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<article article-type="research-article" dtd-version="1.3" xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xml:lang="ru"><front><journal-meta><journal-id journal-id-type="publisher-id">fcmedicine</journal-id><journal-title-group><journal-title xml:lang="ru">Фундаментальная и клиническая медицина</journal-title><trans-title-group xml:lang="en"><trans-title>Fundamental and Clinical Medicine</trans-title></trans-title-group></journal-title-group><issn pub-type="ppub">2500-0764</issn><issn pub-type="epub">2542-0941</issn><publisher><publisher-name>КемГМУ</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="doi">10.23946/2500-0764-2026-11-1-25-36</article-id><article-id custom-type="elpub" pub-id-type="custom">fcmedicine-1150</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group><subj-group subj-group-type="section-heading" xml:lang="ru"><subject>ПАТОЛОГИЧЕСКАЯ ФИЗИОЛОГИЯ</subject></subj-group><subj-group subj-group-type="section-heading" xml:lang="en"><subject>PATHOPHYSIOLOGY</subject></subj-group></article-categories><title-group><article-title>Иммуно-гормональная регуляция метастазирования опухоли у больных раком молочной железы</article-title><trans-title-group xml:lang="en"><trans-title>Immuno-hormonal regulation of tumor metastasis in breast cancer patients</trans-title></trans-title-group></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0002-8560-6719</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Глушков</surname><given-names>А. Н.</given-names></name><name name-style="western" xml:lang="en"><surname>Glushkov</surname><given-names>A. N.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Глушков Андрей Николаевич, доктор медицинских наук, профессор, главный научный сотрудник лаборатории иммуногенетики Института экологии человека</p><p>пр-т Ленинградский, д. 10, г. Кемерово, 650065 </p></bio><bio xml:lang="en"><p>Prof. Andrey N. Glushkov, MD, Dr. Sci. (Medicine), Professor, Chief Researcher, Laboratory of Immunogenetics, Institute of Human Ecology</p><p>Leningradsky Prospect, 10, Kemerovo, 650065 </p></bio><xref ref-type="aff" rid="aff-1"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0002-9368-2340</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Поленок</surname><given-names>Е. Г.</given-names></name><name name-style="western" xml:lang="en"><surname>Polenok</surname><given-names>E. G.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Поленок Елена Геннадьевна, кандидат фармацевтических наук, ведущий научный сотрудник лаборатории иммунохимии Института экологии человека</p><p>пр-т Ленинградский, д. 10, г. Кемерово, 650065 </p></bio><bio xml:lang="en"><p>Dr. Elena G. Polenok, MD, Cand. Sci. (Pharmacy), Leading Researcher, Laboratory of Immunochemistry, Institute of Human Ecology</p><p>Leningradsky Prospect, 10, Kemerovo, 650065 </p></bio><email xlink:type="simple">egpolenok@mail.ru</email><xref ref-type="aff" rid="aff-1"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0009-0008-9559-4396</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Аносова</surname><given-names>Т. П.</given-names></name><name name-style="western" xml:lang="en"><surname>Anosova</surname><given-names>T. P.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Аносова Татьяна Петровна, ведущий инженер-биолог лаборатории иммунохимии Института экологии человека</p><p>пр-т Ленинградский, д. 10, г. Кемерово, 650065 </p></bio><bio xml:lang="en"><p>Mrs. Tatiana P. Anosova, Leading Biological Engineer, Immunochemistry Laboratory, Institute of Human Ecology</p><p>Leningradsky Prospect, 10, Kemerovo, 650065 </p></bio><xref ref-type="aff" rid="aff-1"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0009-0009-7248-5987</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Аносов</surname><given-names>М. П.</given-names></name><name name-style="western" xml:lang="en"><surname>Anosov</surname><given-names>M. P.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Аносов Михаил Петрович, ведущий инженер-биолог лаборатории иммунохимии Института экологии человека</p><p>пр-т Ленинградский, д. 10, г. Кемерово, 650065 </p></bio><bio xml:lang="en"><p>Mr. Mikhail. P. Anosov, Leading Biological Engineer, Immunochemistry Laboratory, Institute of Human Ecology</p><p>Leningradsky Prospect, 10, Kemerovo, 650065 </p></bio><xref ref-type="aff" rid="aff-1"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0001-5870-7584</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Гордеева</surname><given-names>Л. А.</given-names></name><name name-style="western" xml:lang="en"><surname>Gordeeva</surname><given-names>L. A.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Гордеева Людмила Александровна, кандидат биологических наук, ведущий научный сотрудник лаборатории иммуногенетики Института экологии человека</p><p>пр-т Ленинградский, д. 10, г. Кемерово, 650065 </p></bio><bio xml:lang="en"><p>Dr. Lyudmila A. Gordeeva, Cand. Sci. (Biology) Leading Researcher, Laboratory of Immunogenetics, Institute of Human Ecology</p><p>Leningradsky Prospect, 10, Kemerovo, 650065 </p></bio><xref ref-type="aff" rid="aff-1"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0002-5530-3469</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Мун</surname><given-names>С. А.</given-names></name><name name-style="western" xml:lang="en"><surname>Mun</surname><given-names>S. A.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Мун Стелла Андреевна, кандидат медицинских наук, доцент, старший научный сотрудник лаборатории иммуногенетики Института экологии человека</p><p>пр-т Ленинградский, д. 10, г. Кемерово, 650065 </p></bio><bio xml:lang="en"><p>Dr. Stella A. Mun, MD, Cand. Sci. (Medicine), Senior Researcher, Laboratory of Immunogenetics, Institute of Human Ecology</p><p>Leningradsky Prospect, 10, Kemerovo, 650065 </p></bio><xref ref-type="aff" rid="aff-1"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0003-0053-1752</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Костянко</surname><given-names>М. В.</given-names></name><name name-style="western" xml:lang="en"><surname>Kostyanko</surname><given-names>M. V.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Костянко Михаил Владимирович, ведущий инженер кафедры фундаментальной и прикладной химии Института фундаментальных наук</p><p>ул. Красная, д. 6, г. Кемерово, 650000 </p></bio><bio xml:lang="en"><p>Mr. Mikhail V. Kostyanko, Leading Engineer, Department of Fundamental and Applied Chemistry, Institute of Fundamental Sciences</p><p>Krasnaya Street, 6, Kemerovo, 650000 </p></bio><xref ref-type="aff" rid="aff-2"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0002-6623-8818</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Студенников</surname><given-names>А. Е.</given-names></name><name name-style="western" xml:lang="en"><surname>Studennikov</surname><given-names>A. E.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Студенников Артем Евгеньевич, кандидат биологических наук, ведущий научный сотрудник лаборатории биотехнологии Института экологии человека </p><p>пр-т Ленинградский, д. 10, г. Кемерово, 650065 </p></bio><bio xml:lang="en"><p>Dr. Artem E. Studennikov, Cand. Sci. (Biology), Leading Researcher, Laboratory of Biotechnology, Institute of Human Ecology</p><p>Leningradsky Prospect, 10, Kemerovo, 650065 </p></bio><xref ref-type="aff" rid="aff-1"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0002-9134-5586</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Елисейкин</surname><given-names>А. М.</given-names></name><name name-style="western" xml:lang="en"><surname>Eliseikin</surname><given-names>A. M.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Елисейкин Алексей Михайлович, ведущий инженер-технолог лаборатории биотехнологии Института экологии человека</p><p>пр-т Ленинградский, д. 10, г. Кемерово, 650065 </p></bio><bio xml:lang="en"><p>Mr. Alexey M. Eliseikin, Leading Biological Engineer, Biotechnology Laboratory, Institute of Human Ecology</p><p>Leningradsky Prospect, 10, Kemerovo, 650065 </p></bio><xref ref-type="aff" rid="aff-1"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0009-0003-1731-1534</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Захаров</surname><given-names>В. Н.</given-names></name><name name-style="western" xml:lang="en"><surname>Zakharov</surname><given-names>V. N.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Захаров Вадим Николаевич, кандидат медицинских наук, главный врач</p><p>ул. Волгоградская, д. 35, г. Кемерово, 650036</p></bio><bio xml:lang="en"><p>Dr. Vadim N. Zakharov, MD, Cand. Sci. (Medicine), Chief Executive Officer</p><p>Krasnaya Street, 6, Kemerovo, 650000 </p></bio><xref ref-type="aff" rid="aff-3"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0003-0802-9759</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Антонов</surname><given-names>А. В.</given-names></name><name name-style="western" xml:lang="en"><surname>Antonov</surname><given-names>A. V.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Антонов Александр Витальевич, заведующий отделением опухолей молочной железы</p><p>ул. Волгоградская, д. 35, г. Кемерово, 650036</p></bio><bio xml:lang="en"><p>Dr. Alexander V. Antonov, MD, Chief of the Breast Cancer Unit </p><p>Volgogradskaya Street, 17, Kemerovo, 650036 </p></bio><xref ref-type="aff" rid="aff-3"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0002-4649-5892</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Байрамов</surname><given-names>П. В.</given-names></name><name name-style="western" xml:lang="en"><surname>Bayramov</surname><given-names>P. V.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Байрамов Павел Валерьевич, заведующий патологоанатомическим отделением</p><p>ул. Волгоградская, д. 35, г. Кемерово, 650036</p></bio><bio xml:lang="en"><p>Dr. Pavel V. Bayramov, MD, Chief of Pathology Unit</p><p>Volgogradskaya Street, 17, Kemerovo, 650036  </p></bio><xref ref-type="aff" rid="aff-3"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0003-3860-825X</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Вержбицкая</surname><given-names>Н. Е.</given-names></name><name name-style="western" xml:lang="en"><surname>Verzhbitskaya</surname><given-names>N. E.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Вержбицкая Наталья Евгеньевна, кандидат медицинских наук, врач-патологоанатом патологоанатомического отделения</p><p>ул. Волгоградская, д. 35, г. Кемерово, 650036 </p></bio><bio xml:lang="en"><p>Dr. Natalia E. Verzhbitskaya, MD, Cand. Sci. (Medicine), Pathologist, Pathology Unit</p><p>Volgogradskaya Street, 17, Kemerovo, 650036 </p></bio><xref ref-type="aff" rid="aff-3"/></contrib><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">https://orcid.org/0000-0002-5526-2687</contrib-id><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Колпинский</surname><given-names>Г. И.</given-names></name><name name-style="western" xml:lang="en"><surname>Kolpinsky</surname><given-names>G. I.</given-names></name></name-alternatives><bio xml:lang="ru"><p>Колпинский Глеб Иванович, доктор медицинских наук, профессор кафедры лучевой диагностики, лучевой терапии и онкологии; главный врач</p><p>ул. Ворошилова, д. 22А, г. Кемерово, 650056 </p><p>пр-т Октябрьский, д. 53/1, г. Кемерово, 650066 </p></bio><bio xml:lang="en"><p>Prof. Gleb I. Kolpinsky, MD, Dr. Sci. (Medicine), Professor, Department of Radiology, Radiotherapy and Oncology; Chief Executive Officer</p><p>Voroshilova Street, 22a, Kemerovo, 650056 </p><p>Oktyabrsky Prospekt, 53/1, Kemerovo, 650066 </p></bio><xref ref-type="aff" rid="aff-4"/></contrib></contrib-group><aff-alternatives id="aff-1"><aff xml:lang="ru"><institution>Федеральный исследовательский центр угля и углехимии Сибирского отделения Российской академии наук</institution><country>Россия</country></aff><aff xml:lang="en"><institution>Federal Research Center of Coal and Coal chemistry SB RAS</institution><country>Russian Federation</country></aff></aff-alternatives><aff-alternatives id="aff-2"><aff xml:lang="ru"><institution>Кемеровский государственный университет</institution><country>Россия</country></aff><aff xml:lang="en"><institution>Kemerovo State University</institution><country>Russian Federation</country></aff></aff-alternatives><aff-alternatives id="aff-3"><aff xml:lang="ru"><institution>Кузбасский клинический онкологический диспансер им. М.С. Раппопорта</institution><country>Россия</country></aff><aff xml:lang="en"><institution>Kuzbass Clinical Oncology Dispensary</institution><country>Russian Federation</country></aff></aff-alternatives><aff-alternatives id="aff-4"><aff xml:lang="ru"><institution>Кемеровский государственный медицинский университет ; Клинический консультативно-диагностический центр им. И.А. Колпинского</institution><country>Россия</country></aff><aff xml:lang="en"><institution>Kemerovo State Medical University ; Kemerovo Clinical Diagnostic Сenter</institution><country>Russian Federation</country></aff></aff-alternatives><pub-date pub-type="collection"><year>2026</year></pub-date><pub-date pub-type="epub"><day>22</day><month>03</month><year>2026</year></pub-date><volume>11</volume><issue>1</issue><fpage>25</fpage><lpage>36</lpage><permissions><copyright-statement>Copyright &amp;#x00A9; Глушков А.Н., Поленок Е.Г., Аносова Т.П., Аносов М.П., Гордеева Л.А., Мун С.А., Костянко М.В., Студенников А.Е., Елисейкин А.М., Захаров В.Н., Антонов А.В., Байрамов П.В., Вержбицкая Н.Е., Колпинский Г.И., 2026</copyright-statement><copyright-year>2026</copyright-year><copyright-holder xml:lang="ru">Глушков А.Н., Поленок Е.Г., Аносова Т.П., Аносов М.П., Гордеева Л.А., Мун С.А., Костянко М.В., Студенников А.Е., Елисейкин А.М., Захаров В.Н., Антонов А.В., Байрамов П.В., Вержбицкая Н.Е., Колпинский Г.И.</copyright-holder><copyright-holder xml:lang="en">Glushkov A.N., Polenok E.G., Anosova T.P., Anosov M.P., Gordeeva L.A., Mun S.A., Kostyanko M.V., Studennikov A.E., Eliseikin A.M., Zakharov V.N., Antonov A.V., Bayramov P.V., Verzhbitskaya N.E., Kolpinsky G.I.</copyright-holder><license xml:lang="ru" license-type="creative-commons-attribution" xlink:href="https://creativecommons.org/licenses/by/4.0/" xlink:type="simple"><license-p>Данная работа распространяется под лицензией Creative Commons Attribution 4.0.</license-p></license><license xml:lang="en" license-type="creative-commons-attribution" xlink:href="https://creativecommons.org/licenses/by/4.0/" xlink:type="simple"><license-p>This work is licensed under a Creative Commons Attribution 4.0 License.</license-p></license></permissions><self-uri xlink:href="https://fcm.kemsmu.ru/jour/article/view/1150">https://fcm.kemsmu.ru/jour/article/view/1150</self-uri><abstract><sec><title>Цель</title><p>Цель. Определить участие эстрадиола и прогестерона (E2 и Pg), гормон-специфических идиотипических и антиидиотипических антител, а также антител против бензо[а]пирена (Bp) в регуляции метастазирования опухолей у больных раком молочной железы (РМЖ).</p></sec><sec><title>Материалы и методы</title><p>Материалы и методы. Обследовали 475 больных II стадии РМЖ до начала лечения (254 – без метастазов в лимфоузлы, 221 – с метастазами). Содержание в сыворотке крови E2 и Pg исследовали с помощью тест-систем «ИммуноФА-Эстрадиол» и «ИммуноФА-ПГ» («Иммунотех», г. Москва) до начала лечения. Содержание идиотипических IgA1 и IgG1антител против E2, Pg и Bp, а также антиидиотипических IgG2 антител к E2 и Pg исследовали с помощью иммуноферментного метода. CART-анализ использовали в статистической обработке результатов.</p></sec><sec><title>Результаты</title><p>Результаты. Обнаружены корреляции уровней IgA1-Bp с IgA1-E2 и IgA1-Pg (rs = 0,71 и rs = 0,60; p &lt; 0,01), IgG1-Bp с IgG1-E2 и IgG1-Pg (rs = 0,75 и r s = 0,69; p &lt; 0,01). Содержание E2 и Pg не коррелировало с исследуемыми антителами. Выделены группы больных с определенными индивидуальными комбинациями IgG2-Pg + IgA1-Bp, статистически значимо взаимосвязанными с наличием метастазов. У 51 пациентки (группа 1.1) с низкими уровнями IgG2-Pg ≤ 2,19 у.е. + IgA1-Bp ≤ 2,21 у.е. метастазы выявлялись реже, чем у 137 (группа 1.2) с IgG2-Pg ≤ 2,19 у.е. в комбинации с IgA1-Bp&gt;2,21 у.е. (21,6 % vs 46,0 %; p = 0,004). У 15 больных (группа 2.1) с уровнями IgG2-Pg = 2,19–3,6 у.е. в комбинации с низкими уровнями IgA1-Bp ≤ 1,41 у.е. метастазы обнаруживались чаще, чем у 199 (группа 2.2) с такими же уровнями IgG2-Pg в комбинации с высокими уровнями IgA1-Bp &gt; 1,41 у.е. (86,7 % vs 53,3 %; p = 0,026). У 73 больных (группа 3) с высокими уровнями IgG2-Pg&gt;3,6 у.е. метастазы выявлялись в 38,4 %, реже, чем в группах 2.1 (p = 0,002) и 2.2 (p = 0,04).</p></sec><sec><title>Заключение</title><p>Заключение. IgG2-Pg способны угнетать, а IgA1-Bp – стимулировать метастазирование опухолей у больных II стадии РМЖ в определенных индивидуальных комбинациях друг с другом</p></sec></abstract><trans-abstract xml:lang="en"><sec><title>Aim</title><p>Aim. To determine the participation of estradiol and progesterone (E2 and Pg), hormone-specific idiotypic and antiidiotypic antibodies and antibodies against benzo[a]pyrene (Bp) in the regulation of tumor metastasis in breast cancer patients (BCP).</p></sec><sec><title>Materials and Methods</title><p>Materials and Methods. There were studied 475 BCP II stage (254 – without metastases and 221 – with metastases). Test-systems “ImmunoEA-Estradiol” and “ImmunoEA-Pg” (Immunotech, Moscow) were performed for blood serum E2 and Pg concentration analysis before antitumor treatment. Enzyme-linked immunosorbent assay was used for study of IgA1 and IgG1 antibodies against E2, Pg and Bp and antiidiotypic antibodies (IgG2). Associations of these serum factors with tumor metastasis were studies by CART-analysis.</p></sec><sec><title>Results</title><p>Results. There were revealed the correlation of IgA1-Bp with IgA1-E2 and IgA1-Pg (rs = 0.71 and rs = 0.60; p &lt; 0.01), IgG1-Bp with IgG1-E2 and IgG1-Pg (rs = 0.75 and r s = 0.69; p &lt; 0.01). Concentration of E2 and Pg were no correlated with studied idiotypic and antiidiotypic antibodies levels. There was revealed 5 groups of BCP with definite personal IgG2-Pg + IgA1-Bp combinations associated with metastases significantly. Metastatic tumors were revealed in 51 BCP (group 1.1) with low levels of IgG2-Pg ≤ 2.19 cu + IgA1-Bp ≤ 2.21 cu rarely than in 137 BCP (group 2) with IgG2-Pg ≤ 2.19 cu + IgA1-Bp&gt;2.21 cu (21.6% vs 46.0 %; p = 0,004). Metastasis were detected in 15 BCP (group 2.1) with IgG2-Pg 2.19–3.6 cu + IgA1-Bp levels ≤ 1.41cu frequently than in 199 (group 2.2) with IgG2-Pg 2.19– 3.6 cu + IgA1-Bp&gt;1.41cu (86.7 vs 53.3; p = 0,026). Metastases were found in 73 BCP (group 3) with high IgG2-Pg&gt;3.6 cu rarely (38.4%), vs groups 2.1 (p = 0.002) and group 2.2 (p = 0.04).</p></sec><sec><title>Conclusion</title><p>Conclusion. IgG2-Pg may inhibit whereas IgA1-Bp may stimulate the tumor metastasis in BCP II stage with definite personal combinations.</p></sec></trans-abstract><kwd-group xml:lang="ru"><kwd>рак молочной железы</kwd><kwd>эстрадиол</kwd><kwd>прогестерон</kwd><kwd>бензо[а]пирен</kwd><kwd>антитела</kwd></kwd-group><kwd-group xml:lang="en"><kwd>breast cancer</kwd><kwd>estradiol</kwd><kwd>progesterone</kwd><kwd>benzo[a]pyrene</kwd><kwd>antibodies</kwd></kwd-group><funding-group><funding-statement xml:lang="ru">Работа выполнена по государственному заданию Министерства науки и образования Российской федерации (проект FWEZ-2024-0012).</funding-statement><funding-statement xml:lang="en">The study was carried out according to the state assignment of the Ministry of Science and Education of the Russian Federation (project FWEZ-2024-0012).</funding-statement></funding-group></article-meta></front><back><ref-list><title>References</title><ref id="cit1"><label>1</label><citation-alternatives><mixed-citation xml:lang="ru">Howlader N., Altekruse S.F., Li C.I., Chen V.W., Clarke C.A., Ries L.A. et al. 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