Prostate Cancer Awareness: What We Need to Know

Welcome to the Living to 100 Club Podcast. Here's our host, Dr. Joseph Casciani.

Well, hello to everyone joining us today on our podcast. You're listening to one of our Successful Aging episodes this month on the Living to 100 Club program, and I am your host, Joe Casciani. Each week, our conversations educate and inspire, helping you get the best out of all the years we're given, regardless of what obstacles come our way. You can learn more about our club at our website. And be sure to take a look at my new training and activities manual, Better, Longer, and Happier: A Guide to Aging with Purpose and Positivity. This is a series of 12 modules in a card deck format developed for activities directors at senior living communities to learn more about psychologically healthy aging. And to engage senior residents in activities that are cognitively challenging and foster a positive mindset. Module 1 is on sale now. Visit our website, livingto100.club/blh. Now on to our podcast. On today's program, we take a close look at the risk factors for prostate cancer, the second leading cause of cancer deaths in the US. Our guest is Paul Arangua, M— Master's in Public Health and Epidemiology, and an educator researcher with the Prostate Conditions Education Council. We explore the incidence of prostate cancer, the risk factors, screening recommendations, and treatment outcomes. Why is prostate cancer so virulent when left untreated? And why does it spread so rapidly to other tissue and organs in the body? What's the survival rate when caught early? And what's the mortality rate if left unidentified? Our guest shares PSA screening recommendations for different age groups, as well as newer screens using genomic markers. What lifestyle changes are closely aligned with prevention? This is a highly educational and must-know topic. For all men and partners. First, a little background. Paul Arangua, MPH, is an accomplished public health professional specializing in prostate cancer and men's health. With a strong background in clinical environments, Paul has navigated various aspects of prostate cancer from screening to 3D diagnostics, innovative focal therapies, and disease progression. His expertise spans over 17 years working alongside Dr. E. David Crawford, conducting research in clinical epidemiology, medical device proof of concept, FDA regulatory strategy, and health administration. Beyond his professional work, he actively engages in educational initiatives and patient advocacy He serves as the Director of Research and Patient Insights at the Prostate Conditions Education Council. Paul has taken part in numerous speaking engagements, abstracts, and publications highlighting his commitment to research and knowledge sharing within the medical community, covering topics from innovative biomarkers to novel diagnostic algorithms. His extensive skill set in data management, research project management, and patient education underscores his dedication to advancing prostate cancer research and promoting men's health awareness. Paul, I'm honored to have such an esteemed authority and expert on this topic. Thank you for joining our program today.

Thank you for having me.

Yeah, you're welcome. You're, you're very welcome. I always like to open by asking our guests to tell us a little bit about the journey that brought you to where you are today. I know I touched on maybe the highlights of your professional work, but how did you get to where you are today?

So I, you know, when I was in college, I was very interested in studying biology and I had the idea of becoming a physician. And when I was in college, I received a grant to do some research at UCLA as a student studying substance abuse, HIV, and hepatitis C incidence within Skid Row, Los Angeles, which is actually the largest population of homeless in the United States.

Yeah.

And from that, I became very interested in epidemiology and diseases and trying to mitigate disease spread in populations. And so I ended up as a student still securing a research position with Dr. Crawford back in 2006 at the University of Colorado. And once I graduated, I continued research and I was hired on there full-time and really just enjoyed the aspects of research and enjoyed the idea of being able to help a large population of people and developing, you know, different types of research modalities that could significantly improve public health within populations. And so When I was at the university, I continued working and I got my master's degree and I advanced and worked with several startups as well as with the Prostate Conditions Education Council. And so it's been a really interesting journey and learning as much as I've learned about this very interesting disease, it's been a very fruitful and very rewarding process. And, you know, the idea that I had in college about going to medical school after doing research, I decided that research was really my true calling. So, uh, those initial early years of my life of, of doing research, or early years I should say of, of my, uh, my in, in college, uh, really kind of seeded my idea and my, my goals of, of continuing, uh, research.

So you've been immersed in that research field, and I'm sure the industry is, uh, much better for it. So, um, tell us about what's your current work schedule like. Is it research? Is it education? Clinical work? Give us a, maybe a typical day or a typical week.

Sure. So a typical week for me right now really is more involved with developing programs for men in who have prostate cancer. So working with the folks at the Prostate Conditions Education Council, my other colleagues, to create public health programs aimed at targeting men through screening targeting underserved populations through screening and trying to get the awareness out there about why it's important to receive screening for prostate cancer. So we're doing a lot of program development as well as launching different types of programs where the end goal will be to develop a publication to increase awareness amongst other individuals and, and other healthcare professionals. As to why screening is important and ways that men should actually go about getting screened for prostate cancer. I also work alongside some startups. One of them is called Triopsy, where we are developing an adjustable biopsy needle that aims to reduce the variance that we see a lot in normal prostate biopsies. There's a lot of issues with prostate biopsies that are caused by needles that are too short or that take fragmented samples. Bringing a system to market soon where we can actually take a sample that's almost 3 times as long and it doesn't fragment. So, it'll improve the diagnostic accuracy of all types of prostate biopsies. And I still continue working alongside Dr. Crawford at UCSD, and we're continuing work on our PCMarkers.com website where we try to educate the public about the importance of screening as well as how they can use some of these innovative genomic and germline tissue, urine, and blood tests to actually improve the diagnostic accuracy, especially in men who have an abnormal PSA and who may need to undergo a biopsy. It gives the patient a little bit more confidence as to the proper steps to take so that they feel that they are going down a path that's appropriate for their particular level of risk.

Always continuing to improve the diagnostic process, the screening process. So did you say UCSD is where Dr. Crawford is? Here in San Diego?

Yes, Dr. Crawford currently practices out of UCSD at the Department of Urology.

Oh, good. Yeah. Okay.

You can work with him remotely.

I see.

On numerous projects.

Yeah, okay. So I know when we spoke earlier, you told me that prostate cancer is the second leading cause of cancer death in the US. What do you think contributes to this high mortality rate?

Well, high mortality rate is likely due to an underutilization of screening in men. You know, back in 2012, the US Preventative Services Task Force had analyzed a couple of multicenter studies that demonstrated that there really wasn't a strong benefit to doing screening amongst men who have prostate cancer. They had initiated a warning against doing screening with using PSA. One of the problems of that, one of the studies they looked at, which was the PLCO study, was that only 7% of the population had a family history of prostate cancer. The generalizability of those individuals who were taking part in the study weren't exactly representative of what we see in the United States. So, you know, if someone does have a family history of prostate cancer as well as other cancers, it actually increases their risk of developing a clinically significant prostate cancer. So after that happened, we actually saw over time an increase in the prostate cancer-specific mortality between 2012 and 2020. And a lot of research out there has actually demonstrated that this is due to men who avoided screening or whose doctors recommended against screening. And in states where there were men who received less screening, we were seeing even higher rates of prostate cancer-specific mortality. So the big take-home message there to us was really the importance of screening using PSA and the importance that men get this done on a regular basis. Another problem is, as men age, we know that they aren't always the best at taking care of their health, and, you know, visiting the doctor may not be on their highest priority. So it's really important that men do visit their physician and, you know, get annual physical exams and blood work done. As well as requesting tests like prostate-specific antigen. And also for their wives and their spouses and loved ones to do this as well, because we actually know through research that the majority of men end up receiving screening or undergoing some type of screening because their wives or spouses or loved ones encourage them to do so. So it's not only important to educate men on the topic, but their entire family as well. So when prostate cancer is diagnosed locally, or even if there's metastasis just around the prostate itself, the survival rate is over 99%. But once we start to see distant metastases, which we have seen an increase of as a result of men not undergoing screening, so men will actually be presented at the clinic with lower back pain or pain in their bones or in their hips. When we start getting distant metastases, those survival rates go down to around 32%. So we see a really big drop. So one of the biggest things we want to see in men is that they get screening and that they find the cancer early if they have it, because there are a lot more effective and more efficient treatment options for men when we find it early as opposed to when we find it at a later stage.

Sure. So the incidence, the higher incidence is really due to the lack of kind of a widespread screening process, even though the physicians gonna recommend it, but people may not come in for checkups. And I don't know what age is it's, what, what age is, is this recommended? When do we wanna start?

So it, it depends. So there's several different guidelines out there that discuss screening for men with prostate cancer. So, Men who have like a, a high risk or a strong family history according to the NCCN, or they have a lot of environmental exposures, people like veterans, pilots, firefighters, or African American men, the NCCN recommends beginning PSA screening at the age of 40. And they recommend screening for all men between the ages of 45 to 75. And they actually don't necessarily recommend screening for men over the age of 75, but There's also other guidelines like the ACS guidelines. They recommend, you know, men starting at the age of 50 who are at average risk for developing prostate cancer, or 45 for those who are at higher risk like the group I mentioned before, you know, as low as 40 for those who have a first-degree relative who has prostate cancer at an early age. So there are several different ages that it kind of falls into. The The American Neurological Association, for instance, recommends that they see screening of men between 55 and 69 to be very beneficial, but they still do recommend PSA screening in men over the age of 70 if they have, you know, longer than a 10 to 15 year life expectancy. Sure. Men with excellent health can benefit from prostate cancer screening even at older ages. So it kind of depends on which organization we look at, but overall it's really anywhere between 40 and 75 are kind of like the key age ranges.

So all the different entities there, it's all in the same ballpark, generally the 40s, 50s, and cutoffs at 70 plus, unless the longevity average life expectancy is greater for someone. Yeah. So how does this compare here in the US, these, the prevalence with other countries? Roughly comparable or higher or lower?

The US, our incidence of prostate cancer seems to coincide sort of closely with countries, I should say it coincides more closely with countries who adopt a more westernized diet. So we've kind of seen in other countries where there was once kind of a lower incidence of the cancer as as people kind of maybe become more sedentary or their diet or lifestyle changes begin to change, we see upticks in prostate cancer and other cancers as well. So right now, it kind of just depends on what the population makeup is and the family history distribution within different countries. But for the most part, I would say the US, Italy ranks higher than average across the world for prostate cancer mortality. Let me check again real quick too. That's an important data question. I like, I know I had some information exactly on that, but I always have to like brush up on the worldwide stuff.

So it's really another instance where lifestyle is a culprit for certain chronic conditions and cancer, for one.

Oh, definitely. Yeah. We know that lifestyle changes most definitely impact overall health in men. You know, we, we know that anything that's heart healthy is prostate healthy. So maintaining an active lifestyle and maintaining healthy eating habits is extremely important in avoiding sedentary lifestyles. What we actually see in men who are diagnosed with prostate cancer oftentimes you know, men with all stages of prostate cancers, their life expectancy actually ends up increasing because they start changing their exercise routines. They start changing their diet habits, and they end up living longer than they likely would have if they weren't diagnosed. Now, this doesn't happen with all men, you know, men who are diagnosed at very high-grade cancers or with distant metastases, but It just kind of goes to show that the importance of maintaining an active lifestyle, especially as you age, and also the importance lies in, you know, not wanting to change your lifestyle just because of a diagnosis, but doing it before a diagnosis and starting off earlier the better. And continuing to live an active lifestyle actually significantly reduces a man's risk of not only prostate cancer, but a ton of other diseases as well.

Well, that's fascinating. I don't think I've heard that, that trend where the diagnosis triggers a more active kind of recovery or lifestyle improvement, and it extends our, our longevity. And without that diagnosis, without that positive diagnosis, the individual might have continued down the same road. How fascinating. Yeah. Wow. So there is an upside to having a positive diagnosis.

I mean, You don't like to put it that way, I'm sure, but yeah, it's kind of like maybe one of those things that jumpstarts a man to realize that he needs to make some changes. And there aren't always a lot of things that can stimulate that in men, especially in older men. But in, for instance, for prostate cancer, that's certainly one of the things we see occurring.

How about different ethnic groups? Is the incidence rate higher for different groups?

Yeah, so African American men are at a higher risk of developing and actually getting prostate cancer. They are one of the higher or the highest risk groups of absolutely getting it. Also, men with Ashkenazi Jewish heritage can also be at a higher risk of developing prostate cancer, and that's largely due to kind of like a larger incidence of a a BRCA or a breast cancer mutation that occurs within this lineage of people.

Mm-hmm.

Also, we're seeing more and more Hispanic men as well are being diagnosed with higher rates. And a lot of this could very likely be due to, you know, individuals who live in— who are poorer, really amongst all races, maybe have a higher likelihood of living a more sedentary lifestyle or are eating a higher quantity of processed foods or fast foods and, you know, their diets may have a less, their diets may be restricted in terms of receiving, you know, green leafy vegetables and proper quantities of fiber and vegetables. So it, it really just kind of depends on, on the individual and within the population that they live.

Great. Okay, thank you. So you mentioned, certainly if there's a history of prostate cancer in the family, that individual is going to be more vulnerable. Are there other risk factors, other considerations? Who's most vulnerable to this?

Yeah, so family history of prostate cancer is certainly something that'll increase a man's risk of developing prostate cancer. Also, other risks include other cancers. So, if a man has a family history of breast, ovarian cancer, pancreatic cancer, colorectal cancers, they actually also are at a higher risk of developing a clinically significant prostate cancer. And as I mentioned before, this is because some of these individuals who have these types of family histories may be carriers of this BRCA1 or BRCA2 gene, which creates a kind of a loss of control of DNA replication that occurs naturally in the body. So people that have this particular mutation seem to develop prostate cancer at a higher rate as well as develop more clinically significant prostate cancers as well. So, to diet and lack of exercise, we also know that, you know, family history of cancers and, and definitely has an impact on what a man's likelihood of developing it.

So, can you tell us what are the, what are the latest approaches for screenings? I mean, you talked about the PSA, but what, what's on that continuum here? What do we, what do we have going for us?

Yeah, so there's, there's a lot of things going on right now in prostate cancer screening. Obviously, initiating the screening with a PSA test is great, and it's always recommended. If a man is hesitant to receive, you know, a digital rectal examination, we would like to think that at least if they receive a PSA test, that that'll give us a nice baseline. And if their PSA is elevated, then they could maybe talk to their physician later on about the need of of getting a digital rectal exam. If we were able to get more men in and receive PSA tests, we feel that we could try to find a lot of these men who are potentially harboring a clinically significant cancer earlier. You know, and the problem with PSA testing has always been that it is a prostate tissue-specific test. It's not prostate cancer-specific. So there are benign conditions like an infection, inflammation, or natural growth of the prostate that occurs with a lot of men as they age is called hyperplasia or benign prostatic hyperplasia, also known as BPH. That can cause elevated levels of PSA.

A false positive, so to speak.

Yeah, exactly. Yeah, the false positive rate can be relatively high for this test, but it's still one of the, you know, the most powerful biomarkers that we have, the most powerful cancer biomarkers that exists.. And we know that by using it, it can really help us to identify men who may need to be further worked up. In addition to PSA, as we kind of mentioned before, there's also other types of genomic tests that we can use, blood-based, urine-based tests, such as 4K SelectMDx, the Prostate Health Index, that more sensitive and more specific to identifying men who may be harboring a cancer as opposed to a benign condition. So they're a little bit better at differentiating between who has a cancer versus who doesn't. And another test we can use for this as well is what's called the PSA density test. So it's determining the volume of a man's prostate, and then we can take his PSA and divide it by that volume to determine the likelihood that he might be harboring a clinically significant cancer. So that's a more accurate way of determining if a man might have prostate cancer as opposed to just using PSA alone. The only drawback to that is the only way to really find a very accurate prostate cancer or prostate volume is to conduct either an ultrasound or an MRI and, and get a volume that way. So between that as well as the introduction and the utilization of things like multi-parametric MRI to try to locate lesions within the prostate. You know, there are ways where we can work up men much more effectively now to determine actually who needs a biopsy versus who doesn't. So we're trying to reduce the number of men who are found with low-grade prostate cancers. We call those Gleason 6s or grade group 1 cancers. These cancers very rarely impact a man's life. The metastatic and mortality rates are close to zero. We're more interested in finding cancers that are more aggressive and more clinically significant.

So, so the PSA is taken from a blood test, right? I mean, you can get the reading from a blood test. Yeah.

Yes. Simple blood test.

How about the false negatives? Do we miss it sometime?

Yeah, you can. PSA cutoff of 4 currently is kind of the most commonly adopted cutoff for prostate cancer around the United States. But we know that in the literature, a PSA between 1.5 and 4, we'll see about 20% of the, the most aggressive cancers occur within that PSA range. So there are cancers that do occur where the PSA is low, where they're not strong producers of PSA, and where men may feel that they're in kind of like a safe zone, but they might actually not be. So we also look at things like PSA velocity. So the changes in PSA over time and how quickly the PSA should double over time is an important thing for us to look at. But PSA in and of itself certainly has limitations for both men who have elevated PSAs and men who have PSAs in the normal range. You know, if a man has a strong family history or if they have like a PSA that's within the normal range, they may consider doing something like a genomic marker to just kind of understand if there might be an additional risk factor or if they might be at higher risk and need to be further worked up by their clinician.

Something that the PSA does not reveal or reflect. Exactly. Yeah. Yeah. So it is possible to miss it. I mean, I could go in for a medical workup, lab, uh, labs, uh, you know, or John, and it could be missed, right? I mean, well, what do we do about that?

That's, and that's, I mean, that's why it's important too to, uh, you know, to get screened regularly.

Yeah. Okay.

Generally speaking, you know, if, if you do have an organ-confined cancer and it's aggressive, Once, you know, it becomes more active, your PSA will very likely start to elevate. So there's only a, you know, a small subset of men who will actually get a PSA in the normal range and experience metastatic disease.

Hmm.

At times, once the cancer starts to really metastasize or, you know, become more active within the prostate, we will actually see generally speaking, rises in the PSA that would likely trigger a biopsy or further workup of that patient.

I see. So, yeah, so if we have good results from one test, we gotta keep going back for more testing.

Yeah, exactly.

Makes perfect sense. Yeah. So it is, as we said, a virulent type of cancer. It spreads quickly. But yet you said if we catch it early enough, the treatment rates are very effective.

That's true, yeah. And like, there are many prostate cancers where it will likely never pose a, a risk to a man's life. There are low-grade prostate cancers, and research has actually demonstrated that some men, even in their 20s, mid-20s and 30s, show histological evidence of prostate cancer. These were studies done in the inner cities that were autopsy studies and that they likely would've never been found until they became older and their PSA started going up because of a benign condition. And then once a man hears the word cancer, they automatically think, you know, that something's gonna happen and they're going, you know, that this is a life-threatening situation they have to take care of.

But—

We do know that overtreating prostate cancer is just as big of a problem as undertreating prostate cancer. So we have to really choose the patients who need treatment versus those who we can do active surveillance on or just monitoring their PSA, monitoring the volume of their tumor via things like MRI, perhaps biopsies that occur at specific intervals. But there are men who definitely don't need treatment. But prostate cancer certainly is also a disease that can cause significant mortality as well. It's the second leading cause of cancer death in men, and that's because there are many types of prostate cancers that are aggressive, that spread quickly, and ideally what we would want to do is find those before they get too far away in the body so that we can improve a man's likelihood of surviving this disease.

Okay. So there are some some that are benign, benign cancers, and it doesn't necessarily mean aggressive treatment. It can be, as you said, just watching closely. But when it is a more aggressive type radiation, what's the typical treatment? Radiation, chemotherapy?

Yeah, it depends on the man and kind of the stage of the cancer. Usually, you know, if you see some regional metastases or metastases kind of like getting just outside the prostate, but it hasn't spread very far, A man will usually be recommended to have something like external beam radiation for that so that the areas of metastasis can also be targeted. If you find it early and the cancer is organ confined, we can do a prostate removal surgery, also known as a prostatectomy, and they can remove the prostate and seminal vesicles. And the likelihood of survival is very high in that case. And, you know, in men who have distant metastases or they are, you know, the cancer is no longer confined to the prostate or just around the prostate, we can see utilization of things like androgen deprivation therapy, which is injections that we will use or pills that we will use to actually shut off a man's testosterone. And also, you know, in certain types of prostate cancer, we do see immunotherapies that are utilized as well as chemotherapies as well. So it really just kind of depends on the grade and stage. And one of the things I also wanted to discuss kind of along those lines is we do have also tissue-based genomic tests now where we can actually look at, you know, the positive tumor within a biopsy. And many of the companies who have developed these tests have actually kind of looked at the entire human genome and determined exactly which genes are turned off or turned on that lead to more aggressive diseases. And they've developed algorithms which can actually risk stratify a man for having a cancer that may be more aggressive, that may necessitate the need to have surgery versus a man who— or radiation versus a man who has more of an indolent cancer that they may be able to watch. So We have a lot of cool tools out now that we can use to further risk stratify men and try to reduce this burden of overtreatment.

Yeah, that's great. That's really encouraging to hear that. Yeah. So can we prevent prostate cancer?

I think you can likely reduce the risk of prostate cancer again by living active and healthy lifestyles and by exercising and eating healthy. This doesn't always mean you have to, you know, become a vegan or or have some sort of an extreme lifestyle change. You know, there are physicians out there. I know I need to think of his name because he's actually really good and I wouldn't mind giving him a shout out.

Mm-hmm.

I'm glad we talked about this. Oh, his name is Mark Moyad.

Oh, okay.

So there are individuals such as Mark Moyad who is out of Michigan and he has produced tons of articles and, and tons of information about supplements that work for prostate cancer. Diet and exercise regimens that work well for prostate cancer. And honestly, following also some of the guidelines from the American Heart Association in terms of meat intake and things that are ideal for diet or for meals is a good way to reduce the risk of getting prostate cancer. And clearly, there are some men who are genetically predispositioned in a way to be at a high risk of getting prostate cancer. And so it's potential— it's possible that these men may actually still develop prostate cancer no matter kind of just how diligent they are with their lifestyle or dietary restrictions. But at the same time, encouraging men to have these types of lifestyle and, you know, positive lifestyle changes will reduce their risk of developing many other diseases.

Sure.

Something that we try to encourage men to do as often as we can.

Yeah, no, I'm really glad you said that. That's, that's so important for everyone, not just those who are at risk for these diseases. Yeah, so important. But, um, I know we're running out of time, but I, I have to get to this program that you have across the country. You do the annual screenings. Tell us about the Prostate Conditions where you do the annual screenings around the country. Tell us about that.

Yeah, so Prostate Conditions Education Council was founded in the late 1980s by Dave Crawford and several other individuals. And every year we run a national screening event across different states in the United States. On our website prostateconditions.org, you can actually see various free screening events that we put on every year for men across the United States. We also have a lot of different educational resources for men, and we've been doing this ever since the late 1980s when PSA first came out. So any one of our screening events, a man can go and get not only a PSA but things like their lipid profiles, their fasting blood glucose, to really kind of give a man an assessment of what their health looks like at that state. We can thereby identify men who may be at high risk. You know, when we, when we do these screenings, we see men all the time who come in who've been screened before and they have PSAs that are in the 50s or 60s. And we try to encourage these men to go and receive further workups from their physicians because there's a strong likelihood that there could be a malignant condition going on within their prostate. We also at Prostate Conditions Education Council have a fantastic patient advocate. Her name is Cara. And she works closely with patients from across the country who are diagnosed with prostate cancer. We provide a free service to any patient who has questions about their prostate cancer or, or benign prostate conditions like BPH or inflammation and infection. And we are able to provide this free service to patients because of donors and because of grants that we receive to conduct this research. So we always encourage men. One of our biggest times of year for screening is in September, which is kind of like the Men's Health Awareness Month. Mm-hmm. And but we still do screenings throughout the year. So it's always important to check our website and see when we're doing screenings in your area. And, you know, we're always open as well to doing screenings in new areas as well if there is a need or a demand for it and we feel that we could screen more men, we will always— will do that.

So, wow, that is great. Really, gold stars to you and to Prostate Conditions Education Council. I think that's great, great reliable service. And prostateconditions.org is the website where people can check the schedule and get other resources and learn a lot more about our risk. Well, that's great, Paul. Thank you. Thank you.

Thank you.

Yeah, I'm happy to be the messenger for this kind of information. I, you know, I just love it. It's, uh, these messages are so important to aging well, and I, I like to be a part of that. Looks like we're outta time for today though. But before we wrap up, I just wanna remind our listeners to visit my website, livingto100.club, sign up for my email list and download a free copy of my 9 Tips to Make Living Longer Enjoyable. And if you're affiliated with a senior living setting, be sure to look for my new training manual and activity guide, Better, Longer, and Happier. It's on the website. Paul, thanks so much for being a guest on our show. For those who might want to contact you, can they reach you through prostateconditions.org, or is there another way?

They absolutely can. My, my email is listed on prostateconditions.org, but they can also reach me at paul.arangua@prostateconditions.org. Prostateconditions.org, and I, I'd be happy to answer anyone's questions.

Great. Well, thank you so much. This has been just great information, invaluable information. I really thank you for sharing it with my audience.

Yeah, thank you, Joe, for having me on.

Yeah, you're welcome. And thanks to everyone for tuning in today. I hope to see you next time.