Abstract
Purpose
This study aimed to (1) describe the proportion of survivors reporting that a physician discussed strategies to improve health and (2) identify which groups are more likely to report these discussions.
Methods
Lung cancer and colorectal cancer (CRC) survivors (>5 years from diagnosis) (n = 874) completed questionnaires, including questions on whether, in the previous year, a physician discussed (1) strategies to improve health, (2) exercise, and (3) diet habits. Chi-square tests and logistic regression models were used to examine whether the likelihood of these discussions varied by demographic and clinical characteristics.
Results
Fifty-nine percent reported that a physician discussed strategies to improve health and exercise, 44 % reported discussions on diet, and 24 % reported no discussions. Compared to their counterparts, survivors with lower education were less likely to report discussing all three areas, but survivors with diabetes were more likely. Survivors ≥65 years old were less likely to report discussing strategies to improve health and diet. Males and CRC survivors reported discussing diet more than their female and lung cancer counterparts, respectively.
Conclusion
The frequency of health promotion discussions varied across survivor characteristics. Discussions were more frequently reported by some groups, e.g., survivors with diabetes, or among individuals less likely to engage in healthy behaviors. In contrast, males and older and less educated survivors were less likely to have these discussions.
Implications for Cancer Survivors
Decreasing physician barriers and encouraging patients to discuss health promotion, especially in the context of clinical care for older survivors and those with low education, is essential for promoting the overall well-being of cancer survivors.
Similar content being viewed by others
Avoid common mistakes on your manuscript.
Introduction
The 5-year relative cancer survival rate has improved to 68 %, greatly increasing the number expected to reach long-term survivorship [1]. Long-term survivors are at increased risk for comorbid conditions (i.e., diabetes, osteoporosis, cardiovascular disease) compared to the general population [2, 3]. These comorbidities, as well as cancer recurrence and overall mortality, are caused not only by the primary cancer and its treatment, but potentially by poor diet, limited physical activity, and other lifestyle behaviors [4]. Survivors fall short of meeting dietary and physical activity recommendations [5–7] and have a high risk for comorbid conditions. Given findings that provider-delivered information is effective for encouraging healthy behaviors [8, 9], promoting healthy behavior habits and sharing information on how to maintain overall health and wellness is especially important for this population in both primary care and oncology settings [10].
The frequency of survivors reporting having health promotion discussions with their physicians is varied. One investigation based on the 2005 California Health Interview Study found that 68 % of cancer survivors reported that a physician discussed exercise and 61 % reported discussions related to diet [11]. Studies conducted using data from 2000 found that less than half or the survivors received advice on physical activity (35 %) and dietary habits (<30 %) [12, 13]. However, most survivors (80 %) indicated that they were interested in receiving health promotion advice [12]. Moreover, some groups may be more likely to have these conversations. In non-cancer populations with conditions such as hypertension, blacks, males, adults with Medicare insurance, and medically complex patients, such as overweight and diabetic patients, were more likely to receive lifestyle advice than their counterparts [14, 15]. Given the importance of a healthy diet and a program of regular physical activity for all adults, determining whether physician discussions about health promotion varies across subgroups of cancer survivors, as it does in other patient groups, will help identify gaps in care for specific groups of cancer survivors.
Despite the emphasis on long-term survivorship care by medical and non-medical organizations since 2000 [16, 17] and increasing evidence on the importance of lifestyle behaviors in survivorship [10, 18, 19], survivors have reported limited communication on health promotion with their health care providers, and few recent studies have sought to examine the issue [20]. The aims of the present study were to determine the proportion of long-term lung cancer and colorectal cancer (CRC) survivors participating in the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium study reporting that a physician discussed strategies to improve health or prevent illness and/or discussed current exercise and diet habits. Moreover, whether these discussions were more likely for some groups of survivors than others was examined. Based on findings in non-cancer populations, we hypothesized that blacks, males, and complex patients, i.e., with other comorbidities, would be more likely to have health promotion discussions with physicians than their counterparts. Similarly, because CRC incidence may be associated with lack of healthy eating and exercise [21], we expected that these participants would be more likely to have their physician discuss health promotion than lung cancer patients.
Materials and methods
Data and sample selection
The CanCORS Consortium was established by the National Cancer Institute in 2001 [22]. When initially funded, it was comprised of five geographically distinct sites, five Cancer Research Network (CRN) integrated health systems, and 15 Veterans Health Administration hospitals. CRC and lung cancer patients within 4 to 7 months of diagnosis, recruited through state cancer registries and health care administrative data, participated in baseline and follow-up surveys about initial treatment, care, and symptoms between 2003 and 2005 (CanCORS I). Minorities (African American, Asian/Pacific Islander, and Hispanic) were oversampled. For CanCORS II, patients were re-contacted beginning in 2012. Surveys focusing on long-term follow-up care and health were administered to patients and survivors. For CanCORS II, an advanced-disease survey was delivered to those with recurrent disease (n = 101), and a disease-free survey was administered to those without recurrent disease (n = 889). CanCORS II was available only in English. The survey instruments, comprised of validated questionnaires as well as new items developed for CanCORS, were pilot-tested prior to implementation [23]. Human subjects review boards approved all procedures at participating sites.
Sample selection criteria
The present study focused on the disease-free (no recurrent cancer) survivors from the CanCORS II survey (n = 889). Fifteen survivors who did not see a physician (primary care or any other type) in the previous 12 months were excluded. The final sample size was 874.
Measures
Four primary dependent variables were used based on three study questions: “In the past 12 months, did a physician discuss: specific things you could do to improve heath or prevent illness?”; “How much or what kinds of food you eat?”; and “How much or what kind of exercise you get?” The fourth dependent variable was a summary variable indicating whether the survivor reported having any of the three discussions with their physician. Response options were “yes, definitely”, “yes, somewhat”, and “no”. The options “yes, definitely” and “yes, somewhat” were collapsed to create a dichotomous variable where one equals “yes” and zero equals “no” for each of the three dependent variables.
Survivors self-reported frequency of alcohol use and smoking status. Frequency of alcohol use was assessed through two items, extracted from the Behavioral Risk Factor Surveillance Survey, that measure frequency of drinking alcohol and the amount per occasion. Sine there was no item to assess whether a physician discussed drinking, alcohol consumption was not examined further. Less than 2 % of the entire sample qualified as heavy drinkers (women = ≥4 drinks on any occasion and men = ≥5 drinks). Overall, 44 % did not drink at all, and 47 % reported only one to two drinks per occasion. For smoking, survivors were asked whether they had smoked in the past 12 months. Those who responded “yes” then indicated whether they were a current smoker and whether a health care provider advised them to quit smoking. Only 13 % (n = 110) of the sample reported smoking in the past 12 months, and 56 % of the 110 reported current smoking. Among those with a smoking history, 71 % reported that a health care provider had advised them to quit.
Data on age category, race, gender, marital status, and highest education achieved were obtained from baseline surveys. Clinical information on cancer type, stage, and time since diagnosis was obtained from medical records or cancer registries if medical records were unavailable. Comorbidities, including high blood pressure, heart condition (heart attack, congestive heart failure, angina), stroke, diabetes, and pulmonary condition (chronic lung disease, emphysema) were self-reported by survivors at the time of the CanCORs II survey.
Data analysis
Frequencies are presented for categorical variables, and mean and standard deviations (SD) are presented for continuous variables. Chi-square tests were used to assess for differences in each physician advice variable by age (<65 vs. ≥65 years), race (non-minority vs. minority), gender, cancer type, education, comorbidities (high blood pressure, diabetes, heart condition, stroke, pulmonary condition), diagnosis stage (stage 0/I vs. stage II–IV), and treatment type (surgery, radiation, and chemotherapy).
Four multivariable logistic regression models were conducted for each of the dependent variables. Variables found to be significant (at p = <0.05) with any of the dependent variables in the chi-square analyses were included in each of the multivariable models. Although treatment type was not significant in a bivariate analysis, it was included in the multivariable model because of its association with comorbidities (e.g., treatment-induced diabetes). Multicollinearity checks indicated no collinearity issues. Hosmer-Lemeshow goodness-of-fit statistics indicated adequate model fit [24]. Analyses were conducted with SAS V9.3 (Cary, NC) [25].
Results
Sample characteristics
Of the sample, 73 % were 65 or older at the time of survey, 52 % were male, and 80 % were White (Table 1). Most survivors had at least some college education. Of the survivors, 74 % were CRC survivors, and 69 % were diagnosed at stage I or II. The mean number of years from diagnosis was 7.5 years (SD = 0.58) with a range of 6.1 to 9.4 years. Sixty-three percent had high blood pressure, 29 % reported a heart condition, and 26 % reported having diabetes. Almost all survivors (91 %) reported that the type of physician they had seen in the past 12 months was a primary care physician. Most survivors (75 %) reported that a physician discussed at least one of the health care topics (Table 2). Approximately one third of the survivors discussed all three health promotion topics with their physicians (results not shown), and 24 % did not have these discussions.
Physician discussions on strategies to improve health or prevent illness
Over half of the participants reported that a physician discussed strategies to improve health or prevent illness (Table 2). As determined by bivariate analyses, younger survivors, those with higher education, and those with diabetes or with high blood pressure had a higher frequency of reporting these discussions (Table 3). Significant associations were confirmed in the multivariable model, where those with diabetes, high blood pressure, and/or pulmonary conditions were more likely to report discussing strategies to improve health. Older patients and those with lower education (less than high school or high school degree) were less likely to report discussing strategies to improve health compared to their counterparts (Table 4).
Physician discussions on how much or what kinds of food were eaten
Less than half of participants (44 %) reported that the physician discussed how much and what kinds of food they eat. Younger survivors, minorities, males, CRC survivors, and those with diabetes had higher frequencies of reporting receiving advice on food (Table 3). The multivariable model supported findings from the bivariate analysis (Table 4).
Physician discussions on how much or what kind of exercise
Over half of the participants reported that a physician discussed exercise habits (Table 2). Compared to their counterparts, younger survivors, minorities, CRC survivors, those with higher education, and those with diabetes had a higher frequency of reporting that a physician discussed exercise. The multivariable model indicated that those with diabetes were significantly more likely to report that a physician discussed exercise (Table 4). Survivors with less than a high school education (OR 0.45, 95 % CI 0.27–0.75) or a high school education (OR 0.66, 95 % CI 0.45–0.97) were significantly less likely to report that their physician discussed exercise habits compared to those with a college degree or higher.
Physician discussions of any of the three health promotion topics
Younger survivors, males, minorities, those with higher education, those who received chemotherapy and radiation, and those with diabetes or high blood pressure had higher frequencies of a physician discussing any of three areas of health promotion (Table 3). In the multivariable model, age, education, treatment, and diabetes remained significant (Table 4.)
Discussion
Among long-term CRC and lung cancer survivors who had seen a physician in the past 12 months, 59 % reported that their doctor discussed strategies to improve health, 59 % reported that their doctor discussed exercise, and 44 % reported that their doctor discussed the foods they ate. Of concern, almost one in four did not discuss any of the three areas with their physicians. Additionally, subgroups of survivors, older survivors and those with low education, who are also at higher risk of poor outcomes compared to their counterparts, were less likely to report discussions related to health promotion.
The percentages of survivors reporting that their physician discussed exercise and diet (59 and 44 %, respectively) were higher than those previously reported from studies conducted using data from 2000 (35 and 30 % [12]; 26 and 30 % [13]) but slightly lower than those from Weaver and colleagues (68 and 61 %, respectively) [11]. It is possible that the present findings provide evidence for a trend toward improvement in physicians having discussions of health promotion topics with cancer survivors. However, the present population was comprised of CRC and lung cancer survivors; previous studies included only breast and prostate cancer survivors or a heterogeneous mix of cancer types. It is possible that health promotion discussions in these cancer survivor groups remain low as previously reported.
Despite the potentially improved frequency of health promotion discussions, a substantial proportion of survivors surveyed in CanCORS reported not having them. Physician-reported barriers to discussing lifestyle behaviors with cancer survivors include concerns that lifestyle advice may be perceived as insensitive or implying blame [26], lack of knowledge and confidence to discuss the benefits of lifestyle factors [27], and lack of awareness of the importance of lifestyle factors [28]. To some extent, these barriers contradict how survivors perceive health promotion advice from physicians. One study of survivors recently completing treatment found that 80 % reported lifestyle advice to be helpful and stated that doctors had a duty to provide this information; only a few (15 %) felt advice would be insensitive [29].
Although physician engagement in information exchange for lifestyle behaviors can effectively and positively change behavior [8, 9], in the present study, some survivors, particularly those who were older and those with low education, were less likely to report having health behavior discussions. Compared to younger survivors, older survivors were less likely to report having at least one discussion of health promotion and less likely to discuss strategies to improve health and diet. However, they are especially in need of physician advice on health behaviors, given that older survivors are less likely to undertake healthful behavior change [12, 30] or maintain healthy behavior [30]. Further, compared to younger survivors, older survivors are more receptive to advice from physicians (e.g., perceived as beneficial) [29]. On the contrary, survivors with lower education may not have such attitudes: in fact, survivors with higher education had more positive attitudes toward receiving advice from physicians than those with lower education [29]. This may explain our finding that CanCORS survivors with lower education were less likely to have at least one discussion of health promotion and discussions about exercise. These findings are of concern because older and less educated populations are, compared to their counterparts, less likely to engage in healthy behaviors [30, 31] but are at higher risk for recurrence or other comorbid conditions [31].
Several of the present findings are encouraging. Although some groups are less likely to engage in healthy behaviors, e.g., males and minorities [12, 32, 33], as determined in the present research, they were more likely to report discussing the foods they eat with their physicians. Similarly, survivors with health conditions for which there are clear linkages between healthy behaviors and better outcomes were more likely to discuss health improvement strategies, exercise, and diet [34]. For CRC survivors, there are benefits (e.g., long-term survival, recurrence) of healthy lifestyle behavior [35]. Diabetes was the only comorbidity associated with higher likelihood of discussing all health topics with physicians. Not only are cancer survivors with diabetes more likely to report that cancer is affecting their health [36] and desire information on lifestyle behaviors [37, 38], but there is evidence for the health benefits of physical activity and improved diet for diabetes, independent of cancer [39]. In contrast, survivors with high blood pressure were more likely to report discussions about strategies to improve health, but not specifically on diet or exercise. This finding is in part consistent with data from a previous study in which survivors with cardiovascular disease were more likely to report that a physician discussed with them overall behavior change and exercise, but not diet [11].
There are limitations of the present study. CanCORS’ survey questions referred only to discussions with one doctor and did not assess whether other types of health care professionals discussed health behaviors. The questions also did not identify whether the physician gave specific advice or simply had a conversation with the survivor about current habits. Since data on height and weight were not available, we could not determine if a discussion of health promotion differs for normal weight vs. overweight patients. Without a measure of overweight status, we cannot determine the clinical relevance of some of the discussions that were missed (e.g., greater implications for an overweight CRC survivor vs. a normal weight lung cancer survivor). The evidence is mixed on the difference in receiving health promotion advice by overweight status. Some studies found that the receipt of health promotion advice did not differ by overweight status [13]; others did find differences [11]. Comorbidities were self-reported, and their duration was not known. Persistent, long-term comorbidities may increase health care utilization and the likelihood that physicians will discuss health promotion with survivors. Finally, there was a potential for recall bias with the patient report of the discussion questions, and we were unable to validate the responses with physician notes.
The results indicate that more survivors may be having health promotion discussions than in the recent past, yet a substantial proportion of survivors do not report these discussions. Furthermore, while physicians are more frequently having health promotion discussions with some survivors for whom there are known benefits from healthy behaviors and/or who are known to be less likely to engage in healthy behaviors (e.g., survivors with diabetes and males), they are not discussing these behaviors with other survivors who are at higher risk for poor outcomes associated with limited healthy behaviors, e.g., older and less educated survivors. Further research is warranted on how to promote these discussions; to educate physicians, other health care providers, and survivors on evidence-based guidelines related to health promotion; and to encourage health lifestyle strategies for survivors.
References
American Cancer Society. Cancer facts and figures 2014. Atlanta: American Cancer Society; 2014.
Holmes HM, Nguyen HT, Nayak P, Oh JH, Escalante CP, Elting LS. Chronic conditions and health status in older cancer survivors. Eur J Intern Med. 2014;25:374–8.
Smith AW, Reeve BB, Bellizzi KM, Harlan LC, Klabunde CN, Amsellem M, et al. Cancer, comorbidities, and health-related quality of life of older adults. Health Care Financ Rev. 2008;29:41–56.
Ligibel J. Lifestyle factors in cancer survivorship. J Clin Oncol. 2012;30:3697–704.
Bellizzi KM, Rowland JH, Jeffery DD, McNeel T. Health behaviors of cancer survivors: examining opportunities for cancer control intervention. J Clin Oncol. 2005;23:8884–93.
Coups EJ, Ostroff JS. A population-based estimate of the prevalence of behavioral risk factors among adult cancer survivors and noncancer controls. Prev Med. 2005;40:702–11.
Rebholz CE, Rueegg CS, Michel G, Ammann RA, von der Weid NX, Kuehni CE, et al. Clustering of health behaviours in adult survivors of childhood cancer and the general population. Br J Cancer. 2012;107:234–42.
Pinto BM, Papandonatos GD, Goldstein MG. A randomized trial to promote physical activity among breast cancer patients. Health Psychol. 2013;32:616–26.
Moldovan-Johnson M, Martinez L, Lewis N, Freres D, Hornik RC. The role of patient-clinician information engagement and information seeking from nonmedical channels in fruit and vegetable intake among cancer patients. J Health Commun. 2014;19:1359–76.
Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62:242–74.
Weaver K, Foraker R, Alfano C, Rowland J, Arora N, Bellizzi K, et al. Cardiovascular risk factors among long-term survivors of breast, prostate, colorectal, and gynecologic cancers: a gap in survivorship care? J Cancer Surviv. 2013;7:253–61.
Demark-Wahnefried W, Peterson B, McBride C, Lipkus I, Clipp E. Current health behaviors and readiness to pursue life-style changes among men and women diagnosed with early stage prostate and breast carcinomas. Cancer. 2000;88:674–84.
Sabatino SA, Coates RJ, Uhler RJ, Pollack LA, Alley LG, Zauderer LJ. Provider counseling about health behaviors among cancer survivors in the United States. J Clin Oncol. 2007;25:2100–6.
Lopez L, Cook EF, Horng MS, Hicks LS. Lifestyle modification counseling for hypertensive patients: results from the National Health and Nutrition Examination Survey 1999–2004. Am J Hypertens. 2009;22:325–31.
Martin MY. Missed opportunities? Improving the care of patients with high blood pressure. Am J Hypertens. 2009;22:242.
Institute of Medicine [IOM]. From cancer patient to cancer survivor: lost in transition. Washington, D.C.: National Academies Press; 2006.
Jones L, Demark-Wahnefried W. Recommendations for health behavior and wellness following primary treatment for cancer. Washington, DC: National Academies Press; 2007.
Winger J, Mosher C, Rand K, Morey M, Snyder D, Demark-Wahnefried W. Diet and exercise intervention adherence and health-related outcomes among older long-term breast, prostate, and colorectal cancer survivors. Ann Behav Med. 2014;1–11.
Demark-Wahnefried W, Jones LW. Promoting a healthy lifestyle among cancer survivors. Hematol Oncol Clin North Am. 2008;22:319–42.
Arora NK, Reeve BB, Hays RD, Clauser SB, Oakley-Girvan I. Assessment of quality of cancer-related follow-up care from the cancer survivor’s perspective. J Clin Oncol. 2011;29:1280–9.
Kushi LH, Byers T, Doyle C, Bandera EV, McCullough M, Gansler T, et al. American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin. 2006;56:254–81.
Ayanian JZ, Chrischilles EA, Fletcher RH, Fouad MN, Harrington DP, Kahn KL, et al. Understanding cancer treatment and outcomes: the Cancer Care Outcomes Research and Surveillance Consortium. J Clin Oncol. 2004;22:2992–6.
Malin JL, Ko C, Ayanian JZ, Harrington D, Nerenz DR, Kahn KL, et al. Understanding cancer patients’ experience and outcomes: development and pilot study of the Cancer Care Outcomes Research and Surveillance patient survey. Support Care Cancer. 2006;14:837–48.
Hosmer DW, Lemeshow S. Applied logistic regression. Hoboken: Wiley; 2000.
SAS Institute. SAS 9.3. 2012; 9.3.
Macmillan Cancer Support/ICM. Move more: physical activity: the underrated wonder drug. 2011.
Miles A, Simon A, Wardle J. Answering patient questions about the role lifestyle factors play in cancer onset and recurrence: what do health care professionals say? J Health Psychol. 2010;15:291–8.
Rodman S, Murphy JL. Nutrition knowledge and attitudes of pre-registered and registered nurses in relation to cancer survivorship. Proc Nutr Soc. 2011;70:E307.
Williams K, Beeken RJ, Wardle J. Health behaviour advice to cancer patients: the perspective of social network members. Br J Cancer. 2013;108:831–5.
Demark-Wahnefried W, Aziz NM, Rowland JH, Pinto BM. Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. J Clin Oncol. 2005;23:5814–30.
Aarts MJ, Kamphuis CB, Louwman MJ, Coebergh JW, Mackenbach JP, van Lenthe FJ. Educational inequalities in cancer survival: a role for comorbidities and health behaviours? J Epidemiol Community Health. 2013;67:365–73.
Blanchard CM, Courneya KS, Stein K, American Cancer Society’s SCS-II. Cancer survivors’ adherence to lifestyle behavior recommendations and associations with health-related quality of life: results from the American Cancer Society’s SCS-II. J Clin Oncol. 2008;26:2198–204.
Hong S, Bardwell W, Natarajan L, Flatt S, Rock C, Newman V, et al. Correlates of physical activity level in breast cancer survivors participating in the Women’s Healthy Eating and Living (WHEL) Study. Breast Cancer Res Treat. 2007;101:225–32.
Blanchard CM, Stein KD, Baker F, et al. Association between current lifestyle behaviors and health-related quality of life in breast, colorectal and prostate cancer survivors. Psychol Health. 2004;19:1–13.
Vrieling A, Kampman E. The role of body mass index, physical activity, and diet in colorectal cancer recurrence and survival: a review of the literature. Am J Clin Nutr. 2010;92:471–90.
Stava CJ, Beck ML, Feng L, Lopez A, Busaidy N, Vassilopoulou-Sellin R. Diabetes mellitus among cancer survivors. J Cancer Surviv. 2007;1:108–15.
Coa K, Smith K, Klassen A, Caulfield L, Helzlsouer K, Peairs K, et al. Capitalizing on the “teachable moment” to promote healthy dietary changes among cancer survivors: the perspectives of health care providers. Support Care Cancer. 2015;23:679–86.
Volker DL, Becker H, Kang SJ, Kullberg V. A double whammy: health promotion among cancer survivors with preexisting functional limitations. Oncol Nurs Forum. 2013;40:64–71.
Fowler MJ. Diabetes treatment, part 1: diet and exercise. Clin Diabetes. 2007;25:105–9.
Acknowledgments
The work was supported by the CanCORS consortium, which was supported by grants from the National Cancer Institute (NCI) to the Statistical Coordinating Center (U01 CA093344) and the NCI-supported Primary Data Collection and Research Centers (Dana-Farber Cancer Institute/Cancer Research Network [U01 CA093332], Harvard Medical School/Northern California Cancer Center [U01 CA093324], RAND/UCLA [U01 CA093348], University of Alabama at Birmingham [U01CA093329], University of Iowa [U01CA093339], University of North Carolina [U01 CA 093326] and by a Department of Veterans Affairs grant to the Durham VA Medical Center [CRS 02–164]), and grant 2 T32 HS013852 from the Agency for Healthcare Research and Quality, Rockville, MD, USA (KK). We thank Dr. Donald Hill from the UAB Division of Preventive Medicine for his editorial review of the manuscript.
Conflict of interest
The authors declare that they have no competing interests.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Kenzik, K., Pisu, M., Fouad, M.N. et al. Are long-term cancer survivors and physicians discussing health promotion and healthy behaviors?. J Cancer Surviv 10, 271–279 (2016). https://doi.org/10.1007/s11764-015-0473-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11764-015-0473-8