Credit: Darryl Leja National Human Genome Research Institute National Institutes Of Health
Because low-risk prostate cancer is unlikely to spread or impact survival, experts and guidelines recommend active surveillance, which involves regular monitoring and thus avoid or delay treatment like surgery or radiation therapy and their life-changing complications. A new study examined the rates of active surveillance use and evaluated the factors associated with selecting this management strategy over surgery or radiation, with a focus on underserved Black patients who have been underrepresented in prior studies. The findings are published by Wiley online in CANCER, a peer-reviewed journal of the American Cancer Society.
For the study, called the Treatment Options in Prostate Cancer Study, Jinping Xu, MD, MS, of Wayne State University, and her colleagues analysed data from metro-Detroit, Michigan, and Georgia cancer registries, focusing on patient self-reported information related to Black and White patients who were newly diagnosed with low-risk prostate cancer in 2014–2017.
Among 1688 patients, 57% chose active surveillance (51% of Black patients and 61% of White patients) over other treatments. After adjusting for other influencing factors, the strongest determinant of active surveillance uptake was a urologist’s recommendation to choose this option. Other factors linked with the decision to undergo active surveillance included a shared patient-physician treatment decision and greater knowledge about prostate cancer. Also, participants living in metro-Detroit were more likely to choose active surveillance than those living in Georgia.
Conversely, men were less likely to try active surveillance if their considerations were strongly influenced by the desire to achieve a “cure” or they expected to “live longer” with treatment, or if they perceived that their low-risk prostate cancer diagnosis was more “serious.”
Education and interventions for patients and especially urologists that address these factors may increase the use of recommended active surveillance among individuals with low-risk prostate cancer.
“I am glad to see that the majority of our study participants selected active surveillance, which indicates that acceptance has improved over the last decade; however, there is room for greater acceptance. Our study findings shed new light on potentially modifiable factors that can help further increase active surveillance use among patients with newly diagnosed low-risk prostate cancer to avoid unnecessary invasive treatment and improve their quality of life,” said Dr Xu.
Credit: Darryl Leja National Human Genome Research Institute National Institutes Of Health
By James White, Head of Sales and Marketing at Turnberry Management Risk Solutions
According to the National Cancer Registry (NCR) of South Africa, prostate cancer is the most commonly diagnosed cancer among men in South Africa. In 2020, it accounted for more than 22% of all male cancers, with the average age of diagnosis being 65 years old. While prostate cancer is more common among older populations, it can affect men of any age, and although the disease is often treatable, the success of treatment and survival rate depends heavily on an early diagnosis and access to appropriate treatment. The last thing anyone wants to think about after a diagnosis is how they will pay for the treatment, or if they can even afford it, which is why gap cover has become an essential weapon in the fight against cancer.
Key points about prostate cancer
While the exact cause of prostate cancer is unknown, there are several risk factors that increase a man’s likelihood of developing the disease. These include age, family history, and lifestyle factors such as diet and exercise. However, if it is caught early, prostate cancer can often be successfully treated, so it is important for men to get regular check-ups and prostate cancer screenings starting at age 50 (or earlier if they have a family history or other risk factors). Regular screenings can help detect prostate cancer before it has a chance to spread, giving men the best chance of a favourable outcome.
It is also important to know that help and support are available. Prostate cancer can be a difficult diagnosis for men and their families, but there are many resources available for support, including support groups like the Machi Filotimo Cancer Project, as well as online forums, and counselling services. These resources can help men and their families cope with the emotional and practical challenges of a prostate cancer diagnosis and treatment. When it comes to the financial side, it is important to understand your medical aid scheme and plan option, and how treatments will be covered.
Shortfalls and PMB conditions
Prostate cancer is a Prescribed Minimum Benefit (PMB) condition, which means that medical aid schemes in South Africa are required by law to provide cover for diagnosis, treatment, and care, in line with that which is available at a state hospital. However, this does not mean that medical expense shortfalls will not occur. Co-payments may still apply for certain aspects of treatment and making use of a non-Designated Service Provider (DSP) may attract penalties. Depending on the scheme and plan option a patient has, there may also be other limitations on the cover received for cancer treatment.
For example, a PMB will cover the treatments that are available as per the protocols of a state hospital, including surgery, chemotherapy, immunotherapy, radiation, and hormone therapy. There are also next-generation biological cancer drugs that are used to successfully treat prostate cancer while being minimally invasive and having fewer side effects. These drugs, however, are not part of the basket of PMB care, and will be covered according to the cancer benefits of a patient’s medical aid scheme and plan. There is significant potential for shortfalls here, as these drugs are expensive, are not often fully covered, and need to be administered multiple times to be effective.
A significant gap
As with all cancers, early detection saves lives, and the sooner a patient can start to get the treatment they need, the better their prognosis. However, having to think about the financial implications can add strain to an already stressful situation. Having the right gap cover policy can be invaluable in ensuring that you can receive the best treatment, quickly, to give you the highest chance of surviving and thriving after a prostate cancer diagnosis.
At Turnberry, prostate cancer claims make up a significant 17% of all cancer-related claims, and the amounts claimed for are substantial sums of money. In 2022 alone, we paid out several high-value claims related to prostate cancer – a shortfall of R29 530 from a total bill of R84 889.50; a shortfall of R31 496.60 from a bill of R47,244.90; a claim of R54 555.50 from a total charged amount of R84 899.50; a claim of R53 722 from a total bill of R80 583; and a shortfall claim of R26 765.86 from a total bill of R39 392.80. Without gap cover, these patients would have had to fund these shortfalls out of pocket, which could significantly impact their financial wellbeing long after they received a clean bill of health.
Always talk to your broker
Medical aid schemes and the various plan options within the schemes vary in the coverage they provide as well as the way in which their cancer benefits are structured. In addition, different gap cover policies have different coverage options, which means that it is important to talk to your broker or financial advisor to find the best gap cover policy to augment your medical aid cover. Ultimately, gap cover is a small price to pay for the peace of mind it offers, that you will be covered for cancer treatments and that the financial burden of shortfalls will not fall on your shoulders, or on those of your family members either.
About Turnberry Management Risk Solutions
Founded in 2001, Turnberry is a registered financial services provider (FSP no. 36571) that specialises in Accident and Health Insurance, Travel Insurance, and Funeral Cover.
With extensive experience across healthcare and insurance industries in South Africa, Turnberry offers unsurpassed service to Brokers and clients. Turnberry’s gap cover products are available to clients on all medical aid schemes, as they are independently provided and are therefore transferable in the event of a change in the client’s medical aid scheme.
Turnberry is well represented nationally, with its Head Office based in Bedfordview, Johannesburg with Business Development Managers in Cape Town and Durban. The Turnberry Team’s focus on outstanding client service comes from having extensive knowledge and experience in the financial services sector and is underwritten by Lombard Insurance Company Limited. Lombard Insurance Company Limited is an Authorised Financial Services Provider (FSP 1596) and Insurer conducting non-life insurance business.
A technique that uses MRI as a guide can make radiotherapy safer for prostate cancer patients by better aiming beams at the prostate while sparing nearby tissue in the bladder, urethra, and rectum. That is the finding of a thorough analysis of all published clinical trials of the technique, called magnetic resonance–guided daily adaptive stereotactic body radiotherapy (MRg-A-SBRT). The analysis is published in CANCER.
By providing detailed images, MRg-A-SBRT can be used to adjust a patient’s radiation plan every day to account for anatomical changes and to monitor the position of the prostate in real time while the radiation beam is on to ensure that treatment is being directed accurately to the prostate. Although MRg-A-SBRT is becoming more popular and multiple clinical trials have tested it, it is unclear whether the technique, which requires more time and resources than standard procedures, has an impact on clinical outcomes and side effects compared with other ways of delivering radiation.
To investigate, Jonathan E. Leeman, MD, of the Dana-Farber Cancer Institute and Brigham and Women’s Hospital, and his colleagues combined data from 29 clinical trials testing MRg-A-SBRT versus conventional CT-guided treatment, with a total of 2457 patients.
MRg-A-SBRT was associated with significantly fewer urinary and bowel side effects in the short term following radiation. Specifically, there was a 44% reduction in urinary side effects and a 60% reduction in bowel side effects.
“The study is the first to directly evaluate the benefits of MR-guided adaptive prostate radiation in comparison to another more standard and conventional form of radiation, and it provides support for use of this treatment in the management of prostate cancer,” said Dr Leeman.
Dr Leeman noted that the study also raises further questions regarding this type of treatment. For example, will the short-term benefits lead to long-term benefits, which are more impactful for patients? Longer follow-up will help answer this question because MRg-A-SBRT is a relatively new treatment. Also, which aspect of the technology is responsible for the improved outcomes seen in clinical trials? “It could potentially be the capability for imaging-based monitoring during the treatment or it could be related to the adaptive planning component. Further studies will be needed to disentangle this,” said Dr Leeman.
An accompanying editorial discusses the analysis’ findings, weighs the potential benefits and shortcomings of adopting this treatment strategy for patients, and questions the value of broad adoption.
Ccancer-associated fibroplasts surrounding a prostate tumour. Credit: Moscat and Diaz Meco lab.
Transgender women keep their prostates after gender-affirming surgery, and as a result are still at risk for prostate cancer, though to what extent remained unclear. A first-of-its-kind study estimates the risk at about 14 cases per 10 000, a little less than half the risk for cisgender males.
The UC San Francisco-led study drew on 22 years of data from the Veterans Affairs Health System. Despite the small sample size due to the size of the transgender population, it is still the largest of its kind.
“What we know about prostate cancer to date is almost exclusively based on cisgender men,” said the study’s lead author, Farnoosh Nik-Ahd, MD, a urology resident at UCSF. “This is an important first step in reshaping how clinicians think about prostate cancer in transgender women.”
Transgender people often face discrimination and disparities, and there has been a growing acknowledgment of the complexities involved in their health care.
The study found 155 confirmed transgender women with prostate cancer and stratified them according to whether they had used oestrogen: 116 had never used oestrogen, 17 had once used oestrogen but stopped before they were diagnosed with prostate cancer and 22 were actively on oestrogen.
The median age of diagnosis was 61 years, and 88% of the patients were white. Just 8% were Black, suggesting possible disparities affecting this group. Black cisgender men are at higher risk of being diagnosed with and dying from prostate cancer.
Though reduced compared to cisgender males, risk remains
The authors found that prostate cancer occurs in transgender women more frequently than published accounts suggest, with about 14 prostate cancer cases annually per 10 000 transgender women. Still, that rate was lower than what could be expected based on cisgender males, with 33 cases annually per 10 000.
While the numbers were small in the new study, the data suggests that transgender women who take estrogen may have delayed diagnoses. The authors also said that lower rates of prostate cancer may have been due to less PSA screening, misinterpretation of PSA levels in patients on gender-affirming hormone therapies, stigma, lack of awareness of prostate cancer risk and the effects of estrogen.
“We still have a lot of work to do to determine optimal prostate cancer screening for transgender women on oestrogen and related treatments,” said co-senior author Matthew R. Cooperberg, MD, MPH, of the UCSF Department of Urology. “This study should be a reminder to clinicians and patients alike that, regardless of gender, people with prostates are at risk for prostate cancer.”
A study published in BJU International found that while adherence to healthy diets seems to have no effect on prostate cancer risk, following an unhealthy ‘Western’ diet may increase the risk of developing aggressive prostate cancer.
The study assessed the diets of 15 296 men recruited in Spain in from 1992–1996. Among these men, 609 prostate cancer cases were identified during a median follow-up of 17 years. Diets were categorised as Western, Prudent, or Mediterranean. The Western dietary pattern consisted of a high intake of high-fat dairy products, processed meat, refined grains, sweets, caloric drinks, convenience food, and sauces, and a low intake of low-fat dairy products and whole grains. The Prudent dietary pattern was characterised by a high intake of low-fat dairy products, vegetables, fruits, whole grains, and juices. The Mediterranean dietary pattern represented a high intake of fish, vegetables, legumes, boiled potatoes, fruits, olives, and vegetable oil, and a low intake of juices.
No effect over prostate cancer risk was detected for the Prudent and Mediterranean dietary patterns, but detrimental effect was observed with the Western dietary pattern. This effect was only observed for aggressive tumors.
“Our results indicate that avoiding unhealthy dietary habits could be the best nutritional strategy to prevent aggressive prostate cancer,” said lead author Adela Castelló-Pastor, PhD, of the Carlos III Institute of Health and CIBERESP, in Spain. “Substituting the intake of Western-type diet products by products characteristic of the Mediterranean diet could also decrease the risk of other chronic diseases,” added co–senior author Marina Pollán, PhD, of the Carlos III Institute of Health and CIBERESP, in Spain.
“The information provided by the Spanish cohort of the European Prospective Investigation into Cancer and Nutrition – or EPIC – has contributed to improving scientific knowledge of the relationship between diet and cancer and other chronic diseases,” added co–senior author Maria-José Sánchez, MD, PhD, lecturer at the Andalusian School of Public Health, scientific director at ibs.GRANADA and researcher at CIBERESP, in Spain.
New research by scientists at the University of South Australia suggests that consumption of colourful fruits and vegetables on a regular basis reduces the risk of a prostate cancer (PC) diagnosis. These foods, rich in micronutrients, also help speed up recovery from radiotherapy for the disease.
The findings, from two studies published in the journal Cancers, highlight the importance of a Mediterranean or Asian diet that includes these foods. For the first study, researchers compared micronutrient plasma concentrations of prostate cancer patients with a healthy control group, revealing low levels of lutein, lycopene, alpha-carotene, and selenium in PC patients and high levels of iron, sulphur, and calcium in the same group, relative to controls.
The second study found increased DNA damage after radiation exposure was also associated with low lycopene and selenium in blood plasma.
Men with plasma concentrations lower than 0.25ug/mL) for lycopene and/or lower than 120ug/L for selenium have an increased risk of prostate cancer and are likely to be more sensitive to the damaging effects of radiation.
Foods that are rich in lycopene include tomatoes, melons, papayas, grapes, peaches, watermelons, and cranberries. Selenium-rich foods include white meat, fish, shellfish, eggs, and nuts.
Study co-author Dr Permal Deo says that studies show that eating foods rich in lycopene and selenium is preferable to taking supplements, where the benefits are limited.
“Our recommendation is to adopt a Mediterranean diet enlisting the help of a dietician because people absorb nutrients in different ways, depending on the food, the digestive system, the person’s genotype and possibly their microbiome,” Dr Deo says.
Prostate cancer remains one of the most common and fatal cancers in men, but the nutritional deficiencies associated with it remain largely unknown, hence this study. Other risk factors, such as ethnicity, family history and age have previously been linked to prostate cancer.
“There is strong evidence that being overweight and tall increases the risk of prostate cancer. Diets high in dairy products and low in vitamin E may also increase the risk but the evidence is less clear.”
A common method of detecting prostate cancer may not be accurate enough as a reliable screening tool by itself, scientists in Germany have warned. The digital rectal exam (DRE) is widely used by medical professionals to check the prostate gland with a finger for unusual swelling or lumps in the rectum as an initial check for the signs of prostate cancer in men.
But new research by scientists of the PROBASE trial coordinated at the German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ) in Heidelberg, suggests the technique may be missing many cancers in their early stages.
The findings, presented at the European Association of Urology Annual Congress in Milan, could have implications for the early detection of prostate cancer, say the researchers. They are calling for other testing methods to be used in routine screening instead.
“One of the main reasons for screening for prostate cancer is to detect it in patients as early as possible as this can lead to better outcomes from treatment,” said Dr Agne Krilaviciute, a researcher at DKFZ and lead author of the study. “But our study suggests that the DRE is simply not sensitive enough to detect those early stage cancers.”
The PROBASE trial is a multicentre German prostate cancer screening study involving 46 495 men aged 45 years who were enrolled between 2014 and 2019. The men have since been had follow ups to assess their health in the years after the screening. Half of the participants in the trial were offered prostate specific antigen (PSA) blood test immediately at age 45 while the other half were initially offered DRE with delayed PSA screening at age 50.
Ultimately, 6537 men in the delayed screening group underwent DRE and only 57 of these men were referred for a follow-up biopsy due to suspicious findings. Only three were found to have cancer.
When compared to the detection rate using other methods, such as a PSA test, the rate of detection using DRE was substantially lower, says Dr Krilaviciute.
“The DRE was giving a negative result in 99% of cases and even those that were deemed to be suspicious had a low detection rate,” says Dr Krilaviciute. “Results we’ve seen from the PROBASE trial show that PSA testing at the age of 45 detected four times more prostate cancers.”
The researchers believe one of the reasons why the DRE might be failing to detect cancers, particularly in younger men, is because the changes in the tissue in the prostate may be too slight to detect with a finger. In addition, some cancers occur in a part of the prostate that cannot be easily reached by a finger.
“Early stage cancer may not have the size and stiffness to be palpable,” said Professor Peter Albers, a urologist at Düsseldorf University who was the senior author of the study.
“Separate analysis that used MRI scans before biopsies to locate cancers in the prostate showed that about 80% of these are in an area that should be easy to reach with a finger and still cancers were not detectable by DRE.”
The researchers are now calling for widespread use of PSA testing and MRI scans as part of screening programmes instead of DRE.
“If the aim of a screening programme is to pick up cancers as early as possible and the current screening tool isn’t doing that job, then that is a fundamental failure of that approach,” said Professor Albers. “We speculate in our paper that not only is the DRE not useful for detecting cancer, but it may also be one reason why people don’t come to screening visits – the examination probably puts a lot of men off.
“In Germany, for example, the participation rate is less than 20% in the screening programme for men 45 to 50 years. If we were to offer PSA testing instead, more of them might be willing to come.”
Credit: Darryl Leja / National-Human-Genome Research Institute / National Institutes of Health
Men undergoing MRI-guided radiotherapy for localised prostate cancer, had fewer toxicities and better quality of life, according to new research published in JAMA Oncology. This was the first randomised phase III clinical trial to directly compare MRI-guided stereotactic body radiotherapy (SBRT) with the same therapy guided by CT.
“MRI guidance offers several advantages over standard CT guidance, most notably the ability to dramatically reduce planning margins, providing more focused treatment with less injury to nearby normal tissues and organs,” said lead author Amar Kishan, MD, a radiation oncologist. “MRI technology is more costly than CT, both in terms of upfront equipment expenses and longer treatment times, which is one reason our study set out to determine if MRI-guided technology offers tangible benefits for patients.”
SBRT for prostate cancer usually delivers radiation in five or fewer precisely targeted doses. It is an established and generally well tolerated form of treatment, but it can cause toxicities resulting in urinary, bowel and sexual dysfunction. This UCLA-led clinical trial included 154 analysable patients with prostate cancer who were randomised to either a CT-guidance arm (76 patients) or an MRI-guidance arm (78 patients).
This study included assessment by both physicians and patients. From both perspectives, MRI-guided therapy was associated with fewer side effects and better quality of life over at least three months of follow-up.
“In this trial, we demonstrated that the reduction in treatment volumes facilitated by MRI guidance leads to a significant reduction in moderate physician-scored toxicity and to a reduction in the proportion of patients noting significant decrements in patient-reported outcome metrics in the near term,” said Dr Kishan. “Although additional studies will need to confirm these benefits over time, we’re hopeful that these results will lead to better outcomes for men with prostate cancer.”
The 2mm margin used with MRI-guidance in the trial is narrower than has been used in any previous large study. Unlike CT, MRI technology can monitor prostate motion directly, and it offers improved soft tissue contrast, improving the accuracy of alignment prior to radiation.
Cancer-associated fibroplasts surrounding a prostate tumour. Credit: Moscat and Diaz Meco labs
Prostate cancer is the second most common cancer and the second leading cause of cancer death among American men. Now, researchers have discovered key molecular players that drive prostate cancer to progress into a highly aggressive form of the disease called neuroendocrine prostate cancer that currently has no effective treatment. The finding, published in in the journal Scientific Reports, opens new avenues to therapeutics to treat neuroendocrine prostate cancer.
“We have found novel pathways that promote neuroendocrine prostate cancer,” says senior author Lucia R. Languino, PhD, a professor in the department of Pharmacology, Physiology and Cancer Biology and director of the Genetics, Genomics, and Cancer Biology PhD Program at Thomas Jefferson University.
Most prostate cancers are a type of disease called prostate adenocarcinoma. Other types of prostate cancer, including neuroendocrine tumours, are rare. However, unlike prostate adenocarcinoma, neuroendocrine prostate cancer is very aggressive and can quickly spread to other parts of the body. Treatments that are effective for adenocarcinomas in the prostate do not work against neuroendocrine prostate cancers.
Adenocarcinoma prostate cancers can progress into neuroendocrine prostate cancer. Until now, how this transition occurs has been a mystery.
To better understand how neuroendocrine prostate cancer develops, Dr Languino and colleagues looked for biomarkers of the disease. In previous work, they discovered that a molecule known as aVb3 integrin is abundant in mice and humans with neuroendocrine prostate cancer, but missing in prostate adenocarcinoma.
To look for molecules unique to neuroendocrine prostate cancer, the researchers found that aVb3 integrin expression in prostate cancer cells bumped up the expression of a known marker of neuroendocrine prostate cancer and significantly increased the expression of a molecule called Nogo receptor 2 (NgR2).
The finding “was a big discovery,” Dr Languino says. That’s because NgR2 is a protein found in nerve cells, where it contributes to neuronal functions. It has never before been studied in cancer, of any kind.
Dr Languino and her colleagues wanted to find out what this molecule, a neuronal protein, is doing in cancer.
An initial experiment revealed that NgR2 binds the aVb3 integrin. The scientists also saw that in mice with neuroendocrine prostate tumors, aVb3 integrin and NgR2 were both present in the primary tumor and in cancerous lesions that had formed in the lungs of the animals. A follow-up experiment made it clear that both aVb3 integrin and NgR2 are necessary for neuroendocrine prostate cancers.
When Dr Languino and her team lowered the amount of NgR2 in neuroendocrine prostate cancer cells, neuroendocrine markers also decreased. The results suggest that NgR2 plays a role in the development of neuroendocrine prostate cancer. Lowering the amount of NgR2 also reduced the ability of cancer cells to grow and move, indicating that NgR2 may have a hand in cancer spreading to other parts of the body, in a process known as metastasis. Metastases are often what makes cancers fatal.
“These two molecules, aVb3 integrin and NgR2, seem to create a combination that is lethal,” Dr Languino says.
She and her colleagues are now looking for a molecule or antibody that would block the effect of NgR2, or the aVb3 integrin/NgR2 complex, to inhibit their ability to promote neuroendocrine prostate cancer growth and development, and make the cancer more susceptible to therapy.
A systematic review has revealed that plant-based or plant-heavy diets may offer a level of protection against prostate cancer and other male sexual health issues according.
The analysis included 23 studies, 12 of which included prostate cancer, and suggested a link between a plant-based diet and reduced prostate cancer risk. Some evidence also suggested benefits for erectile dysfunction and benign prostate hyperplasia. The findings were reported at the Sexual Medicine Society of North America (SMSNA) annual meeting.
“Medicine has moved to a more holistic approach overall, and with that, more researchers have started to look into [the question of] ‘Can we use these plant-based diets to help manage and prevent conditions like prostate cancer, erectile dysfunction [ED], and benign prostate hyperplasia [BPH]?’ Nathan Feiertag, MD, a medical student at Albert Einstein College of Medicine in New York City, told MedPage Today. “There were relatively few studies that we were able to find for this literature review, but that’s the current state.”
With the growing popularity of plant-based diets, studies have shown their benefits for patients with hypertension or diabetes. Dr Feirtag said that less is known about their effect on prostate cancer, ED and BPH.
Dr Feiertag told MedPage Today that “Urologists can maybe consider our review as an opportunity to incorporate or modify existing diet counselling for their patients, especially the ones who are eager to implement lifestyle changes, particularly as it pertains to prostate hyperplasia, ED, and prostate cancer.”
The review mostly consisted of cohort studies, along with cross-sectional studies, and a handful of randomised controlled trials. Studies included those on vegan diets, vegetarian diets, and plant-heavy diets, such as the Mediterranean diet. In a number small cohort studies, there was a significant decrease in prostate cancer velocity, though not sustained at six months, Dr Feiertag said.
Two of the five ED studies found a link between plant-based diets and improved International Index of Erectile Function scores, though one reported worsening scores. The two studies included on ED reported a reduced relative risk of ED for patients on plant-based diets. For BPH, five of six studies reported an inverse relationship between plant-based diets and developing BPH.
Limitations including not being generalisable due to the number of observational and cohort studies that relied on patient-reported evaluations of diet. Additional high-quality studies are needed to confirm the link between diet and urological conditions.
Fortunately, the studies all reported no non-association or no harmful effects of following a plant-based or plant-forward diet. “For the patients who want to change their diet, this is useful for them. It definitely won’t hurt,” Dr Feiertag told MedPage Today.
