Iciety Fdr Control Of Cancer

Delay reduces the chance for recovery. Library of Congress, Prints and Photographs Division, WPA Poster Collection, reproduction number LC-USZC2-1120.

and bladder. Breast cancer treated early, according to this poster, led to a 70 percent cure rate, whereas breast cancer treated late resulted in a cure rate of only 10 percent. Other posters proclaimed "don't fear cancer—fight it!" and "Don't Fight Cancer Alone." Another series of posters promoted "surgery, radium, and x-rays" as the treatments offered "by reputable physicians" and cautioned that "other methods of treatment are experimental or quackery."

In the early 1930s the ASCC expanded its campaign of public and professional outreach and education. Clarence Cook Little, the new managing director of the ASCC (appointed by the board of directors) divided the United States into four regions and hired one physician to communicate the ASCC's cancer control message to physicians in each region. These ASCC-affiliated physicians organized exhibits, spoke at medical meetings, distributed literature written by the ASCC for physicians, and gave lectures at medical schools.74

Little also approached the General Federation ofWomen's Clubs to "enlist their members in a public-education campaign."75 In his earlier travels to Europe, Little had come away with the impression that European physicians were strongly opposed to cancer-education campaigns directed at the lay public. They, and subsequently Little and the ASCC, were concerned "that a superficial program of lay publicity would only lead more patients to cancer phobia, quacks, and disillusionment." After working with volunteers from the General Federation of Women's Clubs for several years, Little "completely reversed his position" and came to the conclusion that the time was right for a "widespread and intensive campaign" to inform the public about "the prevention of cancer."76 According to Walter Ross, "The Society's need for more volunteers to carry out public education, and for new sources of money, forced it to broaden its volunteer base. The ASCC Executive Committee decided that women would make the best public-education volunteers for a number of reasons: The campaign would go into people's homes, where tact and patience would be essential; it would require a good deal of time, which many women could more easily spare in the mid-i930s than could their husbands; and the emphasis would be on cancers that affected women."77 Thus, in 1936, the Women's Field Army (WFA) was born.

The Women's Field Army, in the words of Ross, "was a quantum leap forward in volunteer power."78 According to Little, "In 1935 there were fifteen thousand people active in cancer control throughout the United States. . . . At the close of 1938, there were ten times that number. This growth [was] due to the Women's Field Army."79 The tremendous success of the WFA enabled the ASCC, for the first time, to reach substantial numbers ofwomen outside the white middle and upper classes of the Northeast.80 Posters and handbills recruiting volunteers for the WFA featured a flaming sword and the proclamation "There shall be light! Enlist in the Women's Field Army!" During its first year of existence, women's field armies were established in twenty-five states.81 The organization of the WFA was loosely modeled after that of the army. At the top of the command structure was the national commander, who issued orders to state commanders and captains. Members of the army—volunteers dressed in brown WFA uniforms—conducted door-to-door campaigns designed to "carry the message of early detection and medical intervention into every home in the land."82

Articles about the WFA appeared in such mass-circulation magazines as Elks Magazine, Women's Home Companion, Good Housekeeping, and American Legion Monthly. In addition, the ASCC enlisted the support of the major news outlets—Time, Life, and Fortune—which showed stories on cancer as part of their newsreel series.83 The WFA successfully recruited the Association of American University Women to its cause and worked extensively with the General Federation of Women's Clubs, which mobilized its membership in support of cancer education. In fact, the commander of the WFA, Marjorie B. Illig, was recruited from the General Federation of Women's Clubs, where she served as the chair of the Public Health Division. The WFA raised money from public donations to subsidize its educational and outreach activities and to subsidize "needy" cancer patients' travel to diagnostic and treatment centers. The WFA also encouraged the public to donate money to hospitals, clinics, and laboratories.84 The WFA eventually grew to approximately 700,000 officers and troops—by far the largest division of the ASCC.85 The WFA, in the words of Kirsten Gardner, "epitomized women's involvement in the ASCC, devotion to cancer awareness, and particular concern for women and cancer." However, as Gardner emphasized, "the limits of the female cancer awareness campaign were ignored . . . cultivating a sense of false optimism that assured women that early detection would lead to a cure."86

In 1946 a palace coup restructured the ASCC, which was renamed the American Cancer Society (ACS). Led by Mary Lasker and her husband

Albert, an advertising tycoon who made his fortune working for the tobacco industry, this "beneficent takeover" transformed the ASCC from a small-scale, weakly organized, fiscally conservative, physician-dominated organization into a high-powered, hierarchically structured, bureaucratic philanthropy organized around the principles of modern management, salesmanship, and advertising. From that point on, the ACS leadership included business and advertising professionals with a knack for marketing and fund-raising. The "modernization" of the health voluntary included a new focus on medical research. The ACS also became "a potent lobby" for cancer research within the federal government.87

The WFA was first scaled back by the new leadership of the restructured ACS and then eliminated altogether in 1951. Over the years, according to Breslow and Wilner, the WFA had come to be regarded as "too independent and frequently unmanageable."88 Furthermore, their support of cancer patients of limited means threatened the ASCC's hands-off approach to cancer patients. In several states the WFA provided assistance to destitute cancer patients. These services were independent of the national structure of the ACS, however, and these were exactly the kinds of activities that made the medical profession, and hence the ACS leadership, uneasy about the WFA.89

The reorganized ACS continued its campaign of medicalization through the development of early detection campaigns that supported the interests of private physicians by channeling more women into the diagnostic and treatment pipeline. A new campaign was launched in the 1950s called "Every Doctor's Office a Cancer Detection Center." This slogan perfectly captures the ACS's dual focus on transforming symptomatic women into cancer patients and integrating ordinary doctors into the larger regime of practices. This campaign was designed with detection technologies for cervical cancer more than for breast cancer in mind. Unlike for breast cancer, which required a surgical biopsy to confirm a diagnosis, the diagnostic test for cervical cancer—a Pap smear—could actually be performed in the doctor's office, although the "smear" had to be analyzed in a pathology laboratory.90 At the same time, the ACS launched a new campaign that extended early detection further into the domestic sphere. In 1949 the ACS created an instructional video that taught women how to systematically examine their breasts on a regular basis in the privacy of their homes. Between 1949 and 1953, over six hundred copies of this film were distributed, and more than three million women attended screenings sponsored by local ACS chapters.91 A newspaper photograph taken in South Bend, Indiana, showed a remarkable scene unfolding. A throng of women gathered outside a movie theater beneath a banner that read "Cancer Program 10 AM Today for Women Only!" The caption beneath the photograph indicates that four hundred women were turned away because the 2,500-seat theater was already filled to capacity.92 Building on this momentum, articles encouraging women to examine their breasts began appearing during the 1950s in mainstream women's magazines such as Ladies Home Journal, Good Housekeeping, and Women's Home Companion.

T he T emporary Sick Role and the Architecture of the Closet

Outside the doctor's office, discourses of early detection circulated in women's magazines, in the pamphlets distributed by women's clubs and ACS volunteers, in the media campaign known as National Cancer Week, in newsreels and news magazines, and in the breast self-examination (BSE) film screenings that were held during the 1950s. Through these discourses of early detection healthy women exhibiting danger signals were reconstituted as responsible, well-informed subjects actively pursuing the medi-calization of their condition. Once they entered the doctor's office, women exhibiting danger signals were reconstituted as symptomatic women. From there, if the consulting physician deemed it necessary, symptomatic women became subjects of, and subject to, the sovereign gaze of the surgeon.

Just as the regime of medicalization invented breast cancer as a curable disease, it invented breast cancer patients as potentially curable patients. As subjects of the regime of medicalization, women diagnosed with breast cancer were shaped, first and foremost, by their experiences of diagnosis and treatment; second, by the norms of nondisclosure that governed physicians' interactions with cancer patients; and third, by the normalizing practices through which "cured" women—the temporary subjects of this regime— were taught to return to their normal lives and pass as "normal" women. This was a deeply gendered and patriarchal regime of practices in which the sovereign rulers were male surgeons who wielded absolute power in the medical setting over breast cancer patients and demanded total obedience from their subjects.

During the regime of medicalization, breast cancer was diagnosed by means of a surgical biopsy and treated by means of the Halsted radical mastectomy. The Halsted, as mentioned earlier, was a deforming, often debilitating procedure that involved the removal of the chest muscles and surrounding lymph nodes as well as the breast tissue. Instead of separating the surgical biopsy from the surgical treatment, however, surgeons combined the two procedures into one operation. First, a surgical biopsy was performed by the surgeon and analyzed by a pathologist present for the procedure. If the pathologist diagnosed cancer and the surgeon agreed, an immediate radical mastectomy was performed while the patient remained unconscious.

From the surgeon's perspective, the one-step procedure made perfect sense. It was safer for the patient because it avoided the risk of a second general anesthesia, and it was more efficient for both patient and physician because it avoided the added time and trouble of scheduling a second operation. The one-step procedure required that a patient sign in advance a consent form authorizing her surgeon to perform an immediate mastectomy if he determined that the tumor was malignant. Practically speaking, this meant that a certain percentage of patients who entered the hospital expecting nothing more than a surgical biopsy awoke to discover that they had been treated for breast cancer by radical mastectomy before learning of their condition.

Although the one-step procedure was the preference of surgeons, in practice many women underwent surgical biopsies in medical facilities without a pathologist on site. In this case the biopsy and surgery were separated while the specimen was sent to the nearest pathology lab and the surgeon waited to hear from the pathologist. In Nothing's Changed: Diary of a Mastectomy, Dorothy Abbott described the two-step procedure that she received in a small, southwestern town in 1978 and summarized the experiences of fourteen other women she interviewed in her town who were treated for breast cancer during the 1940s, '50s, '60s, and '70s. According to Abbot, one woman, who was diagnosed in 1945, was told by her physician, "Go to the Mayo Clinic in Rochester, Minnesota. As far as I know, that is the only place where there are facilities to test for cancer while the patient remains under sedation. The biopsy and the mastectomy, if necessary, can be accomplished in a single trip to the operating room." In the text, Abbott commented approvingly that "this would save Vera the dangers of a second anesthetic and the trauma of waiting for mastectomy."93 The passage quoted thus suggests that the one-step procedure was viewed, at least by some women, as a desirable state-of-the-art treatment available only at top-notch medical facilities. In this instance, the two-step procedure was positioned as the lower-tech, small-town alternative to the high-tech, big-city procedure. During the late 1970s, however, feminist health activists across the country reframed the one-step procedure as a paternalistic, patriarchal procedure that deprived breast cancer patients of their right to be informed of their diagnoses and to participate in medical decision making regarding their treatment. Ironically, these activists demanded access to the old-fashioned, lower-tech, two-step procedure, which became a symbol of breast cancer patients' rights and, within relatively short order, the new standard of breast cancer care in high-tech, leading-edge medical centers.

In theory the two-step procedure, which was performed in towns without pathology facilities, could have opened up additional space for a dialogue between patient and physician and created the opportunity for greater patient participation in decision making. There were additional factors, however, that constrained the opening-up of this space during the regime of medicalization. The most important of these was the absence of treatment alternatives. During the regime of medicalization, it was the Halsted radical mastectomy or nothing. Although European studies suggested that less radical procedures were equally effective, these studies were soundly rejected by surgeons in the United States.94 If surgeons informed anyone of a patient's diagnosis between the performance of the biopsy and the surgical "cure," it was typically the patient's husband, who inevitably authorized the surgeon to proceed.

Diagnosis thus occurred in tandem with treatment—and both typically occurred while the patient was under general anesthesia. When the patient awoke from the one-step procedure, she typically awoke not as a cancer patient but as a mastectomee who had been successfully treated for a condition that was not called by name, at least not in front of the patient. Women with early-stage breast cancer typically recuperated in the hospital for one or two weeks before returning home. Women with more advanced cancer—for example, cancer that had invaded their lymph nodes— were often treated with some form of radiation therapy, depending on the historical period in which they were diagnosed.95 In order to sketch a general picture of treatment during the regime of medicalization, however, I will continue to focus on women with early-stage disease.

For most patients, the only source of information regarding their postoperative prognoses came from their surgeon or their family physician, after he (or she) consulted with the surgeon. It was up to the surgeon to show new mastectomees how to perform therapeutic exercises to regain physical strength and mobility or to arrange for a nurse to teach the patient. It was up to the surgeon to be responsive to the emotional needs of patients who had just suffered the trauma of an unexpected breast amputation. It was up to the surgeon to instruct family members, especially husbands, about the physical, sexual, emotional, and psychological impact of surgery. It was also up to the surgeon, who sometimes delegated this task to a nurse, to inform the new mastectomee where to find a corsetiere who could fit her with a "breast form" to help hide the evidence of her surgery. Surgeons were not trained in these matters, however; nor were they known for their bedside manner. Nurses could assist, but only at the discretion of the surgeon.

"Hiding the awful truth," to quote the words ofJames Patterson, meant teaching women who underwent "the operation" how to avoid crashing headlong into the public stigma and shame of breast cancer. It meant teaching them how to pass as "normal" women. As a general rule, it was the discourse of early detection that dominated the coverage of breast cancer in women's magazines, including instructions and drawings on how to perform breast self-examinations. The actual treatment for breast cancer, however, was rarely discussed or depicted in detail. During the 1950s, however, a small trickle of articles discussing the experience of breast loss and explaining the availability and importance of breast prostheses began to appear in women's magazines.96

A 1954 article published in Good Housekeeping, for example, was called "After Breast Surgery." This article raised the curtain on breast cancer surgery, however, only long enough to explain the importance of keeping it lowered. Most doctors, according to the author, would explain to their patients before "the operation" that "she will emerge from the operating room the same woman she was when she went in" and that "her life will be the same as it always was." The author emphasized that "no one outside the immediate family need know she has had the operation—just as she does not know that many women whose names are household words have undergone the experience."97

This article paints a vivid portrait of the normalizing practices to which women with breast cancer were subject: "No woman," the author wrote,

"need look different after breast surgery than she did before." There are many kinds of devices "that will prevent any suggestion of malformation," the author reassured readers, and "doctors and nurses realize that restoring normal appearance is extremely important to health and recovery as well as to vanity and morale." As soon as possible after the operation, the author explained, "the doctor will suggest that the patient wear a brassiere." Thus, while still recuperating in the hospital, the postoperative patient acquires— although just how this acquisition occurs remains a bit of a mystery—a "special garment" with an opening that can be filled by the patient or nurse with cotton batting or lamb's wool. "When the patient gets out of bed, this makeshift bra helps her keep her balance. . . . But most important of all, the bra reassures the patient—when her husband or family come to visit her—that there is no noticeable, lumpy dressing or sagging negligee to remind anyone of the operation. The patient looks the same as she ever did. When she walks down the hospital corridor, no one can guess what has happened." Advocating the extension of this normalizing process into the everyday world outside the hospital, the author explained that "as soon as the doctor gives his permission, the patient should be fitted with a prosthetic device" that should be worn to maintain the appearance of normality every day.98

In providing advice and information about buying and wearing breast prostheses, women's magazines made the issue of mastectomy visible between the covers of magazines while encouraging the erasure of flesh-and-blood mastectomees from the public sphere. These popular magazines taught women with mastectomies how to successfully "pass" as "normal" women and contributed to a public culture in which passing was expected. Thus, even as they contributed to the production and circulation of new discourses of breast cancer and helped build awareness of the material culture (breast prostheses) of this disease, women's magazines helped design and maintain the architecture of the closet.

Consistent with this, the regime of medicalization positioned breast cancer patients in one of two temporal positions. Either the diagnosis came too late and they were positioned as "hopeless cases," or the operation was a success and they were "cured" and sent on their way after surgery (and, in certain cases, radiation therapy). In either event, the subject position of "cancer patient" was a temporary one that rapidly dissolved upon the patient's brief foray into the world of medical treatment. As temporary subjects, women were enclaved behind the walls of the hospital. Within that enclosure, they were isolated from each other, constituted as individual patient-subjects, and visible as cancer patients only within the confines of the hospital. The regime of medicalization thus shaped breast cancer's social, spatial, and visual dimensions.

Norms of Nondisclosure

A second factor that limited women's ability to participate as agentic subjects in medical decision making regarding their treatment was the norms of nondisclosure that governed physicians' interactions with cancer patients. Despite the proliferation of discourses of early detection in public arenas, explicit discussions of cancer were avoided within the medical setting. Physicians, in the words ofJames Patterson, "conspired with frightened relatives to hide the 'awful truth' of cancer."99 Hiding the "awful truth" involved everything from maintaining a studied silence on the subject, to using euphemistic language, to dexterously dissembling, to, if those all failed, bald-faced lying.

From a contemporary vantage point, the literature on physicians' practices of nondisclosure during the regime of medicalization is a bit shocking. Diagnostic dissembling was clearly the rule rather than the exception in the physician—patient relationship until well into the 1960s. In a 1946 article entitled "The Doctor, the Patient, and the Truth," for example, which was published in Annals of Internal Medicine, the author offers this advice to physicians when discussing their diagnoses with cancer patients: "Certainly, at the start of the interview," the author suggests, the physician "should avoid the words carcinoma or cancer. He should use cyst, nodule, tumor, lesion, or some other loosely descriptive word that has not so many frightening connections." The physician should divulge as little information as possible—just enough, the author indicates, to obtain the patient's consent for an operation. If, however, for some reason the patient shows signs of hesitation and the physician is unable to solicit "the husband's cooperation" in persuading his wife to consent, the physician should explain to the patient "that the lesion is in imminent danger of becoming a cancer and that a good chance of cure still remains if action is immediate."100 As the scenario winds down, the patient, now fearing that any hesitation on her part will lead to cancer (not knowing that she is already, in fact, a cancer patient), agrees to what she believes is an operation to prevent the development of cancer.

Fifteen years later a survey of physicians' "truth-telling" practices showed that norms of nondisclosure still prevailed. According to the results of a survey of 217 physicians at Michael Reese Hospital in Chicago, 90 percent practiced some level of diagnostic dissembling.101 A clear majority told their patients the truth "rarely, if ever," and not one of the physicians reported a policy of truthfully informing every patient of his or her cancer diagnosis.

Follow-up interviews conducted with the survey's respondents provided additional insight into the mind-set of the physicians surveyed and, more importantly, the meaning of their responses. When, for example, the small number of physicians who reported that they "often" told their patients the truth were asked to expound on what they meant by "telling the truth," they revealed that, to them, "telling the truth" meant that while they might use the word "tumor," they strictly avoided using terms like "cancer" and "malignancy." "These words were almost never used," according to the study's author, Donald Oken, "unless the patient's explicit and insistent questioning pushed the doctor's back to the wall."102 Even in such situations, however, euphemistic speech was the accepted practice. These euphemisms ranged from "the vaguest of words ('lesion,' 'mass'), to terms giving a general indication that the process [was] neoplastic ('growth,' 'tumor,' 'hyperplastic tissue')." The euphemisms also included terms like "suspicious" or "degenerated" tumor. Oken explained, however, that the use of terms suggesting that the process was neoplastic were "often tempered by a false explicit statement that the process [was] benign."103 In other words, truth telling—even among the small handful of physicians who reported telling cancer patients "the truth"—ranged from using euphemistic language to making deliberately false statements designed to give the patient the impression that the malignant tumor was benign.

In cases where major surgery or radiation therapy were required, Oken reported, especially if the patient was hesitant about proceeding, "recourse may be had to such terms as 'pre-cancerous,' or a tumor 'in the early curable stage.'" As Oken explained, "The modal policy" was "to tell as little as possible in the most general terms consistent with maintaining cooperation in treatment," but some physicians "avoid even the slightest suggestion of neoplasia and quite specifically substitute another diagnosis."104 A cyst? A nodule? Heart trouble? The possibilities for misdirection were seemingly endless.

Finally, sealing any possible exit from this house of mirrors, Oken reported that "questioning by the patient almost invariably was disregarded and considered a plea for reassurance unless [it was] persistent and intuitively perceived [by the physician] as 'a real wish to know.'" But even then, Oken indicated, "it may be ignored." In sum, the vast majority of doctors simply "feel that almost all patients really do not want to know regardless of what people say."105 Furthermore, regardless of what patients might have believed they wanted to know, and what patients might have believed was best for them, physicians were utterly convinced that the best thing they could do for their patients was to "sustain and bolster" their hope and "communicate the possibility, even the likelihood, of recovery."

It is difficult to know what, from the patient's point of view, was actually being communicated in these conversations. Is it possible that a woman who had just received a radical mastectomy actually believed her surgeon or family physician when they insisted that the tumor was benign? Yes. Is it possible that she suspected she was being lied to? Yes. Is it possible that patients understood what was going on when they heard the euphemisms tripping off the tongues of their physicians? Yes. But surely they also knew that the role scripted for them demanded their full participation in the performance.


During the era of therapeutic pluralism cancer was conceptualized as a systemic disease whose symptoms might be alleviated but whose progression could rarely be arrested. Within the regime of medicalization breast cancer was reconceptualized in theory and reconstituted in practice as a disease of local origins that could be cured if detected early and treated by radical mastectomy. This "invention of a curable disease," in the words of Barron H. Lerner, had important consequences for the newly constituted subjects of this regime.

Through its "Do Not Delay" and "Every Doctor's Office a Cancer Detection Center" campaigns, the ASCC and, later, the ACS promoted public awareness of the danger signals of cancer and directed women to seek immediate medical attention if these signals were discovered. Women exhibiting danger signals were thus constituted as symptomatic subjects of the regime, as patients.

The one-step procedure collapsed the diagnosis and treatment of women with breast cancer into one operation. In practice, this often meant that patients were "cured" before they learned that they had been diagnosed with breast cancer, if indeed they ever did. The conventions of nondisclosure that organized relationships between physicians and cancer patients mitigated against the development of a "breast cancer patient" identity. Women treated for breast cancer became mastectomees—a secret subject position derived from a surgical procedure rather than a disease-based identity. Furthermore, the sick role required mastectomees, like other patients, to return to their normal lives, take up their normal duties, and pass as normal women. Discretion and breast prostheses were viewed as key elements in a patient's successful return to normality.

Women's magazines cooperated in promoting the private management of public appearance, the return to normality, and the invisibility of flesh-and-blood mastectomees. In this way they served as one of the key architects of the closet. Concerns about breast loss and blending in were certainly not invented by women's magazines or the regime of medicalization; nonetheless, this regime of practices did more than simply reflect or reproduce what already existed. It organized a new set of practices to shape, support, and sustain the isolation of breast cancer patients and the invisibility of mastectomees.

Even more important than the constitution of breast cancer patients as silent, obedient subjects was the construction and transformation of dangerous, or endangered, women into patients. The "Do Not Delay" discourse of early detection reconstituted ordinary women as conscientious interpreters of bodily signs, as women who responded proactively by seeking immediate medical attention, and as women who refused to have their concerns dismissed by physicians. These women were encouraged to demand that their doctors seriously investigate any suspicious signs of disease. At the same time, as Leslie Reagan observed, "their energies were contained within a medical model that granted authority to physicians and expected patients to be compliant."106 Thus, in essence, this regime of practices sent a mixed message. On the one hand, women were encouraged to be proactive, independent, mature, and resourceful in reading the danger signals, seeking medical care, and finding a responsive physician. At the same time, they were channeled into a sick role that demanded their unquestioning obedience to the authority of surgeons, as well as their silence and invisibility.

Compared to the proliferation of discourses about breast cancer outside the clinic, the discourse of breast cancer inside the clinic was muzzled and muted. Physicians spoke to each other about their patients but did not speak straightforwardly to their patients about their diagnoses. It would not be entirely accurate, however, to characterize the discourse of breast cancer during the first seventy years of the twentieth century, as many do, as a "conspiracy of silence." It was through a proliferation of public and private discourses and practices, not a deficit, that breast cancer was constituted as a "hidden" disease and women with breast cancer were constituted as its invisible victims.

Inside the surgeon's office, the operating room, and the hospital setting, breast cancer patients were indeed surrounded by silence, lies, and dissembling. It is also true that the role scripted for mastectomees required that, upon leaving the hospital, they return to their normal lives and hide the evidence of their surgery. At the same time, however, discourses of breast cancer proliferated outside the medical setting through high-visibility cancer-control campaigns. Despite their abundance, however, these biopolitical campaigns reinforced the sovereignty of surgeons and the silence and invisibility of mastectomees. Thus, the regime of medicalization and its architecture of the closet protected mastectomees from the stigmatizing gaze of the public and simultaneously protected the public from witnessing the thousands of women with breast cancer living in their midst as neighbors, coworkers, family members, and friends.

chapter 3

10 Ways To Fight Off Cancer

10 Ways To Fight Off Cancer

Learning About 10 Ways Fight Off Cancer Can Have Amazing Benefits For Your Life The Best Tips On How To Keep This Killer At Bay Discovering that you or a loved one has cancer can be utterly terrifying. All the same, once you comprehend the causes of cancer and learn how to reverse those causes, you or your loved one may have more than a fighting chance of beating out cancer.

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