Breast Cancer - causes and treatments

This breast cancer overview and the associated articles on our web site will give you everything you need to know to help you increase your personal odds of beating breast cancer from the symptoms of breast cancer to its diagnosis plus all the latest information on possible breast cancer causes and breast cancer treatment options. We cover everything from breast cancer drugs to the latest breast cancer treatments. At CANCERactive we uniquely provide an extensive coverage of complementary breast cancer therapiesand new and ´alternative´ breast cancer therapies in our section on Alternative Cancer Treatments.

Who gets breast cancer?

It used to be claimed by the major charities and health bodies that despite the high profile cases of Pop Stars contracting the disease in their twenties and thirties, the facts indicated that 80 per cent of all breast cancers came in the over 65 age group. As a result and with an ageing population, numbers developing the disease would get worse.

It is true that you are more at risk of breast cancer the older you get. Sadly, with ageing comes increased deficiency in cellular replication systems, more chances of genetic mistakes, reduced protective hormone levels and a build up of toxins.

However, there has been a gradual lowering of the age of breast cancer diagnosis with approximately 40 per cent of diagnoses now occurring in women below the age of 65, and just 60 per cent above that age. Breast cancer as a middle age phenomeno has increased by 40 per cent or more in the last two decades. It is quite clear that there is more to this cancer than mere ageing.

The breasts are made up of ducts connecting the nipples to glandular tissue containing the lobes. Some of the breast tissue extends into the armpit, the home of some of your lymph nodes. The ducts and the lobes are surrounded by fat and herein lies some possible clues to the causes of breast cancer. Fat is a wonderful solvent and will dissolve and hold all those chemicals, toxins and hormones (your own and ingested ones) that you really should be excreting. Being overweight will worsen the problem as that will increase the percentage of fat in the breast. The good news is that Northwestern University in America showed that women who shed the pounds after developing breast cancer improved their odds of survival over those who did not.

A lack of exercise will compound this as exercise normally helps stimulate lymph flow and the removal of excretion, whilst helping provide more cancer-hating oxygen to the tissues. Certain deficiencies in minerals have been found in women with breast cancer, as have vitamin deficiencies. We will explore this below.

You might like to read our article entitled ´Everything you need to know about breast cancer´, which is arranged as 30 facts: CLICK HERE to go to it.

Although still small numbers, increasingly men are being diagnosed with breast cancer.

Can breast cancer run in families?

Another concern you often hear is that Breast Cancer runs in families. Some people do have a genetic weakness - you may have heard of BRCA1 and BRCA2. These were originally thought to be specifically BReast CAncer causing genes but are now known to be a gene that weakens the immune systems ability to spot a cancer cell, and a gene that prevent the cells ability to repair its own DNA; and these can be found in both men and women and lie behind many cancers. Other genes linked to a higher incidence of breast cancer are still being discovered for example, PALB-2 but, again, these seem more to do with the repair and immune systems than the breast tissue itself. Importantly, only approximately 7 per cent of women carry impaired genes although it is thought that these account for at least 25 per cent of breast cancers diagnosed. 

Genes come in pairs, one from your mother, one from your father. The weak gene is masked by a normally functioning healthy gene. Even if you have one of these weak genes, estimates suggest that the risk of getting breast cancer is less than 70 per cent, although more clues here estimates suggest this figure has risen from about 20 per cent 50 years ago, quite probably along with increased levels of toxins around us, poorer diets and less healthy lifestyles.

By and large breast cancer prevention (see our article Breasts, Breasts, Breasts) is still largely in your own hands and, if you have had breast cancer and been given the all clear, there is so very much you can do to prevent a recurrence.

 

Increasing knowledge, increasing survival 

When my daughter developed her brain tumour and was given just 6 months to live we found out so many things that could help but it took at least 6 months hard work and a pair of science degrees to sort the wheat from the chaff. The aim of the CANCERactive web site is to short circuit the information gathering process for you and to empower you to pass on all our knowledge, the latest research findings, the expert studies on treatments and possible causes so that others can benefit immediately. This is also why, when the doctors asked me exactly what I had uncovered in my searches, I gladly wrote a book, Everything you need to know to help you beat cancer. The book has been a best seller in the UK for eight years and you cannot even buy it in a shop only direct from the Natural Selection shop - click on the tab at the top centre right of this page!!

Now, lets first try to understand what is going on, and what factors might be maintaining this cancer, helping it to progress in your body.

Various epidemiology studies have shown that smoking increases risk, as does increasing levels of regular alcohol consumption. An extra glass of wine a day will increase risk by about 7 per cent.

Dietary factors are clearly important. Various global studies show that women with breast cancer have much lowered levels of vitamin C, vitamin B-12 and long-chain omega-3. Research shows that tocotrienol vitamin E, fish oils and garlic appear to be particularly protective. Unfortunately, high street vitamin E is a usually a limited and synthetic copy of the real thing being usually the alpha-tocopherol form. Studies have shown that women with a history of breast cancer have lowered levels of the mammalian lignans, enterodiol and enterolactone, which are made from plant lignans in the intestine. One very good source is flax seed. Phytoestrogen levels (from green plants and pulses) are also low.

Women with lowered levels of vitamin D have a much higher risk of breast cancer. Professor Hollick of Harvard has stated that 25 per cent fewer women would die of breast cancer if they took adequate daily levels of vitamin D, the vitamin developed under your skin by the action of sunlight. Unfortunately, women in Britain do not see too much of the sun in winter. D3 is a supplement often used and 5000IU´s a day the level suggested. Vitamin K seems to aid the action of vitamin D. It is found in a daily helping of ´greens´. But......
 

It is important to note that various protective natural compounds and vitamins cannot be released from your food unless you have good levels of beneficial bacteria in your intestine. One study showed that women who had a history of taking antibiotics were twice as likely to develop breast cancer (Journal of the American Med Assn 2004, Feb 18; 291).  Research, including clinical trials, suggests that such bacteria help release and so boost your vitamin levels (for example: K, B-12, folic acid, biotin), your immune system, the production of anti-cancer chemicals like sodium butyrate, whilst helping to bind to and remove heavy metals and oestrogenic chemicals from the body. Taking multi-strain probiotics may thus be advantageous.

Women who exercise  regularly (the best is a little - 20 minutes - every day) have less breast cancer and those with it have 50 per cent less mortality if they take daily exercise as part of their cancer-fighting regime.

However by far the biggest risk factor is a heightened level of the hormone oestrogen. Oestrogen-driven cancer may well account for over 70 per cent of all breast cancers. Cancer Research UK has stated that Breast Cancer rates are rising at 2 per cent per year, while oestrogen levels are rising in women by 7 per cent.

There are a number of possible reasons for this. For example:

Women are having less children and breast-feeding them for shorter periods. Both factors (more children and breast feeding for 9 months or more) decrease risk. This may well be due to decreases in the lifetime levels of natural progesterone, a known oestrogen balancer.

Women are starting their periods earlier and ending them later. Modern woman has almost twice the number of periods of her 16th century predecessors.

        
Women in the Western World consume large amounts of saturated fats         
and especially cows dairy. Saturated fat can provide the building blocks         
for oestrogen in the body. Fat is also an excellent solvent and brings with it the animals hormones and pesticides from the fields.

Several research studies from the Swedish experts at the Karolinska Institute suggest that a critical factor is the cows hormone Insulin Like Growth Factor (IGF-1), which seems to stimulate hormones such as oestrogen and other localised cell factors that make your cells grow rapidly. The more dairy you consume, the greater your breast cancer risk according to Karolinska. Another study, this time by researchers in Denmark, amongst 117,000 girls showed that those who put on a big growth spurt between ages 8 and 14 eventually had a higher risk. Again a finger was pointed at dairy. We have an article linking the level of saturated fat and cows dairy consumption during a girls growing years with the incidence of cancer later in life, in our next magazine.

Women now have more stressful occupations; many of these lead to sleep irregularities and deprivation (e.g. Nurses and Air Hostesses). Research shows that this results in lowered levels of the hormone melatonin, which seems to counter excess oestrogen under normal conditions. Melatonin is produced by the pineal gland about 90 minutes after falling asleep. If the room is not completely dark when you sleep, melatonin production can be affected. (Blind women never develop breast cancer).

But there are other reported causes you should be clear about:

The US State of Evidence report 2006 summarises the findings of more than 350 experimental, epidemiology and ecological studies and recommends new directions for the future in disease management. In particular it looks at the growing and vast amount of research on the effects of ENVIRONMENTAL POLLUTION - like toxic chemicals and EMFs on the risks of developing the disease:

There is increasing evidence that various Electromagnetic Forces  can also reduce these levels of melatonin whilst stimulating levels of IGF-1 and other hormones. This is not a modern myth. Scientists are growing increasingly worried by the electronic smog that surrounds us all from masts, to mobile phones, to WiFi even electric blankets! One study even showed that EMF´s could reduce the effect of the breast cancer drug Tamoxifen!

The use of synthetic oestrogens: CRUK has provided data on the increased risks of breast cancer when women take an oestrogen based contraceptive pill especially if they take it after the age of 30. HRT is also a risk factor. Indeed research from the USA has shown that breast cancer levels declined by 7 per cent in 2005 as a direct result of women giving up HRT.

Xeno-oestrogens, or chemical oestrogen mimics: Increasingly, chemicals that mimic the action of oestrogen in the body are believed to be a significant and modern link to risk. Pesticides like DDT and Lindane were linked to 4-fold increases in breast cancer in Israel. They are banned for use in Western countries, but still sold to Third world countries for use on vegetables we import. Chemicals contained in common in home products like Household Cleaners, toiletry and personal care products may act as oestrogen mimics. For example chemicals in perfumes (which do not have to be listed on labels) like DEHP and toluene, BPA from plastic bottles, white lined cans and even kiddies toys, Phthalates from plastic bottles and packaging, Parabens, often used as a preservative, are all thought by experts to be capable of mimicking the action of oestrogen in the body. Worse Dr Ana Soto of Tufts has shown in her research that such toxins and their effects `are cumulative´.

All in all, there may be many factors that contributed to your breast cancer, and many are relatively easy to side-step. On this web site we also cover possible links to the synthetic thyroid hormone, Thyroxine, plus an article from Eileen OConnor who is so convinced EMFs from a local mast gave her breast cancer that she is now a leading campaigner against such EMFs.

Now, the important point is that we are not listing the possible contributory factors so that you dwell on things that have happened in the past. We want you to understand what factors might still be present in your life and might still be contributing to the maintenance of your cancer. Then you can formulate an action plan for example, to reduce these factors and increase the chances of preventing the cancer recurring. You might try to cut EMFs out of your life, or you can act to lower the oestrogen (natural and synthetic) in your life. (We have a book Oestrogen the killer in our midst that tells you the simple steps you can take to cut your natural and synthetic oestrogen levels today). After all that is exactly what your oncologist will try to do with Aromatase Inhibitor drugs like Arimidex. Then there are minerals you can take, like selenium, or complex compounds like chlorella that can help you eliminate heavy metals, or increase levels of Vitamin B-12. And articles on why breast cancer patients should take vitamin D and other natural supplements. You can find comprehensive research information and expert articles on these topics and more, uniquely on this web site.
 
Diagnosis

About 44,000 cases of Breast cancer will be diagnosed in the UK in the next 12 months. Note we said diagnosed.

We have an extensive article on screening mammograms on our web site. Up to 15 per cent of problems diagnosed can be false positives. Worse, there is increasing research evidence that those women particularly at risk of breast cancer who have a genetic issue, are more likely to develop breast cancer if they have a regular screening mammogram.
 
Many experts question the mammograms save lives story. One European breast cancer symposium in recent years included research showing mammograms were at best only 60 per cent accurate. Do not under any circumstances have any treatments until cancer has definitely been confirmed through a means other than mammography screening. (You could use Thermal Imaging, even Iridology as a back up). A biopsy is the most reliable method - but you should read our article on the dangers of any surgery and how you can prevent complications in advance. (Can surgery cause cancer?) 



You should check your own breasts regularly. You are looking for lumps, or thickenings especially behind the nipple, sudden inversion of a nipple, dimpling on the skin surface, a rash, or a swelling under the armpit.

Most lumps are not cancer and are benign. Most often they are cysts, which are sacs of liquid randomly appearing in the breast tissue, or they can be benign fibroadenomas. Either way they are easily treated and no cause for concern.

If a cancer is suspected, the normal procedure is to have a biopsy. This may take tissue from under your armpit as well as from your breast. Only after tissue has been taken can anyone correctly tell you the spread (the Stage) and aggressivity (the Grade) of the cancer. After analysing the biopsy tissue, the experts should be able to tell you clearly

A       Whether the tumour is oestrogen and/or progesterone sensitive

B       Whether you are HER-2 positive

Other

There have been articles in the Lancet about biopsies possibly spreading the disease, but it is a small risk.

There have been research studies covered in icon on abortion and whether it increases risk of breast cancer. Absolutely no evidence of increased risk has been reported by expert studies.

US research on Swedish women with silicone breast implants showed that, while they had no higher risk of breast cancer, cases of lung cancer were higher than expected (Journal of the Nat. Cancer Inst. 2006; 98; 557).

DCIS and LCIS

About 50 per cent of the anomalies shown up by mammograms are Ductal (DCIS) irregularities. There seems total disagreement around the world on what this means. The team at Christie Manchester sent us a press release stating that they were going to test various drugs on women with DCIS to try to halt this ´very aggressive´ form of cancer. Meanwhile US experts were claiming that DCIS is neither cancer nor pre-cancer but calciferous particles blocking the ducts The lead Professor at the 2004 US Breast Cancer Symposium told everybody that only 20 per cent of cases go on to be full breast cancer. (If these are calcium deposits, it might explain some of the problems with dairy and the benefits of both fish oils and vitamin D).

Surgery: If you are pre-menopausal, you must try to have your operation in the second part of your cycle not the first, for then progesterone, not oestrogen dominates. Two studies from Guys in the mid-nineties reported significant long-term survival benefits.

We have a very important article on this web site on how to prepare yourself for surgery there are a number of American and UK studies that suggest surgery may possibly spread cancer, but there are clear ways to reduce this possibility.

Oncologists are mindful of the risks and where possible now prefer lumpectomy to full breast mastectomy. (You may be advised to have chemotherapy prior to surgery to reduce the size of the tumour and increase your chances of a lumpectomy rather than full-blown breast removal). If you have lymph node removal you should find out about lymphatic drainage and lymphodaema. We have articles on these too.

Reconstructive surgery  may be proposed and effected at the same time, although US research suggests waiting gives better results.

BREAKTHROUGH: If your cancer is a solid tumour with no spread or metastatic activity, you need to know that, in 2011, the Karolinska Institute have reported on three studies involving 80 women all treated with a form of localised hyperthermia, called Ablatherm. The treatment can take as little as 10 minutes and involves heating the cancer cells to kill them, using electrodes under local anaesthetic. A similar treatment, called HIFU, has been used with prostate cancer in 60 centres in Europe for over 7 years. The cancer tumour ´melts´ away according to the team at the Karolinska. Read our articles under Hyperthermia. This is a real alternative breast cancer treatment of potential.

Radiotherapy: Most commonly used after surgery to kill off any localised and remaining cancer cells. It may also be used on the lymph glands under the armpit if they were infected. The Lancet has warned that the side-effects of radiotherapy are not insignificant  women should ask their doctor about possible effects on lung and heart tissue. Modern radiotherapy is much more targeted and has reduced risks. 

We have a good article on how to maximise the effectiveness of your radiotherapy there are a number of research findings on astragalus, selenium and isoflavones from around the world. (Look under Treatments radiotherapy.) Reports from MD Anderson and UCLA suggest that you can continue to take all anti-oxidants and supplements during this time and that they increase the effectiveness of Radiotherapy.

It is very important that you attend all your radiotherapy appointments as the dose of radiotherapy you need has been carefully worked out. Up to 80 per cent of women miss one or more treatment!

Chemotherapy: The actual programme of chemotherapy depends totally upon the individual (age, health etc) and the state of the cancer. Several drugs may be suggested at the very outset, before a very specific plan is drawn up. 

We have a highly regarded article entitled A Diet for Chemotherapy on our web site.

Be clear. The purpose of the chemotherapy drugs is to try to kill any remaining cancer cells and especially to try to PREVENT a recurrence in the other breast or spread to secondary organs like the liver.

New biologic drugs are coming thick and fast these target deficiencies in proteins or messages caused by the particular cancer. In a few years your oncologist will have a wide range of drugs to choose from. One issue is that the more breast cancer is studied the more oncologists and cancer bodies agree with the stance that we at CANCERactive have taken for almost 10 years - ´Your cancer is as individual as you are - one size does not fit all, when it comes to treatment´. Some cancers are oestrogen driven and Tamoxifen and Aromatase Inhibitors will be prescribed. Some are HER-2 positive leading to Herceptin. It is now thought that as many as 30 per cent of breast cancers are neither of these categories and new drugs are on their way to treat these cases.

There are also complementary therapies that can help; for example, Vitamin K has been shown in Japanese and US research to reduce the dangers of spread to the liver. Milk thistle and mistletoe have been shown to reduce the toxic load in the liver during radio or chemotherapy.

We have a detailed review, including all the latest research, of 94 cancer drugs on our web site. The two standard therapies that are most commonly talked about are:

 

1. Tamoxifen for five years, followed by three years of an Aromatase Inhibitor (e.g. Arimidex).

CRUK has opined that by the end of the 8 years your cancer will have gone away. (We think it may, but only if you have altered the factors that gave it to you in the first place). Tamoxifen is not really chemotherapy, in that it is not trying to kill cancer cells but aims to sit on, and therefore block, cellular receptor sites that in breast cancers are attacked by oestradiol, an aggressive form of human oestrogen . Blocked sites means no attack is the theory; and the oestradiol could turn the cell cancerous. You can see why some oncologists think of Tamoxifen as preventative.

Since over 20,000 women in the UK are currently taking Tamoxifen, we thought it wise to say a few words here about this drug:

When told the possible side effects less than 1 in 5 US women want to take the drug (Cancer 2005: 103; 1996-2005). For example: Recent research by CRUK on cancer of the womb, which has risen by 30 per cent in a decade and is now twice as common as cervical cancer, implicates a number of factors like being overweight and not having had children but also Tamoxifen usage. Dr Bushnell of Dukes, USA reviewed 9 studies on Tamoxifen and concluded that it more than doubles a womans risk of ischemic stroke.

Research results carried in icon (Vol 3 Issue 4) from the University of North Carolina showed that it had a minor effect (6-8 per cent) in breast cancer prevention in women with no cancer but at higher risk; however the conclusion was that side-effect risks outweighed the benefits.

US research has shown clearly that the use of natural vitamin E in its total 8 forms reduces the need for Tamoxifen doseage by 25 per cent as it increases its effectiveness. Research also indicates that EMFs can reduce the effectiveness of Tamoxifen.

It is however the first line drug, the Gold Standard, in oestrogen-driven Breast cancer and blocks sites on cells that oestradiol would normally bind to, and then cause havoc inside the cell. Recent US research shows that its effects continue for 5 years after the last dose. 

Normally prescribed for 5 years, followed by an Aromatase Inhibitor for three years, many of the makers of these latter drugs are questioning why the patient is not moved more quickly from Tamoxifen to their drug. But then they would, wouldnt they? There has already been a study (American Soc. Clin. Onc) which suggests better long-term survival results if women come off Tamoxifen and go onto the Aromatase Inhibitor Exemestane earlier.

There is much a woman can do to naturally reduce her oestrogen levels and help the oncologists treatment strategy. For example, losing weight and maintaining a good weight, stopping cows dairy consumption, sleeping in a darkened room, avoiding toxic oestrogen-mimic chemicals, avoiding pesticides, phthalates, BPA, Parabens and toluene, taking daily light exercise, lignans, indole 3 carbinol, medicinal mushrooms and so on its all on our web site. 

2. Herceptin. Lets be clear about 20 per cent of women are HER-2 positive and this drug will work well for about half of them. Yes, and it does cost 20,000 pounds per year. A recent trial (Lancet 2006) confirms that Herceptin offers benefit with early stage breast cancer patients too.

The side effects of any chemotherapy are very individual and depend upon your
condition and the drug. You should also ask whether the combination you are on has actually been through clinical trials. Sometimes only the individual drugs have been.

Treatment for anaemia: Managing and counteracting anaemia can reducedeath from anaemia by 50 per cent. Research published by the Cochrane Collaboration showed that epoetins (alfa and beta epoetin) show significant survival benefits. Particularly striking were the results for patients with solid tumours (Breast, lung, colon) where risk of death decreased by 51 per cent). In a second study (European Soc. For Medical Oncology- 31st Oct 2005) epotin beta was shown to reduce risk of tumour progression in patients with anaemia. 

Treatment for fatigue: icon has run several pieces on fatigue. A qualifiednaturopath will be able to suggest dietary changes to boost energy levels. Qualified homeopaths may be able to suggest ways to counter fatigue. Energy therapists (e.g. acupuncture, cranial osteopaths, Reiki Masters) may well be able to help. Italian research showed a lack of acetyl-carnitine  which supplementation could correct. UCLA scientist report that a series of genetic markers become blocked either due to the cancer or due to the chemotherapy treatment. The California team note promising results with Etanercept. Apparently 30 per cent of women who have had chemo for breast cancer have long-term fatigue, even after the cancer has gone. This may well be true for other cancers.

The Way Forward

building your personal, effective integrative or holistic programme

CANCERactive we have an information discipline to encourage people with cancer who want to empower themselves to cover off all the important areas that research shows can increase your personal odds of survival. This is called the ACTIVE8 Programme. It covers everything from diet to mental state (for example there is clear research that shows people who have stress management programmes as part of their holistic treatment programme do survive longer!) There is a clear link between stress and cancer, just as there is between diet, being overweight, toxic chemicals and cancer. A good holistic programme takes account of them all.

Diet is a particular concern to many women with breast cancer. We explain the research about plant oestrogens and how they are protective. 

The most aggressive oestrogen is oestradiol, which can increase sodium levels and reduce potassium and oxygen levels inside the cell, causing havoc. Oestrone is its less aggressive sister (about 40 times less potent) and plant oestrogens called phytoestrogens are even weaker still. Many people argue that the lowered rates of breast cancers in Asia are due to large levels of circulating plant oestrogens well which one would you rather have sitting on your breast cancer receptor site? The best sources of plant oestrogens come from greens and pulses (like chickpeas, kidney beans and soy) and red clover. The British Journal of Cancer (2006) reports on the benefits of one such phytoestrogen, genistein. Apparently it can increase the repair proteins in a cell even those in short supply due to the presence of BRCA 1 and BRCA 2. 
 Also, it has been shown that Indole 3 Carbinol (in broccoli) can denature aggressive oestradiol into its weaker sister oestrone. I3C can even shut down the receptors for oestrogen and drugs companies are trying to patent it to replace Tamoxifen.

Other foods can make a difference. For example, carotenoids (Carrots, red and yellow peppers, in research reduced levels of recurrence. Polyphenols: Like those in Green tea and olive oil also had beneficial effects.  The same study above on Genistein, showed that Indole 3 Carbinol can also increase repair protein levels in cells. Sulforaphane, also in broccoli and brussel sprouts, can inhibit the development of breast cancer cells. US Dr Keith Singletary and his team claim it works as well as the chemotherapy drugs, by causing the release of certain cancer killing enzymes. Our book The Rainbow Diet - and how it can help you beat cancer will tell you much more, and help you build a healthy, less-acid body.

Several US studies (Seattle, Integrative Cancer Therapies, Philadelphia Uni.) have all shown the importance of exercise and complementary therapies. Moderate daily exercise can reduce mortality rates by 50 per cent according to this research. If you want to know more about complementary therapies start with our kiddies guide  prepared for us by the London Breast Cancer Haven.

According to the American Medical Association, women who take more than 7 aspirin tablets a week reduce their breast cancer risk by 29 per cent. Many solid cancers involve prior inflammation. Aloe Vera would also provide salicylin plus other anti-inflammatories. Since the Nobel Prize winning work by Sir John Vane on localised inflammatory hormones called eicosanoids, we now know garlic, ginger, curcumin, resveratrol and long-chain omega 3 (fish oils) can reduce inflammation too.

There is so very much you can do to build an effective programme around your oncologists orthodox treatment, if you know the research available. 

We also offer a research service it is called a Personal Information Prescription where we pull together all the relevant research information for you and your specific cancer. You will receive a 30 page document tailored to your Personal Circumstances and your cancer. But please be clear; we do not offer treatment advice, just research information so that you can be better informed and you can make better personal decisions about your cancer and your life.  But please always discuss everything with your oncologist before you take any action. 

You can also go to our Living Proofs where genuine breast cancer survivors tell their own very personal stories.

All our articles, as this one, are supported by the very latest research evidence from all over the world in our news section Cancer Watch. We hope this overview has opened your mind to some of the issues involved and helped you towards developing your own treatment programme to beat breast cancer. 

Click here for more details.

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