area summer camps. The choices abound, and for many kids, it’s the highlight of their summer.

Last year, I had the opportunity to visit our own Camp Sunrise, a week-long summer camp, hosted by Johns Hopkins, for children and young adults with cancer.  It’s a special camp that serves as a get-a-way for kids with cancer and lets them push aside their illnesses for a week.  Many of our patients have told me how much they love and look forward to camp; it’s the highlight of their year.  It was the highlight of my summer too.

At a typical day  in Camp Sunrise, there are cabins for the campers, a swimming pool, pavilions, camp fire pits, and of course, the dining hall. Campers swim, sing, dance and play basketball.  Each child can participate, regardless of limitations from their illnesses. Watching these campers swim, dance and sing, you soon forget they battled or are battling cancer. This is exactly the point.

For parents, the camp is a safe retreat for their children, staffed with doctors and nurses from Johns Hopkins.  Camp staff take personal vacation time, leaving work and attending camp. What’s even better for parents is that Camp Sunrise is funded by donors, which makes camp free of charge to families.

Dedicated volunteers will hold the first Camp Sunrise Gala on May 12 at The Grand Lodge in Hunt Valley, MD, to continue raising funds for Camp Sunrise.  Camp Sunrise is a reminder of the importance in continuing our fight to find cures for childhood cancers.  I am hopeful that in the future, as great and fun as it is, we will no longer have a need for Camp Sunrise.

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Evan Lipson

Evan Lipson, M.D.

In 2009, while studying at Johns Hopkins University, Tao Wang, now age 40, was diagnosed with stage one breast cancer. After diagnosis, she began to focus on helping other patients with some of the questions she, herself, faced during treatment. ”Somehow, I want to make a difference in my life,” she says. Now Wang volunteers in the “Survivors Helping Survivors” program at Hopkins. She especially likes discussing treatment options with newly diagnosed cancer patients. ”Life is deeper now anyway,” she says. ”I now will do work in a different way.”

Click below to hear her story.

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Cancer headlines this past month included two studies on colonoscopy, a screening tool for colon cancer.  The first study looks at the long-term benefits of colonoscopy and found that 50 percent of colon cancer cases were avoided by a single colonscopy.  In the Cancer News Review podcast, William Nelson, M.D., Ph.D., director of the Johns Hopkins Kimmel Cancer Center reminds us that colonoscopy is used for both screening and treatment, when precursor cancer lesions called polyps are snipped off during the procedure.  The second study compared fecal occult blood tests with colonoscopy.  Researchers found that one-third of people prescribed fecal occult tests are compliant in taking the test as compared with one-quarter of people scheduled for colonoscopies.  Nelson says people may be more likely to engage in a program that invovles stool testing rather than colonoscopy.  Both of the tests detected equal cases of colon cancers, but colonoscopy found twice the number of adenomas (polyps that can later become cancer).  Nelson says that new technologies are needed to improve on these tests.

Nelson also reviews a study of a drug called venurafenib, which "stops the 'go' switch that drives melanoma cells to divide, accumulate in large numbers and spread throughout the body."  Half of melanoma patients have this "go" switch.  The study shows that melanoma cells become resistant to the drug within an average of six to seven months, and new additive treatments are needed to improve survival.

Finally, Nelson notes a new study from Johns Hopkins scientists that adds to the rapidly changing environment of cancer genome sequencing.  The study introduces a tool called pyromaker that helps make sense of certain sequencing results.

Program notes:

0:20  Colonoscopy reduces colon cancer death
1:20  At least fifty percent of expected deaths avoided
2:22  In cancer world how can we say disease is eradicated
3:20  Fecal occult blood versus colonoscopy
4:23  Colonoscopy found about twice as many polyps
5:14  Melanoma and venurafenib
6:14  How long to become resistant?
7:04  Enables gene sequencing on the go
8:03  Can make sense of the 3 billion pieces of information
9:43  End

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