ONCOLOGY NURSING FORUM – VOL 32, NO 2, 2005
associated with their cancer experience (Badger, Braden, &
Mishel, 2001; Lewis, Zahlis, Shands, Sinsheimer, & Ham-
mond, 1996; Winningham et al., 1994). Women with breast
cancer suffer physically and psychologically in response to
the diagnosis and treatment of their cancer (Badger et al.,
2001; Sandgren & McCaul, 2003), and these responses will
signifi cantly infl uence cancer recovery, quality of life (QOL),
and long-term survival (Badger, Braden, Longman, & Mishel,
1999; Giese-Davis & Spiegel, 2003; Paraska & Bender, 2003;
n 2005, more than 200,000 women will be diagnosed
with breast cancer (American Cancer Society, 2005),
and the majority will have treatment-related side effects
Of the side effects experienced, cancer treatment-related
fatigue is the most common across cancer diagnoses, stages of
disease, and treatment regimens, with estimates ranging from
40%–100% (Meek et al., 2000; Nail, 1996). The most common
psychological response experienced by women with breast
cancer is depression, with estimates ranging from 4.5%–50%
(Newport & Nemeroff, 1998). Women have rated fatigue and
depression among the top fi ve most distressing side effects of
the cancer experience (Badger et al., 2001; Nail).
Substantial evidence exists that distressing side effects
decrease women’s abilities to marshal critical psychological
and social support when the need for it is greatest (Giese-Da-
vis & Spiegel, 2003; Rehse & Pukrop, 2003). Women with
breast cancer routinely describe the negative consequences the
Key Points . . .
➤ Women in the intervention group experienced decreases in de-
pression, fatigue, and stress and an increase in positive affect.
➤ Preliminary fi ndings are consistent with previous research that
counseling interventions work to decrease negative outcomes
in some women.
➤ The telephone may be an effective method to deliver psycho-
social interventions to meet the needs of patients with cancer
and their partners.
➤ Nurses need to assess the quantity and quality of social sup-
port early in treatment, recognizing that social support is vital
during cancer recovery.
Telephone Interpersonal Counseling
With Women With Breast Cancer:
Symptom Management and Quality of Life
Terry Badger, PhD, APRN, BC, Chris Segrin, PhD, Paula Meek, RN, PhD,
Ana Maria Lopez, MD, Elizabeth Bonham, MS, APRN, BC, and Amelia Sieger, BS
Purpose/Objectives: To examine the effectiveness of a telephone
interpersonal counseling (TIP-C) intervention compared to a usual care
attentional control for symptom management (depression and fatigue)
and quality of life (positive and negative affect, stress) for women with
Design: Experimental with repeated measures.
Setting: Academic cancer center and urban, private oncology offi ces.
Sample: 48 women with breast cancer who were in their mid-50s,
married, and employed at the time of the study.
Methods: Women were assigned to either the six-week TIP-C or
attentional usual care groups. Women were matched on stage and treat-
ment. Data were collected at baseline, after the six interventions, and one
month postintervention. Measures included the Center for Epidemiologic
Studies–Depression Scale, Positive and Negative Affect Schedule, Multi-
dimensional Fatigue Inventory, and Index of Clinical Stress.
Main Research Variables: Depression, positive and negative affect,
fatigue, and stress.
Findings: Women in the intervention group experienced decreases
in depression, fatigue, and stress over time and increases in positive
Conclusions: The preliminary results partially supported the ef-
fectiveness of TIP-C for symptom management and quality of life. The
authors hypothesized that decreased depression, reduced negative affect,
decreased stress, decreased fatigue, and increased positive affect over
time would be the resulting psychosocial effects, given the theoretical
underpinnings of the intervention.
Implications for Nursing: Nurses need to assess the quantity and
quality of the social support network early in treatment; women with less
social support need to be referred to counseling and support services.
Because these women have limited participation in face-to-face interven-
tions, they should be encouraged to participate in telephone or online
support programs or in other programs or organizations (e.g., churches,
social clubs) that would provide support.
Terry Badger, PhD, APRN, BC, is a professor in the College of
Nursing, and Chris Segrin, PhD, is a professor in the Department of
Communication, both at the University of Arizona in Tucson; Paula
Meek, RN, PhD, is a professor in the School of Nursing at the Uni-
versity of New Mexico in Albuquerque; Ana Maria Lopez, MD, is an
assistant professor of clinical medicine and pathology in the Arizona
Cancer Center at the Arizona Health Science Center in Tucson; and
Elizabeth Bonham, MS, APRN, BC, is a doctoral student, and Amelia
Sieger, BS, is a nursing student, both in the College of Nursing at the
University of Arizona. Funding for this study was provided by the
ONS Foundation. (Submitted January 2004. Accepted for publica-
tion May 5, 2004.)
Digital Object Identifi er: 10.1188/05.ONF.273-279
ONCOLOGY NURSING FORUM – VOL 32, NO 2, 2005
cancer diagnosis and treatment have on themselves and their
family members. Although face-to-face psychosocial interven-
tions improve the psychological adjustment and health-related
QOL of patients with cancer (Bottomley, 1997; Fawzy, Fawzy,
Arndt, & Pasnau, 1995; Newport & Nemeroff, 1998; Spie-
gel, 1997; Vinokur, Threatt, Vinokur-Kaplan, & Satariano,
1990), psychosocial interventions are not offered routinely
to patients. And even when they are offered, only a small
number of patients with cancer take advantage of face-to-face
psychosocial interventions (Marcus et al., 2002). Recognizing
that breast cancer and its treatment have profound relational
implications for women and their partners, the current study’s
authors have tested the effectiveness of an experimental inter-
personal counseling regimen delivered over the telephone for
women undergoing treatment for breast cancer.
Among therapeutic interventions, interpersonal psychother-
apy has well-documented effectiveness for patients with emo-
tional distress (Rounsaville, Klerman, Weissman, & Chevron,
1985; Weissman & Markowitz, 1998; Weissman, Markowitz,
& Klerman, 2000). Interpersonal psychotherapy is based on
the assumption that problems such as depression affect and
are affected by the nature of an individual’s interpersonal
relationships (Weissman et al.). Regardless of etiology in any
given case, depression and other emotional distress can be
maintained, alleviated, or exacerbated through interpersonal
interactions. Consequently, the focus of interpersonal psycho-
therapy is on examining the nature of current interpersonal
relationships and how they infl uence and are infl uenced by
psychological distress. The role of counseling is to help
patients to decrease interpersonal strains and stresses to im-
prove health. A brief version of interpersonal psychotherapy,
known as interpersonal counseling, has been offered by nurse
practitioners and other healthcare professionals with positive
results (Weissman & Klerman, 1993). Similar to interpersonal
psychotherapy, interpersonal counseling retains a focus on
current relationships and sources of stress and dissatisfaction
in a person’s life from work, family, and friends. Interpersonal
psychotherapy and interpersonal counseling focus on the four
key relationship issues of grief, interpersonal role disputes,
role transitions, and interpersonal defi cits. Clinical trials of
interpersonal psychotherapy and interpersonal counseling
have provided favorable data supporting their effi cacy as acute
treatments in various primary care contexts and suggest that
they would be equally effective in cancer care (Klerman &
Weissman, 1993; Schulberg & Scott, 1991).
Donnelly et al. (2000) recently presented the fi rst published
results of telephone interpersonal psychotherapy with patients
with cancer. An innovative feature of Donnelly et al.’s design
involved the active participation of patients’ close compan-
ions. Patients (n = 14) and their partners (n = 10) received
weekly telephone sessions in concert with the fi rst chemother-
apy administration and ending four weeks after the fi nal ad-
ministration. On average, patients participated in 16 sessions
and partners in 11 sessions. By the end of the clinical trial,
33% of the patients showed “marked improvement” in their
psychological well-being, and another 33% showed a minor
improvement or a stable symptom profi le over the course of
the investigation. Conversely, only 25% of the sample exhib-
ited a “marked worsening” of symptoms from baseline to fi nal
assessment. Despite the chemotherapy that was concomitant
to the interpersonal psychotherapy, two-thirds of the patients
experienced anywhere from stable to markedly improved
symptom profi les. Patients and partners reported high levels of
satisfaction with the telephone interpersonal psychotherapy.
These fi ndings suggest that interpersonal psychotherapy is
capable of decreasing the psychological distress that often ac-
companies chemotherapy for patients and their partners. Inter-
personal psychotherapy had direct positive effects on patients’
psychosocial and physical well-being and indirect positive
effects by assisting their partners. During the course of interper-
sonal psychotherapy, patients and partners benefi ted from being
able to express their anxiety and uncertainty about the cancer
treatment. As a natural extension of the psychoeducational
component of interpersonal psychotherapy, information about
cancer and chemotherapy was provided for the current study.
The conceptual framework for the current study is derived
from interpersonal psychotherapy and diathesis-stress vulner-
ability models of depression (Rounsaville et al., 1985; Segrin
& Flora, 2000; Weissman & Markowitz, 1998; Weissman et
al., 2000). The diathesis-stress vulnerability model posits
that individuals have a predisposition, or vulnerability, to
developing depressive symptoms that may make them more
susceptible to negative health outcomes following a major
stressful event, such as cancer diagnosis and treatment. In this
framework, social support appears to be an especially salient
factor in reducing negative health outcomes (Maunsell, Bris-
son, & Deschenes, 1995; Northouse, 1994). Social support,
defi ned broadly as affective, instrumental, informational, and
appraisal support, is the target of the current study’s interper-
sonal intervention. Social support essentially reduces the ill
effects of stress that typically accompany threats to well-be-
ing. This is achieved largely through interpersonal communi-
cation that allows individuals to “work through” the affective
reaction to the stressor and to marshal instrumental support
for tangible assistance with roles and functions, informational
support for advice or suggestions, and appraisal support for
gauging and adjusting to the stressor. Among patients with
cancer, such behaviors can make the cancer experience seem
less overwhelming and can aid in adjusting to the illness
Recent reports suggest that telephone counseling has become
a standard means of providing education and advice to medical
patients (Greenberg, 2000; Ridsdale et al., 2001). Hunkeler et al.
(2000) found that telephone counseling by nurses with depressed
medical patients reduced depressive symptoms when compared
to patients without telephone contact. Similarly, Braden, Mishel,
and Longman (1998) found signifi cant improvements in psycho-
logical adjustment and QOL among women with breast cancer
who received telephone case management. Telephone interven-
tion eliminates the visual channel of communication, offering
greater anonymity to patients and their partners. Because some
patients undergoing chemotherapy experience extreme self-con-
sciousness about their appearance, use of the telephone allows
patients to interact with their healthcare providers without being
concerned about their visual image. Use of the telephone also
allows for the delivery of counseling to people living in rural
areas who might not otherwise have access to the same range
of medical and psychological services available to those in ur-
ban settings. The telephone may be a cost-effective method of
delivering interventions, and telephone-delivered interpersonal
psychotherapy may be an especially effective intervention for
women with breast cancer and their partners.
The purpose of the current study was to examine the effec-
tiveness of a telephone interpersonal counseling (TIP-C) inter-
ONCOLOGY NURSING FORUM – VOL 32, NO 2, 2005
vention compared to a usual care attentional control group on
women’s symptom management (depression and fatigue) and
QOL (positive and negative affect and stress). This analysis will
focus on women with breast cancer and the hypotheses compar-
ing the two groups (TIP-C and usual care) to determine the ef-
fectiveness of the TIP-C intervention for decreasing depression,
negative affect, general fatigue, and stress and for increasing
positive affect. The fi ndings for these women’s partners are
reported elsewhere (Segrin et al., 2004).
This pilot study used a repeated-measures experimental
design with 48 women with breast cancer assigned to either
the TIP-C intervention or usual care attentional control group.
Participants were recruited from a local cancer center, oncolo-
gists’ offi ces, and support groups and through self-referral
after reading brochures displayed in the various settings.
Eligibility criteria included having a diagnosis of stages I–III
breast cancer, receiving adjuvant treatment for breast cancer,
being able to speak English and talk on the telephone, and
having a partner who also was willing to participate in the
counseling. Adjuvant treatment included any combination
of chemotherapy, radiation, and hormone therapy. After
informed consent was obtained, participants completed the
questionnaires at baseline (T1), after the six-week intervention
(T2), and one month after T2 (T3). All interventions and data
collections were completed over the telephone.
The treatment, TIP-C, is based on theories of interpersonal
therapy (Klerman & Weissman, 1993; Weissman et al., 2000)
and cancer education. Participants received six weekly tele-
phone calls from a nurse counselor while they were undergo-
ing treatment for breast cancer. Nurse counselors were mas-
ter’s-prepared clinical nurse specialists in psychiatric-mental
health nursing who had additional oncology training. Total
training in interpersonal psychotherapy techniques and on-
cology included 32 hours of didactic content plus supervised
counseling practice. The training program included discussion
of the intervention protocol, theoretical aspects of the inter-
vention, and cancer treatment information supplemented with
reading assignments from the scientifi c literature. Ongoing
review of tape-recorded intervention sessions and supervision
provided quality control for the TIP-C sessions.
Counseling sessions focused on issues such as cancer edu-
cation, interpersonal role disputes, social support, awareness,
and management of depressive symptoms, and role transi-
tions. (For a case study, see Badger, Segrin, Meek, Lopez, and
Bonham .) Participants also nominated a close partner,
usually a husband, to participate with them in the study. The
partners received three TIP-C sessions (weeks 1, 3, and 5) dur-
ing the same six-week period as the women. These sessions
also focused on issues such as cancer education, role disputes,
role transitions, and social support. Telephone sessions aver-
aged 32.9 minutes for the women and their partners.
The usual care condition also involved six weekly calls
from the nurse counselor for the woman and three calls for the
partner. Those in the usual care group received a resource list
about cancer and brief, focused calls to inquire about general
well-being and to answer general questions, but no counsel-
ing. Usual care calls averaged eight minutes.
Depression was measured using the 20-item Center for
Epidemiologic Studies–Depression Scale (CES-D) (Radloff,
1977). Scores range from 0–60, with higher scores indicating
greater depression symptoms. Scores greater than or equal
to 16 are considered positive for depression. The CES-D has
been used in numerous studies with general and cancer popu-
lations since the 1980s with satisfactory reliability and validity
results (e.g., Nail, 1996; Visser & Smets, 1998). Cronbach’s
alpha (a) was greater than or equal to 0.90 across all three
measurement periods in this study.
Affect was measured by the 20-item Positive and Nega-
tive Affect Schedule (PANAS) (Watson, Clark, & Tellegan,
1988). Scores range from 10–50, with higher scores refl ect-
ing greater negative or positive affect. PANAS has been used
extensively with general and cancer populations with satis-
factory reliability and validity (Badger, Braden, Mishel, &
Longman, 2004; Manne & Schnoll, 2001). In this study, the
positive and negative subscales had a greater than or equal to
0.88 reliabilities across time.
Fatigue was measured using the 20-item Multidimen-
sional Fatigue Inventory (MFI) (Smets, Garssen, Bonke,
& DeHaes, 1995), which has fi ve subscales, including physi-
cal, general, and mental fatigue and reduced motivation and
activity. Scores range from 4–28, with higher scores refl ecting
greater fatigue. The MFI has had satisfactory reliability and
validity in previous studies (e.g., Meek et al., 2000), and in
this study, the MFI total score reliabilities were a greater than
or equal to 0.90 across time. In this analysis, the authors used
the total 20-item scale as a global index of fatigue.
Stress was measured using the 25-item Index of Clinical
Stress (ICS) (Abell, 1991; Attala, Hudson, & McSweeny,
1994). Scores range from 25–175, with higher scores indica-
tive of more stress. The ICS has been used in previous studies
with satisfactory reliability and validity (Abell). In this study,
a was greater than 0.96.
Table 1 lists the demographic and illness characteristics
of the participants. No signifi cant differences existed among
participants for demographic characteristics. The typical par-
ticipant was white, in her mid-50s, married, and employed at
the time of the study. More women in the TIP-C group were
stage II, but the difference was not statistically signifi cant (c2=
1.80, df = 2, p > 0.41). More women in the usual care group
were receiving hormones in addition to their chemotherapy
and radiation therapy regimens, but again, this difference was
not statistically signifi cant.
Variables of Interest
Prior to testing the effectiveness of the intervention com-
pared to usual care, the inter-relations among the QOL in-
dicators were evaluated with Pearson correlations. Matrices
of correlations for T1, T2, and T3 QOL indicators appear in
Table 2. These correlation analyses reveal moderate to strong
associations among all of the QOL indicators. Particularly
noteworthy are the signifi cant associations between fatigue
and all of the affective indicators of QOL.
Analyses of the effectiveness of the TIP-C intervention
were conducted with a series of mixed model analysis of
ONCOLOGY NURSING FORUM – VOL 32, NO 2, 2005
covariance (ANCOVA). For each analysis, one of the QOL in-
dicators (e.g., depressive symptoms) at baseline (T1), post-test
(T2), and follow-up (T3) was treated as a repeated measures
factor and treatment group (TIP-C or usual) was the between
subjects factor. Because the TIP-C and usual care groups were
not entirely equivalent on stage of cancer, chemotherapy,
radiation, or hormone-blocking therapy, these four cancer-
related variables were treated as covariates in these analyses.
One mixed-model ANCOVA was conducted for each of the
dependent measures: depression, negative affect, positive
affect, general fatigue, and stress. Before interpreting any of
the statistical effects, each dependent variable was tested for
sphericity (homogeneity of covariance) over the three mea-
surement periods. In all cases, the sphericity assumption was
met. Signifi cant fi ndings (p < 0.05) and trends (p < 0.10) were
reported in this exploratory analysis.
Depression: Because symptoms of depression are positive-
ly skewed in the general population and in the study sample,
CES-D scores were square-root transformed prior to analysis.
The hypothesis that depression would decrease over time in the
TIP-C group was partially supported as a trend of change over
time. Results for changes in symptoms of depression over time
revealed no signifi cant main effect for time (F [2, 33] = 1.77,
p = 0.19) nor a time by group interaction (F [2, 33] = 1.87,
p = 0.17). Examination of group means over each measure-
ment indicated a trend suggestive of consistently decreasing
symptoms of depression over the course of the investigation
for those receiving the TIP-C intervention (see Table 3).
Positive and negative affect: The hypothesis that negative
affect would decrease over time for those in the TIP-C group
was not supported. Results for negative affect produced no sig-
nifi cant main effect for time (F [2, 33] = 0.08, p = 0.92) or a time
by group interaction (F [2, 33] = 0.71, p = 0.50). The hypothesis
that positive affect would increase over time was supported. The
ANCOVA for positive affect revealed a signifi cant main effect
for time (F [2, 68] = 3.74, p = 0.03) but no signifi cant time by
group interaction (F [2, 68] = 0.10, p = 0.91). A quadratic effect
existed for time (F [1, 38] = 4.90, p = 0.03) such that levels of
positive affect dropped slightly from T1 to T2 but then increased,
especially for the TIP-C group, from T2 to T3.
Fatigue: The hypothesis that fatigue would decrease over
time for the TIP-C group was partially supported as a trend
in the change over time. No signifi cant main effect existed
for time (F [2, 33] = 1.02, p = 0.37). However, a trend was
found in the time by group interaction (F [2, 33] = 2.65, p =
0.09). Covariate adjusted means for fatigue in Table 3 indicate
that reported levels of fatigue declined for those in the TIP-C
group but not for those in the control group.
Stress: The hypothesis that stress would decrease over time
for the TIP-C group was supported. Results for changes in
stress over time, as measured by the ICS, revealed a signifi cant
effect for time (F [2, 32] = 3.27, p = 0.05), but no time by group
interaction existed (F [2, 32] = 1.78, p = 0.19). An examination
of group means at each measurement indicated a trend sugges-
tive of decreasing stress for both groups from T1 to T2. This
decrease was more precipitous for those in the TIP-C group,
however. By T3, the authors found that this trend in the direc-
tion of decreasing stress clearly continued for the TIP-C group.
In contrast, levels of stress increased on average from T2 to T3
for participants in the usual care group.
Table 2. Intercorrelations Among Quality-of-Life Indicators
at Time 1, Time 2, and Time 3
2. Negative affect
3. Positive affect
2. Negative affect
3. Positive affect
2. Negative affect
3. Positive affect
*p < 0.05, **p < 0.01, ***p < 0.001
Table 1. Demographic Characteristics
Number of children
Stage of cancer
(N = 24)
(N = 24)
TIP-C—telephone interpersonal counseling intervention
Note. Because of rounding, percentages may not total 100.
ONCOLOGY NURSING FORUM – VOL 32, NO 2, 2005
These fi ndings are consistent with previous fi ndings (e.g.,
Giese-Davis & Spiegel, 2003; Marcus et al., 2002) about
the benefi ts of counseling for patients with cancer. These
preliminary results partially supported the effectiveness of
the TIP-C intervention for symptom management and QOL.
Although only an increase in positive affect and a decrease in
stress were found to be statistically signifi cant and that effect
occurred in the treatment and control groups, clear trends
were found for decreases over time in depression, negative
affect, and fatigue for participants in the TIP-C group. Sev-
eral possible explanations exist for these fi ndings. First, given
the theoretical underpinnings of the intervention, the authors
would expect the psychological indicators to improve, and
the trends do, in fact, support that they did. The TIP-C in-
tervention might have helped to reduce fatigue through psy-
chological variables such as depression and stress that were
correlated with fatigue. Although the authors suspect that
fatigue might be indirectly infl uenced by the psychological
indicators, they were unable to test that hypothesis because
of the small sample size.
Second, perhaps these findings can be explained with a
dosage effect. Six weeks may not suffi cient time to achieve
the full impact of the intervention. Additional preliminary
analyses have documented a dosage effect, such that those
who received a greater number of minutes of the intervention
evidenced greater gains in reducing negative and increasing
positive indicators. This pattern also is consistent with meta-
analytic fi ndings showing that the duration of psychosocial
interventions is correlated positively with improvements in
patients’ QOL (Rehse & Pukrop, 2003). Again, in this study,
the trend data also support the premise that increased number
of sessions in future research might be benefi cial to women
for symptom management and QOL.
The results from this investigation also support the theoreti-
cal models that connect social support with positive mental
and physical health outcomes (Cohen, Gottlieb, & Under-
wood, 2000; Cohen & Wills, 1985; Sarason, Sarason, & Gu-
rung, 2001). Researchers generally believe that social support
can reduce the appraised threat and stress responses that com-
monly follow a psychological or physical threat and that social
support provides a general sense of belonging and well-being
that minimizes psychological despair. This is, perhaps, one
reason why social support is such a good predictor of mental
health and QOL in patients with cancer (Devine, Parker, Fou-
ladi, & Cohen, 2003; Parker, Baile, de Moor, & Cohen, 2003).
The TIP-C intervention applied in this investigation provided
a number of different types of social support (e.g., informa-
tional, emotional) in addition to helping participants identify
available social support in their own networks. By including
partners in the intervention, the authors hoped that the social
support available to patients during and after the counseling
would be enhanced. Social support is especially important
for maintaining the psychological well-being of people in
rural areas (Letvak, 2002). Such individuals ordinarily do
not have the same access to healthcare systems as those in
developed urban areas. Because more than 40% of the sample
in the present investigation resided in small towns and rural
communities, the authors believe that the six-week telephone
counseling intervention helped to improve or maintain their
mental health and QOL during such trying times.
These preliminary fi ndings provide some practice implica-
tions, however. Nurses need to assess the quantity and quality
of the social support network early in treatment, recognizing
that this network is vital to the recovery and QOL of women
with cancer. Women who have less social support need to be
routinely referred and encouraged to participate in counseling
and support services. And because participation in face-to-face
psychosocial interventions is poor, nurses could encourage
women to participate in telephone or online support programs
or in other programs or organizations (e.g., churches, social
clubs) that would provide support. Although this interven-
tion requires additional training in the advanced practice
role, some techniques in the intervention could be used by all
nurses, regardless of specialty training, to provide critical edu-
cation and support to women with breast cancer. For example,
nurses could provide education to reduce anxiety.
In conclusion, these preliminary fi ndings are consistent with
previous results indicating that counseling interventions work
to decrease negative outcomes in some women. Although
healthcare providers must proceed with caution because of the
exploratory nature of these fi ndings and the small sample size
of this pilot study, the challenge is to continue to examine and
refi ne the intervention in future research with larger sample
sizes. The telephone indeed may be an effective method to de-
liver psychosocial interventions to meet the needs of patients
with cancer and their partners.
Author Contact: Terry Badger, PhD, APRN, BC, can be reached
at firstname.lastname@example.org, with copy to editor at rose_
Table 3. Means for Treatment and Control Groups Across Time
Center for Epidemiologic Studies–Depression Scalea
Positive and Negative Affect Schedule
Multidimensional Fatigue Inventory
Index of Clinical Stress
Covariate Adjusted Means (Standard Error)
a Center for Epidemiologic Studies–Depression Scale scores were square-root transformed.
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