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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/56\\\/25\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/56\\\/25\u0022}],\u0022ac\u0022:{\u0022spmdc;14\\\/56\\\/25\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;14\\\/56\\\/25\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThe rates of contralateral prophylactic mastectomy are increasing in the United States, at the expense of unilateral mastectomy and breast-conserving surgery. Reasons include an overestimation of the risk of developing contralateral breast cancer, anxiety, an increase in the use of genetic testing, and a desire for better breast symmetry.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Ebilateral mastectomy\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eunilateral breast cancer\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eclinical implication\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Erisk perception\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Epatient preference\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003ERates of contralateral prophylactic mastectomy (CPM) or bilateral mastectomy to treat unilateral breast cancer have been increasing as a proportion of all mastectomies. Ismail Jatoi, MD, PhD, University of Texas Health Science Center, San Antonio, Texas, USA, discussed the clinical implications of CPM.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EThe rates of CPM are increasing in the United States. Data from 1998 to 2011 show a striking decrease in unilateral mastectomy, a stabilization of breast-conserving surgery, and a concomitant increase in bilateral mastectomy (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Kurian AW et al. \u003Cem\u003EJAMA.\u003C\/em\u003E 2014]. These changes have occurred despite a decline in the annual hazard rates for contralateral breast cancer (CBC) over time [Nichols HB et al. \u003Cem\u003EJ Clin Oncol.\u003C\/em\u003E 2011] and a lack of evidence to suggest that CPM is associated with a survival benefit, noted Dr Jatoi.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/56\/25\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Trends in Breast Cancer Surgery Type, by Patient Age at DiagnosisAdapted from Kurian AW et al. Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011. JAMA. 2014;312:902-914. Copyright \u0026#xA9; (2014) American Medical Association. All rights reserved.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-140492069\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;Trends in Breast Cancer Surgery Type, by Patient Age at DiagnosisAdapted from Kurian AW et al. Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011. \u0026amp;lt;em\u0026amp;gt;JAMA.\u0026amp;lt;\/em\u0026amp;gt; 2014;312:902-914. Copyright \u0026#xA9; (2014) American Medical Association. All rights reserved.\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/56\/25\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/56\/25\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/56\/25\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11625\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003ETrends in Breast Cancer Surgery Type, by Patient Age at Diagnosis\u003C\/p\u003E\n               \u003Cp id=\u0022p-5\u0022\u003EAdapted from Kurian AW et al. Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998-2011. \u003Cem\u003EJAMA.\u003C\/em\u003E 2014;312:902-914. Copyright \u00a9 (2014) American Medical Association. All rights reserved.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EThe underlying reason for these trends is not fully understood, but a potential explanation is that women may overestimate their risk of developing CBC. Several other potential factors to account for increased rates of CPM may be younger age, a preference for better symmetry with bilateral mastectomy and reconstruction vs unilateral mastectomy and reconstruction, an increase in the use of genetic testing, and wider use of preoperative breast magnetic resonance imaging [Hawley ST et al. \u003Cem\u003EJAMA Surg.\u003C\/em\u003E 2014]. In addition, observational studies that demonstrate reductions in breast cancer\u2013specific and all-cause mortality compared with unilateral surgical treatment alone may influence patients\u2019 decisions. These reductions in mortality, however, may reflect a confounding bias, such as selection of a healthier cohort for CPM, he said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003ETo explore this possibility, Dr Jatoi\u2019s group examined the association between CPM and noncancer mortality in 449\u2009178 adult women diagnosed with unilateral primary American Joint Committee on Cancer (AJCC) stage I to III ductal or lobular breast cancer, using the 1998\u20132010 Surveillance, Epidemiology, and End Results data set [Jatoi I, Parsons HM. \u003Cem\u003EBreast Cancer Res Treat.\u003C\/em\u003E 2014]. Of these women, 5.8% (n\u2009=\u200925\u2009961) underwent CPM as their first course of treatment. Multivariate logistic regression\u2014adjusting for age, race, AJCC stage, estrogen receptor status, progesterone receptor status, and histologic grade of the tumor\u2014showed that among all patients receiving CPM as a first course of treatment, CPM was associated with lower breast cancer\u2013specific (HR 0.84; 95% CI, 0.79 to 0.89), all-cause (HR 0.83; 95% CI, 0.80 to 0.88), and noncancer (HR 0.71, 95% CI, 0.64 to 0.80) 5-year hazard of death. The even stronger association between CPM and lower noncancer mortality compared with breast cancer\u2013specific and all-cause mortality is evidence that selection bias is partially attributable for reported associations between CPM and reductions in mortality.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EAnn H. Partridge, MD, MPH, Dana-Farber Cancer Institute, Boston, Massachusetts, USA, spoke about patient preferences and risk perceptions about CPM. In a cross-sectional survey, women reported high overall satisfaction with their decision to have CPM [Rosenberg SM et al. \u003Cem\u003EAnn Intern Med.\u003C\/em\u003E 2013]. Of 123 women with unilateral breast cancer who were \u2264\u200940 years at diagnosis and had undergone bilateral mastectomy (only 25% of whom were BRCA1\/BRCA2 mutation carriers), 90% would definitely have chosen CPM if they had to make the decision again, and 97% believed that they knew the risks and benefits of each treatment option.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EDecisions are potentially being made without adequate information and psychosocial support. Physicians were the most important sources of information in the decision to undergo CPM; 80% of women reported speaking with their physicians to at least some extent about the reasons for having CPM [Rosenberg SM et al. \u003Cem\u003EAnn Intern Med.\u003C\/em\u003E 2013]. Few women reported advice from family or friends or abnormal screening tests as important reasons for choosing CPM.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EFurther, women are making decisions about CPM based on inaccurate risk perceptions and understanding. Women who were not at increased genetic risk (noncarriers of BRCA1\/BRCA2 mutation) overestimated their chance of developing a CBC, with noncarriers estimating that a median of 10 of 100 women would develop a CBC without CPM within 5 years [Rosenberg SM et al. \u003Cem\u003EAnn Intern Med.\u003C\/em\u003E 2013], which exceeds the actual risk of approximately 2% to 4% over 5 years.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EAnxiety and fear of recurrence are stoking inaccurate risk perceptions among those with breast cancer. Most women ranked desire to improve survival and a desire to prevent metastatic disease as extremely or very important reasons for choosing CPM, even though most understood that having a bilateral mastectomy would not lead to an extension of survival [Rosenberg SM et al. \u003Cem\u003EAnn Intern Med.\u003C\/em\u003E 2013]. In another survey of 1447 women with breast cancer, 68.9% of women who underwent CPM had no major genetic or familial risks for CBC [Hawley ST et al. \u003Cem\u003EJAMA Surg.\u003C\/em\u003E 2014].\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EPhysicians must offer patient-centered care, ensuring that risks and benefits are effectively communicated in a supportive environment, with the goal of shared decision making, said Dr Partridge.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EAndrea Pusic, MD, Memorial Sloan-Kettering Cancer Center, New York, New York, USA, discussed the implications of CPM for reconstruction, noting that women with breast cancer increasingly seek information on reconstructive options and outcomes. Options for reconstruction are flap reconstruction and tissue expansion with implant, both with nipple reconstruction. Flap reconstruction uses autologous tissue, usually from the abdomen, that is relocated to form a new breast mound. In tissue expansion, a temporary inflatable breast implant put in place for 3 to 6 months stretches the skin and pectoralis muscle to accommodate a permanent implant.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EThe popularity of implant reconstruction is increasing, more than doubling between 1998 and 2008, and has increased for bilateral mastectomies by 17% per year (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Albornoz CR et al. \u003Cem\u003EPlast Reconstr Surg.\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/56\/25\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Unilateral and Bilateral Mastectomy Rates, US, 1998 to 2008IRR, incidence rate ratio.Reprinted from Albornoz C et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131:15-23.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-140492069\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;Unilateral and Bilateral Mastectomy Rates, US, 1998 to 2008IRR, incidence rate ratio.Reprinted from Albornoz C et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. \u0026amp;lt;em\u0026amp;gt;Plast Reconstr Surg\u0026amp;lt;\/em\u0026amp;gt;. 2013;131:15-23.\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/56\/25\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/56\/25\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/56\/25\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11627\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-15\u0022 class=\u0022first-child\u0022\u003EUnilateral and Bilateral Mastectomy Rates, US, 1998 to 2008\u003C\/p\u003E\n               \u003Cp id=\u0022p-16\u0022\u003EIRR, incidence rate ratio.\u003C\/p\u003E\n               \u003Cp id=\u0022p-17\u0022\u003EReprinted from Albornoz C et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. \u003Cem\u003EPlast Reconstr Surg\u003C\/em\u003E. 2013;131:15-23.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EThe changing mastectomy pattern (increasing use of bilateral mastectomies) is one factor that underlies a shift away from use of autologous tissue to implant-based reconstruction [Cemal Y et al. \u003Cem\u003EPlast Reconstr Surg.\u003C\/em\u003E 2013]. Responses to a patient questionnaire showed that more than one third of mastectomy patients chose bilateral mastectomy because they wanted breast symmetry [Han E et al. \u003Cem\u003EAm J Surg.\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EUnilateral implant reconstruction can be disappointing in the long term, said Dr Pusic, and patients must be made aware of expected outcomes. A new way of measuring patient satisfaction\/quality of life with breast reconstruction is a questionnaire called the Breast-Q. Among 294 women who used the instrument to measure satisfaction with breast reconstruction, the mean satisfaction score was higher among the 112 who underwent bilateral reconstruction compared with the 182 who had unilateral reconstruction at a mean of 4.5 years (\u003Cem\u003EP\u003C\/em\u003E\u2009=\u2009.001), but quality-of-life domains did not differ [Koslow S et al. \u003Cem\u003EAnn Surg Oncol.\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EPostmastectomy reconstruction with a direct implant offers a 1-step approach to reconstruct the breast mound in select patients. Direct implant placement forgoing tissue expansion is an appealing option to women, she said, and is best suited for patients with preserved breast skin after mastectomy.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/56\/25.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzo8de\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzo8de\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}