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Racial Disparity in Colon Cancer Incidence and Mortality

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A new study from Colorectal Cancer suggests African Americans are more likely to be diagnosed with colon cancer and die from the disease than Caucasian Americans.

Race has a profound influence on colon cancer survival rates. Colon cancer is the third-leading cause of cancer death among men and women in the United States, but African Americans are more likely to develop the disease and die from it.

In cooperation with the Medical University of South Carolina, Kristen Wallace et al. studied more than 1000 patients diagnosed with colon cancer for survival based on race and risk of death in two age groups: patients under 50 and over 50.

African Americans under 50 were more likely to die of colon cancer than Caucasian Americans under 50. However, in patients over the age of 50, race did not affect colon cancer survival rates. The study found tumor location played an important role in colon cancer survival in younger African Americans.

The authors of the study hope the study results will help doctors target patients who require aggressive treatment and monitoring. They also say they must do further research on how the location of colon tumors influence the patients’ responses to treatment.

Schedule Your Colonoscopy to Prevent Colon Cancer

Most cases of colon cancer are preventable through routine colonoscopies. Colonoscopy is the gold standard of colon cancer screening because it can detect and prevent colon cancer in a single procedure. Your doctor can remove any suspicious polyps before they can develop into cancer, making a colonoscopy a life-saving screening.

The American Cancer Society recommends adults at average risk for colon cancer begin screening at age 45. However, African Americans and individuals with a family history of colon cancer should get screened earlier. Talk to your doctor about when you should get screened for colon cancer.

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Drinking Coffee Could Increase Colon Cancer Survival Rate

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There’s basically an unspoken rule in my house that no one is allowed to talk to me until I’ve had my morning cup of coffee. Let me assure you, it’s in everyone’s best interest. You see, it doesn’t matter how much sleep I get, how rested I feel or what’s on the agenda for the day – I’m just not a morning person. I need at least 30 minutes of solitude and a good jolt of caffeine in my system before I’m ready to take on the world – or at least put on my happy face and say “good morning.”

Whether you consider yourself a morning person or not, there’s a pretty good chance you’re still a fan of coffee. According to a market research study by the National Coffee Association, a whopping 83 percent of Americans are coffee drinkers. Approximately 63 percent report that they have a daily java habit and 75 percent say they drink coffee at least once per week. Coffee is the beverage that fuels our nation, and we love it to the very last drop!

Coffee can have a number of health benefits when consumed in moderation, but experts say there’s one golden rule you should always obey: never drink coffee on an empty stomach. It doesn’t matter whether you enjoy your coffee hot or iced, light roast or dark, caffeinated or decaf, the effect is the same. Drinking coffee without consuming any food can have some negative health consequences.

Digestive problems

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Our stomachs contain hydrochloric acid which helps to efficiently digest food. Drinking coffee on an empty stomach increases acidity, and without food to act as a buffer, this can quickly result in digestive problems. Consistently having too much acid in your stomach can cause damage to the digestive tract and lead to other issues including heartburn, ulcers and irritable bowel syndrome.

Hormone fluctuations

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Drinking coffee on an empty stomach decreases the brain’s ability to produce serotonin, the neurotransmitter responsible for feelings of happiness, calmness and well-being. In some individuals, this may contribute to anxiety and depression. Coffee is also known to boost levels of cortisol (the body’s stress hormone), epinephrine and norepinephrine which can leave you feeling jittery and nervous.

Nutritional deficiencies

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There’s a good reason why morning coffee usually leads to morning bathroom breaks. A study conducted at Yokohama City University School of Medicine in Japan found that coffee promotes “gastric emptying,” meaning it moves food out of the digestive system faster than it would on its own. This ultimately means that food spends less time in the intestines where vitamins and minerals are absorbed (Source: The Good Men Project).

Dehydration

Some experts believe that drinking coffee on an empty stomach increases the amount of fluids released by your body, which can lead to dehydration. This problem compounds if you continue to quench your thirst with additional cups of coffee throughout the day.

Loss of appetite

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Coffee can stave off those afternoon hunger pains to help you avoid senseless snacking after lunch, but you don’t want to use this tactic first thing in the morning. Many individuals choose a morning cup of coffee over a nutritious breakfast, and by lunchtime they feel like they’re running on fumes. While coffee does have some health benefits, it has virtually no nutritional value and should not take the place of a well-balanced meal (Source: David Wolfe).

A hot cup of coffee can be the perfect way to start your morning, but be sure to make it part of a healthy breakfast. Try pairing it with one of our delicious fiber-rich recipes like strawberry banana quinoa bake or carrot and zucchini muffins with nut crumble topping. Powering your body with the right kind of fuel will provide the energy you need to make it through the day – even if you’re not a morning person.

Drugs like Viagra May Decrease Colon Cancer Risk

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A recent study from Region Skåne and Lund University in Sweden discovered potency-enhancing drugs like sildenafil, commonly known as Viagra, can prevent colon cancer in men, as well as improve the prognosis of patients with the disease.

Viagra is one of many potency-enhancing PDE5 inhibitor drugs that have anti-cancer properties. Wuqing Huang, a Ph.D. student at Lund University, and his research colleagues studied data on how PDE5 inhibitors affect mice with colon tumors. They wanted to conduct a study on how the drug affected colon growth in humans.

Dr. Huang used national registers to identify Swedish males with colon cancer who also used PDE5 inhibitors. He found the risk of colon cancer death was reduced by 18 percent among patients who used potency-enhancing drugs. Furthermore, he found colon cancer was less likely to metastasize, or spread to other parts of the body, in patients who used PDE5 inhibitors.

How do potency-enhancing drugs help prevent cancer growth and spreading? It seems that surgery can cause immune suppression, but Viagra and similar drugs have a protective effect on the immune system. PDEF inhibitors Dr. Huang explains, “The results of our study suggest that the anti-cancer ability of PDE5 inhibitors might be related to regulating immunosuppressive effects. However, randomized clinical trials are needed to confirm our research findings before PDE5 inhibitors can be used as an adjuvant drug for men with colorectal cancer, as well as experiments that explore the underlying biological mechanisms.”

Know Your Colon Cancer Risk

Heredity is responsible for only a small percentage of colon cancer, so it is important to understand the multiple risk factors of the disease. Experts are unsure about what causes colon cancer, but some risk factors include:

  • Age
  • Family history of colon cancer or colon polyps
  • Polyps (growths inside the colon and rectum) that may become cancerous
  • Diabetes
  • A high-fat diet
  • Inflammatory bowel diseases involving the colon
  • Sedentary lifestyle
  • Smoking
  • Alcohol
  • Obesity
  • Radiation therapy for cancer

Schedule Your Colonoscopy

The best way to prevent colon cancer is to schedule regular colonoscopies. During a colonoscopy, your gastroenterologist will examine the colon for precancerous growths called colon polyps. Your doctor can remove any suspicious colon polyp during the exam, thus preventing you from developing colon cancer.

Click here to get a list of GI centers in your area. Our fellowship-trained gastroenterologists are accepting new patients and look forward to serving you.

Women are More Likely to Develop Aggressive Colon Tumors

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A new study finds colon cancer cells grow differently in men and women, and women are more likely to develop more aggressive colon tumors.

Men have a higher rate of colon cancer, but women have a higher incidence of right-sided colon cancer. Tumors on the right side of the colon are associated with a 20 percent increased mortality rate than left-sided tumors.

Colon Cancer Growth Rate Differs Between Genders

This new research provides helpful insight into what drives the difference in colorectal cancer risk. The study team utilized innovative techniques called “metabolomics” to analyze the hormones people produce, the cellular processes of digestion, and the bacteria that lives in the colon.

By comparing normal colon tissue to tissue samples from males and females with colon cancer, the team could examine differences in micronutrients like amino acids and sugars which transform during metabolism.

Women with colon cancer on the right side displayed elevated levels of fatty acids and amino acids like asparagine and glutamine, which are associated with aggressive colon tumor growth. Men with colon cancer have increased levels of lactate, which creates energy through a unique pathway.

This research suggests colon cancer growth rate is different in males and females and may require different treatments to effectively stop cancer growth.

Caroline Johnson, Ph.D., assistant professor of Epidemiology at Yale School of Public Health, was co-senior author of the study. “With this new information and many promising leads, our work is helping to determine what can be done to prevent worse outcomes for women who develop this deadlier form of colon cancer,” she said. “This work will benefit all women, but particularly black women, who are at higher risk for colon cancer compared with other races or ethnic groups.”

Dr. Johnson hopes to develop a biological indicator with her co-senior author, Sajid Khan, to predict the formation of right-sided colon cancer, which is more aggressive and more challenging to identify in early stages compared to left-sided colon cancer.

Lifestyle Changes to Prevent Colon Cancer

Only a small percentage of colon cancer is linked to heredity. You can create healthy habits to reduce your risk for colon cancer by:

  • Eating a diet high in vegetables, fruits, whole grains and lean proteins
  • Limiting red meat and processed meats
  • Quitting smoking
  • Improving fiber intake (35 grams of fiber daily for men and 30 grams of fiber daily for women)
  • Drinking plenty of water
  • Limiting alcohol

Make an Appointment for a Colonoscopy

Most colon cancers are preventable with regular colonoscopies. The American Cancer Society recommends all adults who are at average risk for colon cancer get screened beginning at age 45. Call your gastroenterologist to make an appointment for a colonoscopy. If you receive a clean bill of health, you likely will not have to repeat the procedure for ten years.

To find a fellowship-trained gastroenterologist near you, click here for more information. We will connect you to a GI center in your home town, and you can call to make an appointment today for a life-saving screening.

COVID-19 May Increase Colon Cancer Death Rates

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According to a recent article in the Washington Post, colon and breast cancer incidence may increase by 10,000 over the next decade because of coronavirus quarantine measures. Colon and breast cancer account for 17 percent of all cancer deaths, but even a short disruption in screenings could result in a one percent increase and almost one million deaths from these cancers over the next decade. Doctors fear new cases of colon cancer could go undiagnosed for longer periods of time and result in tumor detection at a later stage.

Although colonoscopy is not an elective surgery, most surgery centers halted colon cancer screenings beginning in March of 2020 due to the pandemic. According to a publication by the Epic Heath Research Network, screening appointments for breast cancer, cervical cancer and colon cancer decreased by 86 to 94 percent in March 2020, compared to screening rates between January 2017 and January 2020.

Patients and hospital systems are now advised to resume preventive screenings and testing, but it is difficult to measure the impact of delayed services. Austin Chiang, a gastroenterologist in Philadelphia, told the Philadelphia Inquirer, “On a global scale, it’s a lot of screening procedures being deferred — and maybe some cancers that could develop in this time, as well.”

What are the Colon Cancer Screening Guidelines?

The American Cancer Society suggests all adults who are at average risk for colon cancer begin screening at age 45. Even though Medicare and many insurance carriers do not cover screening colonoscopies until age 50, it is important to schedule this life-saving screening. When discovered early, the survival rate of colon cancer is as high as 90 percent.

Colon cancer prevention is far less expensive than colon cancer treatment. Talk to your doctor about colon cancer screening recommendations so you can get screened at proper intervals. It is also wise to call your insurance provider to receive the most updated information about your plan. Awareness is the first step in colon cancer prevention.

Schedule your Colonoscopy Today

Did you miss your colonoscopy because of COVID-19? Reschedule your colon cancer screening as soon as possible. Your overall lifetime risk for developing colon cancer is 1 in 20, and the disease rarely presents with symptoms in the early stages. Therefore, it is imperative to take action based on the recommended timeline.

Are you searching for a fellowship-trained gastroenterologist in your area? Click here to find a qualified GI specialist.

Patient Safety a Top Priority Amid COVID-19 Pandemic

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COVID-19 has had far-reaching impacts on our lives, with medical procedures and surgeries deemed “elective” postponed in order to slow the virus’s spread. In reality, these procedures are far from optional: delaying medical interventions can result in increased health problems, such as later-stage cancer diagnoses.

Increased Patient Safety Measures to Combat COVID-19

In recent weeks, we have resumed elective cases and implemented a number of protocols to ensure your safety as you take charge of your health and schedule procedures at our ambulatory surgery centers. These measures include:

  • Screening everyone who enters the center for COVID-19 symptoms
  • Taking the temperature of every person who enters the center
  • Requiring masks for all employees and patients
  • Enforcing social distancing guidelines
  • Requesting patient escorts remain in the car until patient is ready to go home
  • Increasing cleaning of high-touch surfaces throughout the day
  • Providing hand sanitizer and tissues

Learn more about all of the steps we are taking to keep you safe.

Patients Feel Safe at our Centers

Patients who have already returned to the centers have first-hand experience of the new protocols in action. Their feedback has been extremely positive, with reactions like:

“During this COVID-19 time, I was especially nervous about my procedure but was immediately greeted by the friendliest nurse around. She was very courteous and kept asking if I was fine. She prepared me for the procedure by carefully doing everything that needed to be done and listened to me. The rest of the staff was also very professional and took great care of my needs. Thank you all for a great experience that I hopefully won’t have to repeat for a while.” – San Antonio, April 2020

“Even during these crazy times, I was treated with the utmost respect, courtesy, and care. My doctor and her amazing team took the necessary steps to make sure I wasn’t put at greater risk during my procedure. They ensured all my questions were answered, and I was 100% ready going into and out of the procedure.” – Escondido, April 2020

“Sanitary, safe, NICE and COMPASSIONATE staff!! Thank you SO MUCH to all of my nurses throughout the entire experience!” – Lakeside, AZ, May 2020

Safely Schedule a Procedure

With increased safety measures in place, there has never been a better time to schedule that colonoscopy; doing so could save your life! Stop putting it off and call your gastroenterologist today.

Will Daily Aspirin Prevent Colon Cancer or Threaten Health?

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Taking daily aspirin could lower risk for colon cancer, according to an animal study published in Carcinogenesis.

We’ve all heard “an aspirin a day keeps the doctor away,” but aspirin may also keep cancer away. New City of Hope Hospital in Duarte, California, conducted a study on mice and found daily doses of 100 milligrams of aspirin causes colon tumor “suicide.” The study also discovered aspirin prevents bowel cancer from returning.

Benefits of Daily Aspirin

This is not the first study to praise the health benefits of aspirin. A 2016 study published in JAMA Oncology found long-term aspirin use correlated with a lower risk of gastrointestinal and colorectal cancer. Furthermore, the U.S. Preventative Task Force recommended “low-dose aspirin therapy for primary prevention of colorectal cancer for patients from age 50 to 59 years if they have a life expectancy of at least 10 years and are willing to take it for at least 10 years.”

Today, about six million Americans take aspirin on a daily basis to prevent heart attacks and stroke. Aspirin may also be instrumental in preventing inflammatory diseases like arthritis, Parkinson’s and Alzheimer’s.

In spite of aspirin’s therapeutic benefits, doctors are increasingly concerned about the side effects of regular aspirin use. In 2019, the American Heart Association altered its guidelines about aspirin and suggested Americans should only take the drug if it is prescribed by a physician. Studies linked aspirin to increased risk of bleeding in the intestines and stomach, and brain bleeding that can cause strokes.

Aspirin’s risks should be weighed accordingly, but its impact on colon cancer prevention cannot be understated. Colon cancer is the third-leading cause of cancer death in the United States, and it is estimated that one in five Americans will develop colon cancer. According to the American Cancer Society, there will be 135,000 new cases of colon cancer diagnosed in 2020 and colon cancer will claim the lives of more than 50,000 people this year.

Who Should Not Take Daily Aspirin?

The good news is that you do not have to make the decision about whether to begin taking aspirin. Your doctor will look at your health history and advise you. Certain individuals should not take aspirin because the risks outweigh the possible benefits. You should not take daily aspirin if you:

  • Will be undergoing a medical procedure soon
  • Have an intolerance to aspirin
  • Are at increased risk for internal bleeding
  • Regularly drink alcohol

Colon Cancer Prevention: Call Your Gastroenterologist

Call your gastroenterologist to talk further about colon cancer prevention. The best way to protect yourself from colon cancer is to schedule routine colonoscopies. The American Cancer Society recommends all adults who are at average risk for colon cancer begin screening at age 45, but Medicare and many insurance carriers do not cover screening colonoscopies until age 50. Call your insurance provider to get the most updated information about your plan. Remember, colon cancer prevention is less expensive than colon cancer treatment. Click here for a list of GI centers in your area.

Doctors Can Lead by Example in Colon Cancer Screening

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Patients are more likely to choose colorectal cancer screening if their doctor has been screened already and discloses this information to them.

A doctor’s recommendation is compelling when it comes to preventive screenings like colorectal cancer screenings, especially when the physician leads by example. Screenings like colonoscopy exams are instrumental in helping people live longer and enjoy a better quality of life. Unfortunately, Americans are not getting all of the preventive care they should be receiving. Many Americans are not getting screened for colon cancer at the correct age or the proper interval, and some tests are inaccurate.

Colorectal cancer screenings performed at the correct age and frequency can reduce the risk of colon cancer death by up to fifty percent, according to data from the American Cancer Society. A new study published in Gastroenterology reports that doctors who follow through with their own colon cancer screenings are more likely to have patients who get screened.

When Physicians Get Screened, Patients Get Screened

Amit X. Garg, M.D., Ph.D., and fellow research colleagues at Western University in Canada wanted to find out whether there is a connection between colorectal cancer screening rates among physicians and their patients.

The researchers conducted a population-based study of patients in Ontario and found that the colonoscopy rate was 67.9 percent among physicians and 66.6 percent among patients. The research team found patients were more likely to comply with colonoscopy when their family doctors had themselves already had colonoscopy screenings.

The study suggests family doctors have significant influence in their patients’ decisions to get screened for colon cancer. If doctors disclose that they have already chosen colon cancer screening, their patients are likely to follow their example.

“Conversely, many physicians report difficulty counseling patients about behaviors they do not practice themselves,” the researchers stated in their report. “Given the clear benefits of colorectal cancer screening, programs that promote greater screening in physicians warrant consideration.”

Why Are We Neglecting Preventive Care?

The Centers for Disease Control estimates one out of three American adults is not being properly screened for colon cancer. Why are adults omitting a life-saving preventive test? Some patients may not be getting a colorectal cancer screening because:

  • They do not carry health insurance
  • They have limited contact with their primary care physician or do not have a primary care physician
  • Their primary care physician did not tell them to get screened
  • They lack the proper information on how to get screened

Screenings like colonoscopy can spare patients the physical, emotional and financial strain of a chronic, life-threatening disease. Also, many screening colonoscopies and other methods of colon cancer screenings are free through private insurance and Medicare.

When to Schedule a Colonoscopy Exam

Due to the increased incidence of young-onset colon cancer, the American Cancer Society suggests all adults at average risk for colon cancer begin screening at age 45. However, many insurance providers will not begin paying for screening until age 50. Talk to your doctor about when he or she began screening, and ask when you should schedule your first colonoscopy.

If you are not under the care of a fellowship-trained gastroenterologist, click here and enter your zip code in the orange box. We can connect you with a highly-skilled physician in your area who can provide quality gastrointestinal care. Our specialists are accepting new patients and are available for appointments.

Will Smith Has Polyp Removed During Colonoscopy

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Colonoscopies save lives every day, and actor Will Smith can attest to that.

Smith, who first gained fame as the Fresh Prince of Bel Air, decided to film his colonoscopy as a vlog for his fans. At the age of 51, he was due for a colonoscopy, but he planned to create the joke-filled video just for fun.

After he woke up from the procedure, he was shocked by what his gastroenterologist discovered. He had a precancerous polyp in his colon.

“You know, when I decided I wanted to shoot this as a vlog, it was much more, ‘Hey, this will be cool. This will be fun,’” Smith shared in an interview with Today.com. “I didn’t realize that there would be a precancerous polyp that would get found out of it.”

Colon Cancer Begins as a Precancerous Polyp

A few days later, Smith’s gastroenterologist called him and said the removed growth was a tubular adenoma containing precancerous cells. Almost all colon cancers initiate from this same type of polyp, but most cases can be prevented if all adults choose routine screening. Smith will likely need to get another colonoscopy in two to three years for monitoring. However, that is a small price to pay for colon cancer prevention.

As Smith reflected on his colonoscopy in his vlog, he tells his fans, “Everything feels normal. 2019, gotta get our health right. There’s a certain amount of commitment and embarrassment involved with being healthy. You just gotta do it, man.”

Guidelines for Colon Cancer Screening

The American Cancer Society’s guidelines for colon cancer screening suggest all adults at average risk for colon cancer begin colon cancer screening at age 45 instead of age 50, the age recommended by the U.S. Preventative Services Task Force. This new guideline was established in May 2018 after reviewing statistics that young onset colon cancer is on the rise in the United States. Earlier screening is important because colon cancer in young individuals tends to be aggressive and difficult to diagnose. Further, the American Cancer Society recommends African Americans get earlier screening due to an increased risk for colon cancer.

Consider these facts about colon cancer:

  • Only 66 percent of people who should be screened for a colonoscopy actually have been screened.
  • 25 percent of people age 50 and older have never been screened.
  • 80 percent of people diagnosed with colon cancer have no family history of the disease, and most show no symptoms.
  • 90 percent of colon cancers can be prevented with a colonoscopy.

Call Your Gastroenterologist

Certain risk factors may increase your risk for colon cancer, so talk to your doctor about when you should get your first colonoscopy. The next step is to call your insurance company. Many insurance plans begin coverage for colon cancer screening at age 50, so call your provider to get specific details about your plan.

If you are not under the care of a fellowship-trained gastroenterologist, click here to enter your zip code and find a specialist near you.

Early Onset Colon Cancer Incidence Increasing in Western U.S.

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Early-onset colorectal cancer incidence is increasing most rapidly in Western states, where healthy lifestyles are typical, according to a new study published in the Journal of the National Cancer Institute. This goes against the established belief that risk factors such as obesity and physical inactivity have contributed to the rise of colon cancer incidence.

Although colon cancer incidence and death rates are decreasing among Americans over 50, colon cancer in young adults is increasing. According to the Mayo Clinic, ten percent of colorectal cancer cases (11 percent of colon cancer and 18 percent of rectal cancer) occur in individuals under 50.  What colorectal cancer causes are being missed?

Geographic Differences and Early Colon Cancer

Researchers at the American Cancer Society and The Ohio State University examined changes in colon cancer incidence and risk factors among Americans under 50 from 1995 to 2015. They organized data by state and ethnicity.

The increase in colon cancer incidence was mainly in Caucasian Americans, and it varied in magnitude across states. In the most recent data decade (2006-2015), colon cancer incidence increased by an average of 1.1 percent per year. Ten states exceeded a 2.5% increase, and six of those states were in the West. Colon cancer incidence increased by 73 percent in Washington and 57 percent in Colorado.

Rebecca L. Siegel, MPH, is the American Cancer Society scientific director of surveillance research and lead author of the study. She observed, “Although early-onset colorectal cancer incidence is currently lowest in Western states and highest in Southern states, consistent with the prevalence of established risk factors, like obesity, physical inactivity, and smoking, this pattern may change because the steepest increases are in Western states.”

Previous research attributed the increase in young-onset colon cancer to limited screening use, lack of recognition of key symptoms and unhealthy habits among the young. However, this new study provides some surprising data. Siegel adds, “This finding suggests that early life exposures in addition to the ‘usual suspects ‘ may be contributing to the rise in early-onset disease. Future studies should explore novel risk factors for colorectal cancer in young adults” (Medical Express).

The Facts About Young-Onset Colon Cancer

Why is young-onset colon cancer such a threat? The answer is: because no one is looking for it. Here are five reasons why young-onset colon cancer is so dangerous:

  1. Most people assume colon cancer is a disease for the elderly.
  2. Colon cancer usually has few or no symptoms in the early stages. This means a young person can have colon cancer but feel quite healthy for years. Seventy-one percent of young Americans with colon cancer are diagnosed with advanced disease (stage III or stage IV).
  3. Most young Americans are unfamiliar with the signs and symptoms of colon cancer like abdominal pain, changes in bowel habits, rectal bleeding, anemia, unexplained weight loss, nausea and vomiting. Many people—including physicians–dismiss blood in the stool as hemorrhoids or infection.
  4. Young-onset colon cancer tends to be aggressive and form in the distal colon near the rectum, which makes it more challenging to treat. Adults under 55 years are 58 percent more likely to be diagnosed with advanced colon cancer than older people and are more likely to die from the disease.
  5. Young-onset colon cancer is more likely to be misdiagnosed. About 67 percent of patients reported seeing at least two doctors, and some more than four doctors, before they were diagnosed correctly with colorectal cancer (2018 Young-Onset Colon Cancer Survey).

Who is at Risk of Colon Cancer?

You’re never too young for colon cancer. The best gift you can give yourself and your family is to educate yourself about the risk factors and symptoms of colon cancer.

If you have a family history of colon cancer, or you are experiencing symptoms, call a GI specialist today. Young people with colon cancer symptoms are more likely to wait at least six months to visit their doctor. Click here to find a gastroenterologist in your area.