This podcast is part of our May 2020 special issue. Download the full issue here.
Colon cancer is one of the most preventable cancers, and yet it is the third leading cause of cancer deaths after lung cancer, and prostate for men and breast cancer for women. In this interview, naturopathic oncologist Tina Kaczor, ND, FABNO, discusses how clinicians can help patients reduce their risk of developing colon cancer. Kaczor has been working in oncology for 2 decades and is a Fellow of the American Board of Naturopathic Oncology.
Approximate listening time: 32 minutes
About the Expert
Tina Kaczor, ND, FABNO, is editor-in-chief of Natural Medicine Journal and a naturopathic physician, board certified in naturopathic oncology. She received her naturopathic doctorate from National University of Natural Medicine, and completed her residency in naturopathic oncology at Cancer Treatment Centers of America, Tulsa, Oklahoma. Kaczor received undergraduate degrees from the State University of New York at Buffalo. She is the past president and treasurer of the Oncology Association of Naturopathic Physicians and secretary of the American Board of Naturopathic Oncology. She has been published in several peer-reviewed journals. Kaczor is based in Portland, Oregon.
Transcript
Karolyn Gazella: Colon cancer is one of the more deadly cancers and yet it's also one of the most preventable. On this episode, we'll find out how we can help make colon cancer less common. Hello, I'm Karolyn Gazella, your host and the publisher of the Natural Medicine Journal, an online, peer-reviewed medical publication for integrative healthcare professionals. My guest is the editor-in-chief of the Natural Medicine Journal, Dr Tina Kaczor. Dr Kaczor has been working in oncology for 2 decades and is a fellow of the American Board of Naturopathic Oncology. Dr Kaczor, always a pleasure talking with you. Thank you for joining me.
Tina Kaczor, ND, FABNO: Well, thank you so much for inviting me.
Gazella: As I mentioned, colon cancer is considered to be a preventable cancer and yet it's still a leading cause of cancer death. Why is that? What's wrong with this picture, Dr Kaczor?
Kaczor: I think colorectal cancer and the risk factors for it are very much a product of our modern lifestyles and our westernized ways. And we'll get to the details of that throughout this discussion I think, but ultimately I think it has a lot to do with lifestyle habits, and what we're eating, and what we're doing on a day-to-day basis, and how we're sleeping, and our stress levels, throw that in there. So I think that the gut really is, as you've heard, it's called our second brain. And it's really intimately linked with our nervous system, and I think that perhaps part of this that we're not going to get to but I just want to put this in the beginning is, this high-stress environment that we're in and the go, go, go and that affects all those lifestyle habits that we are going to think about. So it's all one big package and the rates are higher in westernized societies in general.
And then we'll talk about, when it comes to leading cause of death, that has to do with when it is diagnosed. Ultimately, it's not just the prevalence and the incidence of colorectal cancer, but where along the trajectory of the stages of colorectal cancer from 1 to 4 that is diagnosed? And the higher the stage that is found at, the more likely someone's going to actually die of colorectal cancer and not have a curative intervention.
Gazella: Do you know, I almost didn't ask you that question because I thought, "Gosh, that's an unfair question." Because there's really no simple answer because it is complex and there are many factors, but you did an awesome job. And you also did a great job of teeing up some of the things that we're going to be talking about. And I'd like to start with screening because screening is big when it comes to colon cancer. So take us through the types of screening tests and what the recommendations are regarding colon cancer screening.
Kaczor: Sure. And I want to say that screening for colorectal cancer, just like any cancer, is really governed by the country. So what we do here in the United States is, this does not go for other countries outside of our bounds. I certainly know that Canada has different recommendations and they're much looser, they do not screen as rigorously or have as rigorous a standard, but anyways in short, in the United States, according to the, the United States has the US Preventative Services Task Force, and according to them, which is what the CDC uses as well. For recommendations, we have stool test, we have endoscopy, which is basically a fancy way of saying scope, putting a scope in the rectal area, and then we have imaging. And so stool tests, there's 3 types of stool tests, there is the good old guaiac-based fecal occult blood test. This is the one that is done sometimes in office. If there's a rectal exam, the physician can turn and put a sample of the stool onto basically a little paper and watch it develop, and it's a in-office or at-home test.
There's also another stool test... And that's looking for blood. That's looking for occult blood. The patient doesn't see the blood, but it's looking for occult blood in the stool. Another way to look for occult blood in the stool is a FIT test, the fecal immunochemical test. And it's very similar to the guaiac test, it just uses antibodies to detect that blood in the stool. What I like about that one is that vitamin C doesn't interfere with those results, vitamin C interferes with the guaiac-based test. A lot of our patients are taking that so that can be misleading, give a false positive. And then the last one combining the FIT test with a DNA test. The last stool test I should say, is that combining the FIT test with a DNA test and that is looking at DNA in the stool that's abnormal. So that's a little bit more sensitive.
That one requires an entire bowel movement to be collected and sent out to a lab. So it's a little bit more involved for the patient, but it does offer a little bit more specificity because blood in the stool can be from so many reasons besides colorectal cancer. So those are the 3 ways of testing the stool.
Endoscopy uses either a sigmoid scope, which is a flexible sigmoidoscopy and that looks at the rectum and the descending colon, but it will not and cannot get to the transverse colon or the ascending colon. So you're only going get maybe the latter third of the colon and that's usually done every 5 years, unless it's done with those stool tests for blood where it can maybe be done every 10 years.
Then there's colonoscopy, which is the other type of endoscopy. Colonoscopy, now that one is the one most people are familiar with. And that is scoping the entirety of the colon as it is looked at, if there's anything unusual, that will be biopsied just like it would be with a sigmoid scope. So colonoscopy is the entire colon all the way to the cecum, and it gets a good look and is an intervention of sorts because it will remove polyps, it'll remove suspicious lesions and it will biopsy suspicious areas.
Now imaging, there is one imaging that is approved and it's a virtual colonoscopy. Now it sounds great, no invasion, you want to do an image that sounds great. But it's... What it involves is it's the same prep as a colonoscopy so you still have to clean up the colon. Then they insufflate, which is a fancy word of saying they pump air into your whole colon. My understanding is that's not very comfortable to have your colon inflated with air. And then they put you through a CT scanner so there's a mild amount of radiation involved, and if they see a polyp, if they see anything that's suspicious, they still have to go back and do a colonoscopy with a real scope, to go in and look at it closer and take a sample.
The other reason I'm not a huge fan of virtual colonoscopies is that it can miss one of the most likely polyps to become cancer and that's the sessile polyps. A sessile polyp, almost sounds like an oxymoron because a polyp generally has a like a pedestal to it, like it's pedunculated, it's kind of hanging out, picture of a mushroom that's coming out of the ground, and it has a stock. A sessile polyp is more like a hockey puck, it's just stuck against the sidewall of the colon. And if you're looking at a virtual colonoscopy, you could very easily miss that because it's not, there's no stock to it. So there's many reasons that I think virtual colonoscopies have never really gotten a lot of usage.
And the recommendation for which one to get officially has to do with the preferences of the patient, other medical conditions they may have and risks and benefits to each of these. The likelihood that they'll actually do the test, because some people will show up for, and they don't have time for the procedure, they can't get the time off from work. Whatever it is, there's practicalities and logistics that might get in the way. So one of these tests should be done at the... And then we'll go through the ages in a moment, and then the resources available for testing and follow-up. So that has to do with I think socioeconomic status. For example, it's clear that colorectal cancer is diagnosed at later stages more in those who are more socioeconomically disadvantaged, so there's that.
All of this should start... In someone with low to average risk, they should be done starting at about, not about, should be started at age 50 according to the CDC. Now there's a little bit of controversy here, the American Cancer Society Has come out and said 45 years old is when this should all start, one should be begin screening in low to average risk people. So this is people without any family history or reason to think they have any ... They're asymptomatic, there's nothing going on. Just at 45 years old, go and get a screening procedure for colorectal cancer is what the American Cancer Society is saying. And as I said, the CDC, the US preventative services task force, they say begin at 50. They both agree you should end at 75 years old, which I find very interesting. I find that interesting because your risk of colorectal cancer does not suddenly go down at that age. It actually keeps going up well into your late seventies and your eighties. So someone at 80 something years old is at 10 times the risk of someone in their fifties for example.
So I don't think we should totally just wash our hands and stop thinking about colorectal cancer in our elderly patients. I do think we might want to turn to something less invasive like cologuard, which is a stool test that can be done at home. The reason that they stop the colonoscopy in particular, in checking through a colonoscopy at the age of 75 is, there's a very slight but real risk of perforation with a colonoscopy and that goes up with age. So they start to weigh that risk benefit. It's very low, we're talking like even at that age, I think it's between one and 3% for somebody who's over the age of 75. But it's real, so it's a bad thing to happen when it happens. So the cologuard is a stool test that can be used. It's by no means as thorough or accurate as a colonoscopy. But it does find 94% of early stage colorectal cancers and those are the ones we really want to find, 94% of early stage. That means stages one and two colorectal cancers can be found with this stool test that looks for DNA that's abnormal in the stool.
It's kind of not something you want to just willy nilly use. There is certainly a false negative rate and a false positive rate. The false negative rate for cologuard meaning you miss cancer 8% of the time. So in eight out of every 100 people who do cologuard and have colorectal cancer, eight out of every hundred will think they don't have it. They'll get a test back and he'll say, well you don't have colorectal cancer. On the flip side it has a false positive rate of 13%. So that means that 13 out of 100 people will then go on to get a colonoscopy to look for this cancer that they think they have, from their cologuard's stool tests and there will be nothing there. So you get 13 false positives for every hundred and this is overall not just early stage colorectal cancer. So just so you know, cologuard is nice, it looks great, DNA at home, no scoping, no prepping but it has some drawbacks too.
Gazella: That was very thorough and I didn't realize that about ending at age 75 so you make some great points there. So I want to shift the conversation to risk factors. Now we all know that there are many risk factors that increase colon cancer risk. Which risk factors do you feel clinicians may not be paying enough attention to in their clinical practice?
Kaczor: So the risk factors in general of eating processed meat, abdominal fat, body fat in general smoking, the taller one is the more likely they have colorectal cancer, and age. Like I mentioned, age, the risk keeps going up. Those are the world health organization, tried and true ones. But the less well evidenced or the less... Maybe the less likely to be noticed are things like people who sit a lot as their occupation or their inclination. So sedentarism and sitting still for long periods of time. And this is really common. So a lot of people are on computers, we have jobs that keep us still for long periods, accountants, IT people, pretty much anyone with a desk job, that adds to risk of colorectal cancer. So that should be talked about in the office and actually taken into account when you're putting checks in your mind and whether someone should be screened or not.
Hyperglycemia or high blood glucose is also associated with colorectal cancer. And then one that I think will only get more and more evidence as time goes on dysbiosis. And dysbiosis has to do with the microbes in the gut so we know that dysbiosis is associated with colorectal cancer, and dysbiosis is basically a how do we say it? It's an ecological system in the gut where there should be a good balance between and a predominance of these really good beneficial bacteria, there'll always be a little bit of candida, just like there's a little bit of dandelion in someone's lawn. It's not consequential unless there's a lot of the bad or pathogenic bacteria. But more and more we're seeing that what inhabits the gut as far as organisms and in particular bacteria, is associated with colorectal cancer. So that's something to consider so if someone has gas, bloating, diarrhea, IBS, that kind of thing. Those are the big ones.
Gazella: Yeah, those are great. And as you said, those are on top of the ones that we all know about, so that's great. What role does family history play in increasing one's risk? Or does it play a role?
Kaczor: Certainly, yes. So those rules that I said were for screening people with lower average risk. But when someone has a family history, they may want to get screened at an earlier age. So let me just tell you there's first degree relatives and there is second degree relatives. A first degree relative is parents, children and full siblings, that's it, that's a first degree relative. So basically your parents, your children and full siblings. Half siblings, uncles, nephews, aunts, grandkids, nephews and nieces, all of these qualify as a second degree relatives. So just so we're clear on who's what.
A first degree relative with colorectal cancer or advanced adenomas for that matter, so they're going to treat those the same as far as we as clinicians as far as when to screen for folks. People with first degree relatives with CRC or advanced adenoma diagnosed before 60 years of age, or two first degree relatives at any age. So the earlier the diagnosis, the more vigilant we have to be in our screening procedure with the patients in front of us. So you have to look at the age at which someone in your family was diagnosed with colorectal cancer. So that particular group has a three to four fold increased risk of colorectal cancer and should be screened much earlier.
Usually they say 10 years younger than the earliest diagnosis of the person in your family who was diagnosed. So if someone was diagnosed, if your mother was diagnosed at 45 years of age and you're 35, that's the age you should be diagnosed at. So 10 years prior to your immediate family member. And then if they were diagnosed not below 60 years, but above 60 years of age, then generally they start colonoscopy screenings at 40 years of age instead of 50.
Gazella: That's significant, 3 to 4 times increased risk. That's pretty significant. So let's talk a little bit about diet, because I know diet is pretty big when it comes to reducing risk of colon cancer. Now we know a lot of the basic things about diet and colon cancer, but what dietary advice do you feel clinicians may not be focusing on enough with their patients?
Kaczor: In generic terms and generally, I think that all of the advice should be around creating the proper flora in the gut. People hear that and they think probiotics immediately because I think our brains are trained to go straight to a probiotic in our minds. But I'm thinking prebiotics are just as valuable if not more so, because what you're doing with a prebiotic, and studies are validating that. With a prebiotic food, and this means soluble fibers, this means legumes, it means fruits, it means veggies, and it's all of the color nature holds what are called polyphenols. And these polyphenols are also integral to creating a good flora in your gut. So we're finding out that this may be the crux of why high plant based diets really do ward off colorectal cancer as well as so many others. Because it leads to a diversity in the gut. And that's what we're talking about always is we want the most diverse array of good organisms we can possibly have.
I'm a fan of probiotics at times, but there are some times where a probiotic can actually lessen the diversity in the gut, which is the antithesis of what we want. It depends on the probiotic itself though. So I don't say generically take a probiotic because it would be very selective and you have to make sure that probiotic is linked to creating diversity, not taking away from it. So from a generic level I say, diversity of the gut from a drill down and specific levels, things like nuts on a daily basis, a small amount of nuts and we're talking about maybe a quarter cup a day, I think is really important to gut health and has been associated with less colorectal cancer. Greens in general. Crucifers, cruciferous vegetables, so that's kale and broccoli and cabbages and such.
And that has to do with not just gut health and the biota, but it has to do with getting rid of carcinogens as you take them in. Because we do in westernized societies, whether we're breathing them in or we're eating them or they're going through our skin, we are exposed to things that we need to break down and those crucifers help us do that. And maybe some green tea. People enjoy the green tea, I don't think they have to plug the nose and choke it down, but green tea has been associated with less colorectal cancer risk. And of course I should say very specifically legumes. Beans have been associated with less colorectal cancer risk and I have some concern about longterm diets that omit legumes. I think it's something that is going around in various forms right now for various selective diets, and I think it could be detrimental over time because without legumes we may not have the diversity we're supposed to have.
Gazella: That's all great advice. Now what about coffee? I've read some studies regarding coffee consumption and colon cancer. What does the research tell us about coffee?
Kaczor: Thankfully as a coffee lover, happy to report-
Gazella: Me too.
Kaczor: Consumption of coffee is associated with lower rates of colorectal cancer incidents and that's been consistent. It's almost all observational studies, but there are so many over such a long period of time. I think that we can faithfully say and say with some level of confidence that regular coffee consumption reduces the incident risk of colorectal cancer between 26% to 50%, depending on how much you drink because it has what is called a dose linear relationship. So a dose response relationship is another way of saying that where the more you drink, the more you reduce your risk. I will put a caveat to that of course, and that is, at some point coffee's not good for your other systems, so you do want to do it in moderation. But know that all the research points to benefit, which is great.
Gazella: Yeah, it is. So let's switch to lifestyle. So from a lifestyle standpoint, what are the top three things clinicians should focus on when talking to their patients and why?
Kaczor: Top 3 things. In short, I would put it as body composition, exercise at any size and minding the microbes of the gut. Those are the three things. Those are the three lifestyle things that one can do. Body composition has to do with fat deposition or what we call adipose tissue and it has to do with muscle mass. There's a fat to muscle ratio that we want to keep on that, it's not exact. But I'm saying this because I have been a clinician for 20 years. I can tell you now there are some people, whether it's genetics, whether it's age, whether it's... Their body will not release their fat. We do everything, we go low calorie, they exercise and it won't let it go. In those patients and I think this is the hardest population for us as clinicians to try to really, we want, of course in an ideal world we want a normal body weight, we want a normal BMI, but it's not possible for everybody.
So that muscle mass under the fat, I tell people, "Yes, lose as much fat as you can, get your BMI down below 25 if you possibly can and certainly below 30." If you can't, if you just hit a wall. And again, there's certain reasons this happens in certain body types, build muscle. Because muscle is the antithesis of the fat, so they oppose each other. Each one is its own endocrine organ. When I went to school, we didn't know this over. 20 years ago, we did not talk about fat and muscle creating molecules in their own selves that then affect your body systemically, but now we know they do that. The thing you don't need to know any of the details, all you need to know is they make opposing molecules. So fat makes molecules that increase inflammation. Muscle makes molecules that decrease inflammation and they're constantly opposing one another. And so with that in mind, I say body composition rather than BMI or something. And go ahead.
Gazella: I think that's a really great point to bring up and I can see why you're talking about that one first. So the second one then was exercise.
Kaczor: Yes. And I say exercise at any size because we are in a world, and our social and cultural norms are go out and run or whatever. Exercise, doesn't matter what you do, just staying active, having movement. Basically overweight or obesity affects two-thirds of our population, so 66% of our population is either overweight or obese. And I don't expect these people to go out and run a marathon, but I do want people to exercise to whatever capacity it means that they're slightly breathless. I don't care if it's fast walking, going up a Hill will then create some muscle mass in their legs, which is great, but exercise at any size is really, really important. Exercise by far over any piece of diet over any other piece of lifestyle research we have, exercise has the best evidence. Reduces risk of colorectal cancer specifically between 24 and 50% depending on the studies you look at.
Kaczor: And then I put mind the microbes. Like I've already mentioned, you have to make sure that the gut itself is healthy with its microbes. Because remember colorectal cancer is happening right where the food and the bacteria are against the cells, they're laying against the cells, it's in the inner part of the colon. This more than any other cancer, we affect directly by changing the environment of the inner colon.
Gazella: Right, that makes a lot of sense. So what's the connection between hormone replacement therapy and colon cancer? Is there one?
Kaczor: There is and it's complicated. So the rate of colorectal cancer incidence worldwide is 50% higher in men than it is in women. So there's clearly something, there's always been something going on. Of course, we assume it probably has something to do with estrogen. And at this point it looks like estrogen itself prevents the incidents, the initial diagnosis of colorectal cancer. So premenopausal women, for example, have a lower rate of colorectal cancer than age match men, so that's one piece of it. Now this goes into, what happens once colorectal cancer is present? It may be the opposite. It looks like while estrogen may prevent the initiation of cancer in the colon and rectum, it may actually cause more growth once cancer is present.
So this is an interesting kind of mind bender for us, right? So you're like, "Okay, so in premenopausal women where their natural estrogen are high, they have less incident colorectal cancer. Postmenopausally hormone replacement therapy is fine, but if somebody has a small amount of colorectal cancer, meaning it's a cult, it can't be seen, it's never been diagnosed, and they begin HRT, hormone replacement therapy, they may accelerate the growth of that cancer because it's already present. So this is somewhat difficult for people to understand, but this is analogous to breast cancer. Where if someone starts hormone replacement therapy, they just had a mammogram, everything looks good, but they had a little tiny speck of cancer that didn't show up on imaging and they begin hormone replacement therapy, there's a really good chance that they're going to get to accelerate the growth of an estrogen receptor positive breast cancer. It's no different than that.
Gazella: Interesting. That we might have to have a followup conversation on that because it is kind of fascinating. So what does the research tell us about aspirin use and colon cancer?
Kaczor: This is interesting. Some of the first data looking at the protection from aspirin of colorectal cancer diagnosis was incidental. It was done in people who were on studies using aspirin to prevent stroke for example. And then watching what happened to them over 10 and 20 years, the UK where there's a government healthcare database, they noticed that people who took aspirin in those studies in those stroke studies had a lot less colorectal cancer. Since then there's been a huge, both retrospective and prospective studies looking at aspirin use and colorectal cancer incidents. And an aspirin dose between 75 and 100 milligrams a day, reduces the risk of colorectal cancer by about 10%. And if the dose goes up to 325 milligrams a day, it looks like 35% reduction. And that's according to a meta analysis that came out just last year that looks at a couple of dozen plus studies on this. So it's clear that it protects.
We do have to remember that aspirin also thins the blood in a way that can't be rectified. So if someone is young, active, accident prone, likely to have a bleed for any reason, then we've really don't want to do full dose aspirin in them because you don't want a trauma or I fall and beyond 325 milligrams of aspirin. It's hard to staunch that bleed.
Gazella: Let's talk about nutrients now. Are there any nutrient deficiencies that can actually increase risk of colon cancer that clinicians should be aware of?
Kaczor: Yeah, clearly selenium. Selenium deficiency, which is an interesting thing because there's a lot of selenium deficient soil in the United States. This is one of those deficiencies that you could have if you eat like a standard American diet, which is not very healthy. It's also a deficiency you could have if you are a really good vegetarian chomp and loco vora, you only eat from your own yard for example, or your local market, but you happen to live somewhere in the United States with selenium deficient soil, then you too could be selenium deficient. So I think it's one of those things you do have to be mindful of as a vegetarian in particular because selenium occurs in meat, so you shouldn't be low if that's the case. But selenium is connected to colorectal cancer, low selenium.
Vitamin D has been linked to colorectal cancer. And interestingly vitamin D and colorectal cancer was one of the first cancers that vitamin D was linked to back in 1980. There's a paper by doctors Garland and Garland, two brothers and they published on the mortality from colorectal cancer and levels of sun exposure. And they hypothesized at that time that had something to do with vitamin D. And low and behold, vitamin D deficiency is certainly linked to colorectal cancer incidents and outcomes. So no matter when along the trajectory from prevention all the way to metastatic disease, we say vitamin D needs to be corrected and usually with a supplement. Those are the two biggies. And vitamin C, perhaps. There's a little less evidence, a little shakier evidence, but it looks like that may be a nutrient deficiency.
One thing I want to put a plug in for and is on the list as something that likely is associated with colorectal cancer is not ingesting enough calcium. Whether through dairy or supplements. So calcium, it's not because people are deficient in calcium per se, they're pulling it from their bone. You're never going to see it on a lab. It has to do with calcium as it floats through the lumen of the colon, as it goes through the colon and through the urine, small intestines in particular and through the colon, it's going to bind certain bile acids. And it needs to bind those bile acids because they happen to promote colorectal cancer. So not taking enough calcium in, and this is important for when people go off dairy, they need to replace their calcium. Not only for their own serum in their bloodstream, but also for their gut's health. So calcium would be on my list of things to take if somebody wasn't already eating dairy.
Gazella: Let's talk a little bit more about that, things to take. So in addition to correcting underlying nutrient deficiencies, are there nutrients or herbs that may be helpful when we're talking about reducing risk?
Kaczor: Yeah, I think what stands out is maybe it's more diet than herbs, but garlic. Garlic is really high on the list, and this goes back to the biome, it has to do with compounds that are anticancer within the garlic sulfurous compounds. But that's really high on the list. Other than that, the fibers that I've already mentioned. And as far as supplements go, curcumin might be highest, if I had to say someone who had high risk, I would say supplement wise, curcumin would be on the top. And there's so many different ways of getting that in. Remember we're talking about the colon, we want some of it to go into the bloodstream, but if some of it stays and isn't absorbed, that's perfectly fine because curcumin is having some effect in direct contact with the colon cells. So curcumin might be the top of my list if you had to pop a pill kind of thing.
Gazella: And that's because of its anti-inflammatory activity?
Kaczor: Yes. Yeah, it's anti-inflammatory activity. And the rate of colorectal cancer in India in general is fairly low. And that has not to do just with curcumin, but with the vast array of spices. Bharat Agarwal from MD Anderson has written an entire book on spices and how they are anticancer in general. They almost all have components that block a very, what do you call it? A necessary part of inflammation is something called NF-κB. And this NF-κB is inhibited by nearly all the spices that are used. So a good Curry goes a long way.
Gazella: Yeah. We've had Dr Agarwal on this series, and he's very a wealth of information and, you know what, Dr Kaczor once again, thank you so much for joining me and sharing this important information about reducing risk of colon cancer. I think we've learned a lot today. Thank you.
Kaczor: You're welcome. My pleasure. Anytime.
Gazella: So I want to remind our listeners that you can find more podcasts and more great information at naturalmedicinejournal.com you'll notice on the homepage that you can also sign up to receive the natural medicine journal in your email inbox each month. So thank you so much for listening and have a great day.
