August 2001: No Hair, New Hair, Skin Care

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Ask-the-Expert Online Conference

On Wednesday, August 15, 2001, our Ask-the-Expert Online Conference was called No Hair, New Hair, Skin Care. Mary Gail Mercurio, M.D., Ronda Gates, M.S., R.Ph., and Marisa Weiss, M.D. answered your questions on the physical side effects of breast cancer treatment, and what you can do about them.

When does hair loss happen?

Question from Joann: Hi, I received my first treatment of AC on August first. I have very thick, wavy hair. Until yesterday, I was hopeful that I would be an exception to the rule, but today I started to lose about 10 strands of hair at a time. My question is, does the hair loss only occur when your blood cells are being destroyed by the AC? If I am out of my nadir period will my hair loss stop until the next nadir period?
Answers - Mary Gail Mercurio Hair loss occurs because the chemotherapy targets rapidly dividing cells and the hair follicles are innocent bystanders.
Marisa Weiss, M.D. The rate of hair loss is independent of your blood count.
Mary Gail Mercurio It is dependent on the amount of chemotherapy.
Marisa Weiss, M.D. Hair loss is so devastating when you start to lose it in clumps, it is really so tough, and every woman hopes that she is going to be THE ONE that will escape this side effect.
Mary Gail Mercurio But on a very positive note, this process is completely reversible, so it's a matter of getting through that period of chemotherapy and the associated hair loss and to make that a more bearable time it's helpful to plan ahead—to be aware of this likely occurrence. That can be accomplished by thinking about wigs in advance, or other camouflaging techniques such as scarves.
Ronda Gates, M.S., R.Ph. One of the things that you can do as you start to see hair loss is to have an active plan rather than letting the disease rule how you manage your hair care. Then if you need it, you have a plan in place so that you are proactive rather than reactive.

How to speed up hair growth?

Question from Gizzy: Is there anything I can do to help speed up the hair growth, so eyebrows will fill in and hair will be thicker?
Answers - Mary Gail Mercurio Although the hair that is lost on the scalp is most apparent, this affects any hair on the body. As far as making the hair come in quicker, there are no substances that have been approved or clearly demonstrated to increase the hair growth rate. However, if we think about how minoxodil (Rogaine) works, there is some evidence that it may make the hair grow a little bit faster because it increases the rate of cell division in the follicles.
Marisa Weiss, M.D. As Dr. Mercurio said, the hair that is most likely to fall out is the hair that tends to grow the fastest. The hair on top of your head grows faster than your eyebrows or your eyelashes. This means that some of the mild chemotherapies that produce mild hair loss tend to affect the hair on top of your head and may end up sparing your eyebrows or your eyelashes. Also, when some chemotherapy is given weekly, on a weekly basis, in small doses, rather than every 3 to 4 weeks in higher doses, some hair loss can be minimized. That is to say, the lower doses given more often tend to produce less hair loss. But once hair is lost, the time it takes for it to grow back in depends on how fast your body grows its hair.
Mary Gail Mercurio The rate of hair growth is approximately 1/2 inch per month, so with that number in mind you can extrapolate to how long you will have the head of hair that you are hoping for.
Ronda Gates, M.S., R.Ph. Beforehand, one of the things you can do is to try a new haircut that is shorter, one that essentially is a transition if you do lose all of your hair. It's a transition to the use of scarves and hats. It is a process of again being active in your own change.
Mary Gail Mercurio Along those same lines, it tends to be less traumatic as the hair falls out and you find it on your pillow and combs if it is a shorter hair. So that's another reason that if you start with a shorter hair cut, you will have less fall out.
Ronda Gates, M.S., R.Ph. The other thing that I've experienced is that some women have had the process of having their head sheared or shaved as a celebration of sorts as the process of their treatment instead of a negative statement. This is part of a treatment process, and is also done in groups with friends who share the hair shaving experience and the camaraderie of sisterhood, which is so important to the healing process.
Mary Gail Mercurio Having the head shaved, it will be minimally apparent that this process is even taking place.
Marisa Weiss, M.D. There have been studies that have shown that losing your hair for many women is worse than losing a breast. This is because you can conceal the loss of a breast but hair loss is so obvious and apparent to people you care about and people you'd rather not fuss with, and who you'd rather not share your business with. One thing that helps, as our other guests have suggested, is to think of hair loss as a necessary transformation from where you are now: a person with a problem that you want to get rid of, to where you want to be, the same person, who is clear of this problem, and as healthy as possible. Many women feel uncomfortable going around bald. There are many solutions we will address tonight for how to deal with this.

When will regular hair come in?

Question from Debs: I shaved my head, rather than wait for clumps to fall out. Now that I'm done with the chemo, it's starting to grow back. It's very fine ( I call it "mutant hair") and it's not even over the head. The sides are growing but not the top. Is there any way to make it ALL grow? And when will it get regular hair texture?
Answers - Ronda Gates, M.S., R.Ph. My sister just had the same experience where her hair grew in irregularly and I had other friends have their hair grown back in a wavy texture, which is soft and wavy. I call it first hair. Then in about 3 months they tend to get back their hair or what is their "new" hair. The first 3 months it seems to have a different texture than the women have ever experienced before.
Mary Gail Mercurio There is some variability in the hair growth rate over the top of the scalp and this varies from person to person and even on the same person, but eventually all of that hair is going to come back. It may remain of a different texture or slightly different color. This occurs because we believe the chemotherapy causes an alteration of the hair follicle, which is the biologic machinery that makes the hair. But it has not been clearly demonstrated scientifically what the alteration of the follicle is. Logically speaking, we must think that chemotherapy alters that structure creating the hair, but the majority of my patients, even when the hair is slightly different, are pleased because it IS hair and they are going to have a head full of hair, albeit a slightly different color or texture. Along those same lines, this new hair is no more fragile than the old hair. Once it begins to grow, it is a healthy hair and there is nothing wrong with coloring it or perming it or other cosmetic intervention that will benefit self-esteem.

OK to color, perm new hair?

Question from Maryanne: I've always colored my hair. Now that I've finally GOT hair again, is that ok to do? What about a perm?
Answers - Mary Gail Mercurio Once the new hair is coming in, there is no structural abnormality so there is no problem with cosmetic intervention, such as dying and perming. The hair is only weak at the time of the chemotherapy because of the effect on the hair shaft, because the hair shaft becomes weakened during its creation and it breaks off at the scalp but once the chemotherapy stops, there is a healthy hair shaft.
Marisa Weiss, M.D. Many of my patients dyed their hair for years and forgot what their natural color was. When their new hair grows back in gray or "mousy brown," it seems like a whole new color, when in fact, it could have been their natural hair color that they were dying for all of those years. I suggest to my patients to have a little bit of fun and try some "temporary dyes" first. These dyes are also called "semi-permanent." They wash out after multiple shampoos. You can try various colors to see if you want to go for a whole new look.

Advice for dealing with hair loss?

Question from Phantom: I knew to expect hair loss, but I really wasn't prepared for how I'd feel about it - it's so obvious, and it's scaring my kids. Any advice for me, and other women who have to go through this?
Answers - Marisa Weiss, M.D. When it comes to the people in your life, including the children in your life, realize that hair loss can also be traumatic for them. I had a patient recently whose children and whose children's friends thought that my patient had a "hair disease." They didn't see or understand the whole breast cancer problem—all they could see was that she had lost her hair—so she overhead them talking about her having a disease of her hair. This was very interesting to me because sometimes the obvious things take on more significance than the things that are concealed.
Mary Gail Mercurio This goes back to a point we made earlier about how the hair loss often heralds to everyone around the patient that there is some problem whereas no one knew about the breast biopsy or the loss of the breast. This takes me back to Ronda's comments about being proactive. There are wonderful wigs out there now and they are incredibly naturally appearing. Many of my patients, even when their hair grows back, don't want to give up that wig because it makes their life so simple. They appreciate how natural it looks and they don't have to be concerned about their hair and can focus on other aspects of their life.
Ronda Gates, M.S., R.Ph. It is easy to put on a wig and go. Amazing how my friends have learned to simplify their lives. Another interesting point is that for the process of chemotherapy where hair loss is for a short period of time, there is not a need, in my opinion, of getting natural hair. Synthetic hair will work well for a short period of time. It is less expensive and can be styled any way you like, whether you mimic your natural hair or a new spectacular you.
Marisa Weiss, M.D. I agree that synthetic hair is a much better buy. It is very cheap. You can get a very good wig from Paula's Wigs for $50 that holds up throughout the 6-month period of time that you are without a good head of your hair. The human hair wigs, as Ronda said, are very expensive; they have price tags between $900 and $3,000. They look great in the beginning but they can look very shabby and lifeless after only a few months. Human hair needs natural oils to maintain its luster—when it is in a wig, it doesn't get those natural oils. I also recommend my patients choose a slightly lighter color than their own natural color. This is because the contrast is less harsh against your skin when you are going through chemotherapy and your complexion may be pale. At that time, a dark wig color can accentuate that contrast.
Mary Gail Mercurio Which is a nice way to lead into thinking about your complexion, because it does indeed lose some of its luster.
Ronda Gates, M.S., R.Ph. Consider again having a party of friends at a wig store, where all of you can try on a variety of wigs and again share an experience with your sisters.

What to do for a dry face?

Question from Fawn: Is there anything I can do for my dry face?
Answers - Mary Gail Mercurio The chemotherapy can also affect your skin's natural moisture because your oil glands don't secrete as much oil, so you need to be prepared for using moisturizers more frequently. It is important during the day to use a product that will also provide protection from the sun. The product must block the sun's UVA and UVB rays, so merely stating an SPF is not sufficient. That only reflects the UVB blocking effect. The product must explicitly state that it also blocks UVA and if you look in your drug store, you will see that most moisturizers now have this claim.
Ronda Gates, M.S., R.Ph. As your skin changes, your cosmetics need to change. The color of your foundation and your highlights because you don't wear cosmetics to be someone else. You wear them to be yourself even as you are now, and if you continue to use the colors that you used before your treatment, you may look artificial. So again, here is an opportunity to go to a store and give yourself the treat of a cosmetic makeover.
Marisa Weiss, M.D. During treatment for breast cancer, you may be more sensitive to the fragrances that are put into cosmetics and skin care products. You might want to use fragrance-free products in order to avoid this.
Ronda Gates, M.S., R.Ph. Consider also that the brand that you have trusted for years may not be the right brand for you to use during this period of time.
Marisa Weiss, M.D. I encourage my patients to use a moisturizing soap like Dove and to avoid stronger soaps like Ivory or Dial or Irish Spring.
Mary Gail Mercurio Because all of the skin is impacted by the decreased moisturization it is important to actively moisturize not just the face. You have to think about the entire body. I agree with the prior recommendations but I would also consider liquid formulations of soap, so you get your cleansing and moisturization in one. There are even some products that contain petrolatum, so you get your moisturization and you seal it in.
Ronda Gates, M.S., R.Ph. Regardless of where you are in your life there are still four steps to healthy skin care. Cleansing, exfoliation, moisturizing and protection (against the sun and the elements.)
Marisa Weiss, M.D. When you are receiving radiation therapy, it is important to take extra precaution to protect the skin from the sun within the radiation treatment field. When you receive breast radiation, for example, the part of your breast near your cleavage may be in the treatment field and also be exposed to the sun when you are wearing a bathing suit or a tank top. I recommend a sun protection factor of at least 30 to protect your skin.
Mary Gail Mercurio Another important point about sun protection is to use common sense about protective clothing. It's not always possible to cover every square inch of your skin with a lotion so I encourage my patients, whether they are receiving chemotherapy or not, to wear wide-brimmed hats and clothes that cover as much of their skin as possible.
Marisa Weiss, M.D. Isn't it true that a hat should have a brim of about five inches in order to give good protection of your face?
Mary Gail Mercurio Absolutely.
Marisa Weiss, M.D. And also that clothing only protects you if it is tightly woven or tightly knit. Loosely woven gauze clothing is not considered protection.
Mary Gail Mercurio One can appreciate how much protection their clothing will afford by holding it up to the light and seeing how much light shines through. Just hold a shirt up and you will see that the light goes through a white shirt. It is the color and the weave. Darker colors seem to not allow as much light to penetrate.
Marisa Weiss, M.D. I have to protect my skin from the sun and I have used Solumbra clothing. It blocks the sun and it is also very cool.
Mary Gail Mercurio They also make clothing for your children. As a dermatologist, I feel obliged to bring up the importance of mentioning protecting children from the sun as well.
Marisa Weiss, M.D. If you are receiving 5FU chemotherapy, you will notice that you tan much more easily in the sun. Make sure you take extra steps to protect yourself from the sun if you are receiving this drug.

Irradiated skin prone to skin cancer?

Question from Kate: Down the road, is the skin that has been radiated more prone to skin cancer?
Answers - Mary Gail Mercurio Yes, skin that receives radiation treatment does have an increased risk of developing skin cancer in the future. However, the type of cancers that would develop from this treatment are of the variety that are easily curable and the beauty of skin cancer is that it is readily apparent so it can be diagnosed and treated in its earliest stages with a 100 percent cure rate in most instances.
Ronda Gates, M.S., R.Ph. Although our conference tonight is focused on breast cancer, don't forget that melanoma can occur on any part of the body, and don't forget to examine your body everywhere. Behind your ears, your head, etc.
Marisa Weiss, M.D. During a course of radiation therapy, ordinary freckles and moles can become much darker within the treatment field. This may scare you. These spots are almost always "benign." They just got darker because of the treatment. After radiation is finished, they usually return to their normal color eventually. Some of these spots may actually come off by the end of treatment.

Premature menopause effect on skin?

Question from Jules: I'm concerned about the effects on the skin of premature menopause. What skin care regimen would you recommend to prevent premature wrinkles and maintain its texture?
Answers - Mary Gail Mercurio First of all, I'd like to make a few comments about the changes that occur in the skin at menopause. Declining estrogen decreases the moisturization of the skin and there seems to be an enhancement in the development of wrinkles. The easiest means of preventing this premature aging is avoiding the sun. The sun plays the largest role in the development of premature aging of the skin.
Marisa Weiss, M.D. One of the only advantages of working all the time is that you have less sun exposure and fewer wrinkles at the end of the day!
Mary Gail Mercurio So don't ruin this by abusing your skin on weekends or holidays. We divide sun exposure into two different categories. Acute bursts of sun exposure, which is when people from a climate that doesn't see a lot of sun travel to the Caribbean on holiday for a week in the winter and get a sunburn. A skin-damaging sunburn. Another form of sun damage is a chronic exposure, such as that seen in an individual who works outdoors, such as farming or working as a lifeguard. There is evidence that these different forms of exposures predispose to different types of skin cancers. The acute bursts of sun appear to be associated with melanoma. In contrast, the chronic sun exposure is associated is basal cell and squamous cell. The bottom line is that any sun exposure is harmful to the skin increasing the risk of skin cancer as well as premature aging. Also, contrary to popular belief and what the industry may like you to think, tanning beds are harmful to the skin. They consist primarily of the UVA wavelength which contributes to both the development of skin cancer and to premature aging.

I tell my patients that the only safe tan is the one that comes from a bottle. And this is indeed safe. The active ingredient is dihycroxyacetone (DHA) This is not the same as the products like tanning enhancer, which may not have this ingredient. We have come a long way from the tanning product that I used as a teenager, which made me look like a carrot. These products are dramatically improved and are extremely natural. Unfortunately there is a need for such a product because we haven't achieved the ability for people to appreciate that not having a tan is attractive. As a dermatologist, this is my goal: for my patients to realize that having porcelain white skin is something to strive for and be proud of.

It is also important to realize that pigmented skin is not immune to the development of skin cancer and that it can also occur in women of color. It is a common misconception that only blue-eyed blondes or redheads are susceptible to skin cancer and need to protect their skin.

Products for breast/underarm area?

Question from Bekka: What products help the breast/underarm area during radiation?
Answers - Marisa Weiss, M.D. Radiation to the breast does cause skin changes. The skin can go from pink to red. Usually the red areas are limited to small patches. There can be some itching, burning, and tenderness of the skin. You may notice peeling, but usually in a dry way like an old sunburn. If you are big breasted, or if your doctor is treating the area after a mastectomy, there is a greater chance for peeling in a wet way like a blister, which is usually limited to specific spots. There are many products that can help ease your way through treatment. These include aloe from the plants (watch out for the prickers!) and aquathor. But usually at some point you need to use some part of steroid cream, a 1% hydrocortisone cream. Some women also can benefit from a prescription-strength steroid cream. The good news is that your skin generally heals quickly and completely. The red reaction resolves the fastest. The tan changes can take a few weeks to go away. In women of color, the darkening of the skin can be more significant and also can take longer to go away. In my experience, it does nearly completely or totally go away over time.

Facial creams with vitamin E?

Question from Trishy: Would it be desirable to use facial creams containing vitamin E?
Answers - Mary Gail Mercurio It's most important to find a cream that you find effective. Vitamin E does afford some moisturization. There are many different options and I think it is most important to effectively moisturize and improve the skin's appearance so a product that also exfoliates or removes the dry skin will have the greatest beauty benefit.
Ronda Gates, M.S., R.Ph. Treat yourself to a visit to your aesthetician.
Marisa Weiss, M.D. If it is winter and you have hot air heat, make sure that you humidify the dry air that comes out of such a heater. It can really cause significant drying of your skin.
Mary Gail Mercurio And this dry skin is not merely a cosmetic issue, but often becomes quite itchy. So it is important to combat it for this reason as well. If a medicated cream is desired or necessary to treat the itch, hydrocortisones are also effective, and one can begin with an over-the-counter strength. You can see your physician for something stronger.
Ronda Gates, M.S., R.Ph. Realize that every person's skin and skin care treatment is different—what works for your friends may or may not work for you.
Marisa Weiss, M.D. One woman asked about antiperspirants. In general, mild antiperspirant use is okay. If you are receiving radiation to the breast and underarm area, it is best to avoid any unnecessary substance on your skin. This includes most antiperspirants. If you do need something for odor, try a cornstarch baby powder that is fragrance free. Dusting the armpit can make you more comfortable and cut down on the friction of your arm moving against the area where you may have had lymph node surgery. Some doctors recommend the prescription antiperspirant called "Dry Sol." This works well for some people, but it doesn't work well for everyone. Try a small amount on a small area of skin first before you start using it over your whole armpit.
Ronda Gates, M.S., R.Ph. If a store will not let you test the product, go to a store that will. Dr. Weiss, this is a time where someone should address that antiperspirants do not cause breast cancer.
Marisa Weiss, M.D. OK. Good point. Many people are concerned that the use of antiperspirants may increase your risk of breast cancer. This is a myth that we at Breastcancer.org have addressed.
Mary Gail Mercurio Back to the issue of dry skin being not only unsightly and with the potential to be itchy, it also is more vulnerable, so it can break more easily, making it susceptible to infection, which is something very important to avoid during chemotherapy treatment. So again, this is another important reason to keep the skin well hydrated because this makes it more resilient as well.
Marisa Weiss, M.D. Dr. Mercurio, you raise a very important point which we need to make about skin care of the arms after under arm lymph node removal. In order to reduce your chance of having a swollen arm, called lymphedema, that can occur because of altered fluid drainage from the arms back to the body you need to protect your arm from insult and trauma. Your skin is a very important protector of your arm. Avoid aggressive manicures, wear bug spray when you go out into the woods to avoid bug bites, wear long oven mitts when you are taking a pot out of the oven, wear long thick gloves out in the garden to avoid cuts. Do not wear heavy things on your skin, or on your shoulder or arms that may block fluid drainage. And if you notice any area of the skin of your arms to be swollen, red, warm, and tender, bring it to the attention of your doctor immediately.

Can sun exposure cause breast cancer?

Question from Borewyler: I used to tan all the time. Five years ago, I stopped. Could the excess of sun exposure that I had cause my breast cancer at such a young age?
Answers - Mary Gail Mercurio There is no evidence linking sun exposure to the development of breast cancer. Unfortunately, the tanning that we all did in the past is cumulative and our skin remembers, even if we have now come to our senses. So it is important to watch for the development of skin cancer, but this would be unrelated to the development of breast cancer.
Marisa Weiss, M.D. Whenever you get breast cancer, but particularly when it happens at a young age, it seems so unfair and unexplainable. Why does such a mean disease affect anyone? To read more about risk factors for breast cancer, including special risk factors in younger women, such as the breast cancer gene abnormalities, see our section on breast cancer Risk.
Ronda Gates, M.S., R.Ph. This is a great opportunity for all of us to remind ourselves to watch our children in the sun.

Repair skin damage from smoking?

Question from Betty: Is there any way to repair the damage smoking has done to my skin now that I have quit?
Answers - Mary Gail Mercurio Smoking is yet another external and easily preventable and easily controllable factor that enhances premature aging.
Ronda Gates, M.S., R.Ph. If you smoke, do everything you can to stop. Whether it's a self-induced program or a group program that offers you long-term support.
Mary Gail Mercurio Much to my dismay, many of my young women patients who smoke are more impressed with the fact that the smoking can cause their skin to age prematurely than with the fact that it can cause lung cancer. Whatever it takes to convince these women is the main goal.
Ronda Gates, M.S., R.Ph. Again, this is the breast cancer environment but lung cancer in women is rapidly increasing in the United States and is mostly preventable.

Nail changes during chemo?

Question from Susan: What about toenail and fingernail changes during chemo?
Answers - Mary Gail Mercurio Just as the chemotherapy affects the hair because it contains rapidly dividing cells, it also affects the nails. I see a variety of nail changes in patients during chemotherapy. These include the development of a line in the nail that actually reflects the timing of the chemotherapy. It is not a permanent process and it will grow out with the nail. Often there will be multiple lines and indentations reflecting the different cycles of chemotherapy. Sometimes, the drugs cause nail pigmentation or discoloration. Another change we see is increased brittleness of the nails so that they will not grow as long as they used to, and tend to break more easily. One other change I will mention is the nail actually lifting off of the nail bed. While this, too, is reversible, the patient needs to be careful for two reasons: number one, the nail is more vulnerable and may fall off, and because the nail is not tightly bound to the nail bed, it can be a site for bacteria to enter. So be careful to practice excellent hygiene to avoid infection.
Marisa Weiss, M.D. Many women experience dryness around the nail bed as well as frayed cuticles. Do not rip off the loose cuticle. Cut it with a clean pair of scissors. Don't peel it off. Cut it carefully with a CLEAN instrument. Some women have the habit of biting their fingernails or tearing their fingernails as a nervous habit. This has got to stop, particularly on the hand of the arm that is on the same side as the lymph node dissection. Remember, your skin and your fingernails protect your hand and arm from infection. If it is very hard to stop this habit, consider buying thin, white cotton gloves that you can wear around the house to help you break this tendency.
Ronda Gates, M.S., R.Ph. Again, a lot of women find hand and nail massage to be self-nurturing. But not manicures.

Avoid nail polish during treatment?

Question from Terri: Should I avoid nail polishes during this time?
Answers - Mary Gail Mercurio It is okay to polish the nail, but do not use artificial nails. Select a nail polish that you have used in the past that you know you are not sensitive to. To adhere the artificial nails, very potent adhesives are necessary that have chemicals that women have allergic reactions to. I have seen many severe reactions where swelling and significant inflammation occurs and we would want to avoid this type of trauma.
Marisa Weiss, M.D. What if you used artificial nails in the past without any problems? When you are going through treatment are you more likely to have a reaction during the treatment?
Mary Gail Mercurio If there has not been a problem in the past, it is less likely that an allergic reaction would occur but certainly not impossible. Formulas often change often unbeknownst to the consumer. During chemotherapy is not the time to find out if you are sensitive to a product for the first time.
Marisa Weiss, M.D. Mary Gail, some women look for "natural products" believing that they will be more gentle on the skin. Is this true?
Mary Gail Mercurio No, unfortunately, natural does not always mean safe. Perhaps the best example is poison ivy, which is very natural but it's the last thing we would want to smear all over our skin. So you need to use good judgment. I recommend sticking with well-known brands that have long track records of safety and adherence to ethics.
Ronda Gates, M.S., R.Ph. This is also not the time to experiment with a product that just appeared on the Internet. "Natural" is a very overused marketing term. Professional marketing firms know that Americans trust the word "natural" and will pay up to one-third more and try it over a well-known brand. Don't be misguided.
Mary Gail Mercurio If you are unsure of the appropriateness of a product you would like to use, consult your physician, who is probably familiar with what is best. Keep in mind that your skin and nails are an important protective barrier against insult and you should do all that you can to maintain this important function.
Ronda Gates, M.S., R.Ph. The resiliency of skin, hair, nails is one of the beauties of human life. Although traumatic, the changes that occur with the treatment of breast cancer do not last a lifetime. Do what you can to look good. When you look good, you feel good about yourself.
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