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PubMed2006

NSAID use and survival after breast cancer diagnosis in post-menopausal women.

Many epidemiologic studies, although not all, have shown an inverse relation between non-steroidal anti-inflammatory drug (NSAID) use and risk of incident breast cancer, but the possible influence of NSAID use on breast cancer survival has not been evaluated. We examined the association between self-reported NSAID use and survival after invasive breast cancer diagnosis among 591 postmenopausal women in a prospective study. Cox proportional hazards regression was used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for breast cancer death as well as all-cause mortality associated with NSAID use. There was an indication of reduced risk of breast cancer mortality and all-cause mortality for women reporting any versus no use of NSAIDs, with multivariate-adjusted HRs of 0.64 (95% CI 0.39-1.05) and 0.57 (95% CI 0.40-0.81), respectively. There was no trend of decreasing risk of death with increasing frequency of NSAID use per week. While the results from this exploratory analysis are preliminary, there is biological plausibility for such an association. Further studies should consider whether NSAIDs, which have biological activity affecting tumor promotion and progression and appear to protect against breast cancer incidence, may be associated with better prognosis after a diagnosis of invasive breast cancer.

Aged↗
PubMed2006

A prospective study of adjuvant CMF in males with node positive breast cancer: 20-year follow-up.

PURPOSE: To determine the long-term overall survival of male patients with stage II node positive breast cancer treated with adjuvant chemotherapy. PATIENTS AND METHODS: Between 1974 and 1988, 31 male breast cancer patients were prospectively enrolled on study MB-82 in the National Cancer Institute. Following mastectomy, patients were treated with 12 cycles of cyclophosphamide, methotrexate, and fluorouracil (CMF) chemotherapy. RESULTS: Median patient age was 61 years (38-74 years). Twenty-one patients (68%) had 1-3 positive axillary lymph nodes while ten patients (32%) had four or more positive nodes. Estrogen receptor status was positive in 22 (71%), negative in 1 (3%), and unknown in 8 (26%) tumors. Progesterone receptor status was positive in 18 (58%), negative in 3 (10%), and unknown in 10 (32%) tumors. Median potential follow-up for all patients is 22.5 years with a median survival of 16.3 years. Twenty-one of 31 patients have died; one from a treatment-related complication, nine patients from recurrent breast cancer, five from other cancers, one from non-cancer related causes, and five from unknown causes. Ten patients remain alive at a median of 19.2 years. The overall survival probability at 10 years is 64.5% (95% CI: 46.9-78.9%), at 15 years is 51.6% (95% CI: 34.8-68%), and at 20 years is 42.4% (95% CI: 25.8-60.8%). CONCLUSION: To our knowledge, 20-year prospective data with adjuvant chemotherapy in male breast cancer has never been reported. Adjuvant chemotherapy may benefit male breast cancer patients with positive nodes.

Adult↗
PubMed2004

Recent increase in cancer survival according to age: higher survival in all age groups, but widening age gradient.

A major increase in long-term survival of cancer patients in the 1990s has recently been demonstrated. It is unclear, however, to what extent this increase has been shared by cancer patients at various ages. Using the 1973-2000 data base of the Surveillance, Epidemiology, and End Results programme, recent increase in 10-year relative survival of cancer patients in the US was assessed for 4 major age groups and 15 major cancer sites by comparing results of a period analysis for the 1996-2000 period with results of a cohort analysis for patients diagnosed in 1986-1990. Period estimates of 10-year relative survival for all forms of cancer combined in 1996-2000 were 66.1%, 58.8%, 56.3% and 47.1% for age groups 15-54, 55-64, 65-74 and > or = 75 years, respectively. They were 7.4%, 10.4%, 7.8% and 3.0% units higher than the respective 1986-1990 cohort estimates for these age groups. The increase in 10-year relative survival strongly varied by cancer site, but it was generally less pronounced in older than in younger patients. We conclude that long-term survival expectations of cancer patients have increased in all age groups in the 1990s. However, for most common forms of cancer, the age gradient in survival has either persisted or widened.

Adolescent↗
PubMed2005

Regional variations in breast cancer incidence among California women, 1988-1997.

BACKGROUND: Internationally, California has some of the highest breast cancer rates; these rates also show substantial regional variations within the state. This study describes geographic breast cancer incidence patterns within California and evaluates the degree to which socioeconomic status (SES) and urbanization explain the regional variability. METHODS: Invasive breast cancer cases in women > or =20 year of age were identified from the California Cancer Registry, for 1988-1997, then assigned to one of three regions (San Francisco Bay Area, Southern Coastal Area and the rest of California), based on residence at diagnosis. Neighborhood SES and urbanization were derived from U.S. Census data. Rate ratios (RR) and 95% confidence intervals (CI) were computed using Poisson regression. Analyses were conducted for all invasive breast cancer cases (n=176,302) and by selected histologic subtypes: ductal (n=121,619); lobular (n=13,410); mixed ductal and lobular (n=9744). RESULTS: Compared to block groups with the lowest quartile of SES, rates were highest in block groups with high SES. Rates also were higher in suburban and city areas than in small town/rural areas. Compared to the rest of California, age- and race-adjusted rates for all breast cancer were approximately 20% higher in the San Francisco Bay Area and 10% higher in the Southern Coastal Area. After adjusting for SES and urbanization the rate ratios were reduced to near unity (RR=1.06, 95% CI: 1.03-1.09 for San Francisco Bay Area; RR=1.02, 95% CI: 0.99-1.04 for Southern Coastal Area). Rates ratios for ductal carcinomas mirrored those for all cases. For lobular cases, rate ratios remained elevated after adjustment for age, race/ethnicity, neighborhood SES and urbanization (RR=1.18, 95% CI: 1.11-1.27 for San Francisco Bay Area; RR=1.10, 95% CI: 1.04-1.17 for Southern Coastal Area). For the subset of cases with mixed ductal and lobular histologies, the rate ratio for the San Francisco Bay Area was no longer elevated after adjusting for age, race/ethnicity, SES and urbanization (RR=0.92, 95% CI: 0.84-1.01); the adjusted rate ratio for the Southern Coastal Area, however, remained elevated (RR=1.22, 95% CI: 1.12-1.32). CONCLUSIONS: Regional differences in neighborhood SES and urbanization appear to largely explain regional rate differences in California for all breast cancers and ductal carcinomas but do not fully explain geographic patterns of breast cancer with a lobular component.

Adult↗
PubMed2005

Anthropometrics, physical activity, related medical conditions, and the risk of non-hodgkin lymphoma.

BACKGROUND: Recent reports suggest that obesity, or conditions associated with obesity, might be risk factors for non-Hodgkin lymphoma (NHL), a cancer with dramatically increasing incidence in western countries over the last several decades. Physical inactivity increases the risk of obesity and of type 2 diabetes, but there are few data on the association of physical activity with risk of NHL. METHODS: We evaluated these factors in a population-based case-control study conducted in Detroit, Iowa, Los Angeles, and Seattle from 1998 to 2000. Incident HIV-negative NHL cases aged 20-74 years were rapidly reported in each area (n = 1321). Controls were identified through random digit dialing and Medicare files, and were frequency matched to cases on sex, age, race, and study site (n = 1057). Risk factor data were collected by in-person interviews and self-administered questionnaires. Unconditional logistic regression was used to estimate the odds ratio (OR) and 95% confidence intervals (CI), adjusted for age, sex, race and study center. RESULTS: High body mass index (OR = 1.73 for 35+ versus <25 kg/m2; 95% CI 1.15-2.59) and history of gallstones (OR = 1.95, 95% CI 1.11-3.40) were positively associated with diffuse NHL, but were not associated with follicular or all NHL combined. Height was positively associated with risk of all NHL combined (OR = 1.38 for >70 versus <65 inches; 95% CI 0.98-1.94), and positive associations were apparent for both diffuse and follicular NHL. Non-occupational physical activity was inversely associated with risk of all NHL combined (ORs with increasing level: 1, 0.75, 0.71, 0.55, 0.68; p-trend = 0.04) and for diffuse and follicular NHL. We observed no association of total energy intake, type 2 diabetes, or hypertension with risk of NHL. In a multivariable model to predict risk of diffuse NHL, BMI (OR = 2.15 for 35+ versus <25 kg/m2; 95% CI 1.09-4.25) and height (OR = 1.63 for 71+ versus <65 inches; 95% CI 0.75-3.57) were positively associated with risk while physical activity was weakly and inversely associated risk (ORs with increasing level: 1, 0.76, 0.72, 0.78, 0.82; p-trend = 0.9). CONCLUSION: BMI and history of gallstones were positively associated with risk of diffuse NHL, supporting a role for obesity in this NHL subtype. Height was positively associated with NHL risk across subtypes, and suggests a role for early life nutrition in NHL risk. Non-occupational physical activity was only weakly and inversely associated with NHL risk after adjustment for obesity, height and alcohol use.

Adult↗
PubMed2006

Association between antibiotic use prior to breast cancer diagnosis and breast tumour characteristics (United States).

OBJECTIVE: To determine if breast tumour characteristics varied by antibiotic use prior to diagnosis in 2,266 women with primary, invasive breast cancer. METHODS: Subjects were women enrolled at Group Health Cooperative, a health plan in western Washington state, for at least 1 year and diagnosed with breast cancer between 1 January 1993 and 30 June 2001. Case status, tumour features, and patient characteristics were ascertained from the Surveillance, Epidemiology, and End Results cancer registry and Group Health Cooperative electronic files. Prescription information was obtained from electronic pharmacy records. RESULTS: Compared to non-use, antibiotic use prior to breast cancer diagnosis was not associated with a less favourable tumour profile (as measured by cancer stage, grade, and size), oestrogen receptor negative tumours, or lobular histology, after controlling for age and length of enrollment. Nonetheless, while not achieving statistical significance, our results suggest that antibiotic use may be associated with less favourable breast tumour features. CONCLUSIONS: Overall, we found no association between antibiotic use and breast tumour features and no dose-response gradient. However, the results are consistent with the possibility that antibiotic use may increase the risk of less favourable tumours. Larger studies are required to further investigate this hypothesis.

Adult↗
PubMed2006

Population-based assessment of hospitalizations for neutropenia from chemotherapy in older adults with non-Hodgkin's lymphoma (United States).

OBJECTIVE: To study neutropenia hospitalization (NH) incidence and risk factors in a population-based sample of older adults with non-Hodgkin's lymphoma (NHL) and evaluate the validity of inferences from Surveillance, Epidemiology and End Results (SEER)-Medicare linked databases. METHODS: NHL cases receiving first-course chemotherapy were identified from Iowa SEER-Medicare. Survival methods evaluated NH risk factors. Medical record and Medicare claims data on chemotherapy and NH were compared. RESULTS: Of 761 subjects, 165 (21.7%, 95% CI: 18.8, 24.6) were hospitalized for neutropenia. Of those hospitalized, 41% were hospitalized in cycle 1 and 22% in cycle 2. Significant multivariable risk factors for NH were diffuse large cell histology, renal disease, Charlson comorbidity index, and anthracycline chemotherapy but not patient age. Medicare and medical records agreed on month of chemotherapy initiation 95% of the time and chemotherapy type 95% of the time. ICD-9 code 288.0 sensitivity for NH was 80%. CONCLUSIONS: Neutropenia hospitalizations were common in the first 2 chemotherapy cycles, especially among older adults with comorbidity. Findings conflict with a prior medical records study in which age was a risk factor for NH and dose intensity a negative confounder. Valid inferences about age effects on chemotherapy toxicity require more clinical detail than is available in administrative data.

Adult↗
PubMed2006

Geographic patterns of advanced breast cancer in Los Angeles: associations with biological and sociodemographic factors (United States).

OBJECTIVE: Examination of patterns of advanced breast cancer may provide evidence needed to direct health care resources to those communities or population groups in greatest need. We assessed to what degree biologic, ethnic, and sociodemographic factors could explain such patterns within Los Angeles County. METHODS: The proportion of cases of advanced disease among all breast cancer cases identified during 1992-1996 were analyzed using generalized linear mixed models with random census tract effects. Models included characteristics of the individual and her tumor, census tract of residence, and aggregated health districts. RESULTS: Approximately 6% of cases, ranging from 4% for Asian to 10% for Black women, were diagnosed as advanced, exhibiting striking geographic patterns. Tumor histology and hormone receptor status were most predictive of advanced disease. Sociodemographic variables such as marital status, median income, and distance to nearest mammography unit showed additional association with risk. CONCLUSIONS: These models explain most of the geographical patterns and eliminate differences between White and Hispanic but not Asian or Black women, identify subpopulations at high risk of advanced disease, and suggest cancer control opportunities.

Adult↗
PubMed2006

Breast cancer survival among South Asian women in California (United States).

BACKGROUND: Very little is known about cancer survival patterns among the growing South Asian community in the United States. METHODS: Breast cancer survival patterns were evaluated among South Asians using California Cancer Registry data from 1988 to 1998, and breast cancer survival among South Asians was compared to non-Hispanic Whites and other Asian subgroups. The analysis included all female, invasive, histologically confirmed breast cancer cases diagnosed from 1988 to 1998. The outcome of interest was death due to breast cancer. The Kaplan-Meier method was used to calculate 5- and 10-year survival probabilities. RESULTS: South Asians were less likely to be diagnosed with early stage carcinomas relative to non-Hispanic Whites, Chinese and Japanese individuals. In unadjusted analyses, South Asians experienced poorer survival than non-Hispanic Whites at later survival times. The 5- and 10-year unadjusted survival probabilities for South Asians were 84% and 76%, respectively, compared to those for non-Hispanic Whites, which were 87% and 80%, respectively. There was no significant difference in survival between South Asians and non-Hispanic Whites after multivariate adjustment. CONCLUSIONS: These data suggest the need for targeted efforts to improve early stage diagnosis among South Asian women. Further research into the factors that influence survival among South Asians is also needed.

Aged↗
PubMed2005

Modeling the dissemination of mammography in the United States.

OBJECTIVE: This paper presents a methodology for piecing together disparate data sources to obtain a comprehensive model for the use of mammography screening in the US population for the years 1975-2000. METHODS: Two aspects of mammography usage, the age that a woman receives her first mammography and the interval between subsequent mammograms, are modeled separately. The initial dissemination of mammography is based on cross-sectional self report data from national surveys and the interval length between screening exams is fit using longitudinal mammography registry data. RESULTS: The two aspects of mammography usage are combined to simulate screening histories for individual women that are representative of the US population. Simulated mammography patterns for the years 1994-2000 were found to be similar to observed screening patterns from the state level mammography registry for Vermont. CONCLUSIONS: The model presented gives insight into screening practices over time and provides an alternative public health measure for screening usage in the US population. The comprehensive description of mammography use from its introduction represents an important first step to understanding the impact of mammography on breast cancer incidence and mortality.

Age Distribution↗
PubMed2005

Quality of cancer registry birthplace data for Hispanics living in the United States.

Patient birthplace from the SEER population-based cancer registries is potentially useful for identifying disparities in cancer occurrence and for studying cancer etiology. However, for Hispanics, completeness and accuracy of registry birthplace is unknown. By comparing registry birthplace to self-reported birthplace from 13 interview studies, we determined the completeness and accuracy of this variable and the associations of these measures with patient and hospital characteristics in the Greater Bay Area. Registry birthplace was unrecorded for 46% of 1277 Hispanic cancer cases, and unrecorded birthplace (i.e., incompleteness) was associated with younger age, higher education, English language preference, US birthplace, and admission at certain hospitals. For 691 Hispanics with available registry birthplace, sensitivity and positive predictive value compared to self-report (i.e., accuracy) were 96.3 and 97.3 among foreign-born, and 96.8 and 95.6 among US-born. US-born Hispanics misclassified in the registry as foreign-born were more likely to have unavailable education information, be deceased, prefer a language besides English, and be diagnosed at a smaller hospital or before 1996. Among self-reported foreign-born Hispanics, those misclassified as US-born were less likely to have been diagnosed at an HMO. Although the completeness and accuracy of birthplace information may vary across registries, this variable appears to be limited for analyses involving Hispanics.

Adult↗
PubMed2005

Cancer surveillance research: a vital subdiscipline of cancer epidemiology.

Public health surveillance systems relevant to cancer, centered around population-based cancer registration, have produced extensive, high-quality data for evaluating the cancer burden. However, these resources are underutilized by the epidemiology community due, we postulate, to under-appreciation of their scope and of the methods and software for using them. To remedy these misperceptions, this paper defines cancer surveillance research, reviews selected prior contributions, describes current resources, and presents challenges to and recommendations for advancing the field. Cancer surveillance research, in which systematically collected patient and population data are analyzed to examine and test hypotheses about cancer predictors, incidence, and outcomes in geographically defined populations over time, has produced not only cancer statistics and etiologic hypotheses but also information for public health education and for cancer prevention and control. Data on cancer patients are now available for all US states and, within SEER, since 1973, and have been enhanced by linkage to other population-based resources. Appropriate statistical methods and sophisticated interactive analytic software are readily available. Yet, publication of papers, funding opportunities, and professional training for cancer surveillance research remain inadequate. Improvement is necessary in these realms to permit cancer surveillance research to realize its potential in resolving the growing cancer burden.

Behavioral Risk Factor Surveillance System↗
PubMed2006

Misclassification of race/ethnicity in a population-based cancer registry (United States).

Cancer registry data on race/ethnicity are vital for understanding cancer patterns in population subgroups, as they inform public health policies for allocating resources and form the bases of etiologic hypotheses. However, accuracy of cancer registry data on race/ethnicity has not been systematically evaluated. By comparing race/ethnicity in the Greater Bay Area Cancer Registry to self-reported race/ethnicity for patients from 14 racial/ethnic groups, we determined the accuracy of this variable and the patient and hospital characteristics associated with disagreement. The extent of misclassification (measured by sensitivity and predictive value positive (PV+)) varied across racial/ethnic groups (total n=11,676). Sensitivities and PV+'s were high (exceeding 90%) for non-Hispanic Whites and Blacks, moderate for Hispanics and some Asian subgroups (70-90%), and very low for American Indians (<20%). Overall, registry and interview race/ethnicity disagreed for 11% of the sample. In a multivariate model, disagreement was associated with non-White race/ethnicity, younger age, being married, being foreign-born but preferring to speak English, and diagnosis in a large hospital. Improving data quality for race/ethnicity will be most effectively attempted at the reporting source. We advocate a concerted effort to systematize collection of these patient data across all facilities, which may be more feasible given electronic medical admissions forms.

Bias↗
PubMed2006

Recreational physical activity and prostate cancer risk (United States).

OBJECTIVE: To examine recreational physical activity (PA) and prostate cancer risk in a large cohort of men living in Washington State, focusing on frequency and type of physical activity at various times throughout life. METHODS: In a prospective cohort study, we assessed physical activity in 34,757 men (50-76 years at baseline) using a questionnaire. Men were recruited into the study between 2000 and 2002. Five hundred and eighty-three men developed prostate cancer. RESULTS: Using Cox proportional hazards regression, PA either in the 10 years before baseline or earlier in life was not associated with prostate cancer risk. However, compared to no activity, >or=10.5 MET-h per week (the median level) of PA was associated with a reduced prostate cancer risk among men who were normal weight (HR = 0.69, 95% CI 0.46-1.0), >or=65 years at diagnosis (HR = 0.75, 95% CI 0.55-1.0) and who had not had a recent PSA (HR = 0.47, 95% CI 0.28-0.81). Greater PA was associated with an increased risk among men who were obese (HR = 1.5, 95% CI 0.95-2.4), and no association among men <65 years or with a recent history of PSA screening (all p for interactions <or=0.02). CONCLUSIONS: PA was not associated with prostate cancer risk, except in subgroups defined by age, obesity, and screening history.

Adiposity↗
PubMed2006

Benefit of screening mammography in reducing the rate of late-stage breast cancer diagnoses (United States).

OBJECTIVE: We studied the benefit of modern mammography screening in community settings, evaluating age-related differences in rates of late-stage breast cancer detection. METHODS: Our multicenter population-based case-control study included 931 black and white women with incident breast cancer (American Joint Commission on Cancer Stage IIB or higher) diagnosed 1994-1998 and 4,016 randomly sampled controls never diagnosed with breast cancer. Adjusted odds ratios (ORs) estimated the relative rate of late-stage diagnosis in screened and non-screened women. RESULTS: Women aged 50-64 at diagnosis with at least one screening mammogram in the previous 2 years were significantly less likely to have late-stage diagnosis (OR = 0.41, 95% CI 0.33-0.52). Results for women aged 40-49 were consistent with a screening benefit, although the confidence interval marginally overlapped the null (OR = 0.81, 95% CI 0.64-1.02). Mammography screening was associated with lower rates of late-stage breast cancer among both premenopausal (OR = 0.64, 95% CI 0.50-0.81) and postmenopausal (OR = 0.44, 95% CI 0.35-0.56) women. CONCLUSIONS: With modern mammography in the community, rates of late-stage breast cancer diagnoses are lower in screened compared to non-screened women ages 40 and older, but age-related differences persist.

Adult↗
PubMed2006

Risk patterns of multiple myeloma in Los Angeles County, 1972-1999 (United States).

OBJECTIVE: To describe the risk patterns of multiple myeloma in Los Angeles County (LAC). METHODS: Incident multiple myeloma cases diagnosed from 1972 to 1999 were ascertained by the population-based cancer registry for LAC. Average annual age-specific and age-adjusted incidence rates (AAIR), standardized to the 2000 US census age distribution, were calculated using age-, race-, sex- and socioeconomic status (SES)-specific denominators estimated for all years from US census data for 1970, 1980 and 1990. Odds ratios (ORs) for risk by birthplace and religion were estimated using multivariate logistic regression, comparing multiple myeloma patients with other cancer patients. RESULTS: All groups experienced increasing incidence with age; African-Americans experienced the steepest increase which began a decade earlier compared to other groups. Overall incidence rates were 50% higher among males (n = 4,692) than females (n = 4,343) (p < 0.05). AAIRs were highest for African-Americans, followed by Spanish-surnamed whites (SSW), non-Spanish-surnamed whites (NSSW), Filipinos and other Asian groups. Among African-Americans, incidence rates increased with increasing SES. US-born SSW had 14% lower risk compared to non-US born SSW (OR = 0.86, 95% confidence interval [CI] = 0.74-0.99]. Jews had an 11% higher risk compared to Protestants (OR = 1.11; 95% CI = 0.99-1.24). CONCLUSION: Risk patterns suggest a role for both environmental and genetic factors.

Adolescent↗
PubMed2006

Age effects and temporal trends in adenocarcinoma of the esophagus and gastric cardia (United States).

A number of hypotheses have been advanced to explain the rapid increase of the incidence of esophageal adenocarcinoma in the US. A major problem in identifying and understanding the nature of this increase is the difficulty in untangling age effects from temporal trends due to cohort and period effects. To address this problem, we have developed multi-stage carcinogenesis models that describe the age-specific incidence of adenocarcinoma of the esophagus and of the gastric cardia with separate adjustments for temporal trends. These models explicitly incorporate important features of the cancers, such as the metaplastic conversion of normal esophagus to Barrett's esophagus (BE). We fit these models separately to the incidence of adenocarcinoma of the esophagus and of the gastric cardia reported in the Surveillance Epidemiology and End Results (SEER) registry over the period 1973-2000. We conclude that the incidence of both cancers is consistent with a sequence that posits a tissue conversion step in the target organ followed by a multi-stage process with three rate-limiting events, the first two leading to an initiated cell that can expand clonally into a premalignant lesion, and the third converting an initiated cell into a malignant cell. Temporal trends in the incidence of both cancers are dominated by dramatically increasing period effects.

Adenocarcinoma↗
PubMed2006

Oral contraceptive use and risk of breast carcinoma in situ (United States).

OBJECTIVE: Our study assesses the impact of oral contraceptive use on breast carcinoma in-situ (BCIS) risk. METHODS: We conducted a population based case-control study of incident BCIS among black and white women ages 35-64 years residing in Los Angeles County. Case patients (n = 567) were newly diagnosed with BCIS and control participants (n = 614) were identified by random digit dialing between 1 March 1995 and 31 May 1998. All subjects were required to have had a mammogram in the 2 years before case diagnosis or control recruitment. Data were collected during in-person interviews. Multivariable logistic regression analyses provide estimates of odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS: Oral contraceptive use was not associated with risk of BCIS (OR = 1.04, 95% CI (0.76-1.42)). Risk did not increase with longer periods of use. No associations with BCIS risk were observed for oral contraceptive use before first term pregnancy, age at first oral contraceptive use, or for time since last use. Risk was not modified by estrogen dose, age, race, or parity. CONCLUSIONS: Our results are consistent with recent results on invasive breast cancer reported for the Women's Contraceptive and Reproductive Experiences Study and show no association between oral contraceptive use and risk of BCIS.

Adult↗