Advanced breast cancer edges up in younger women

CHICAGO (AP) — Advanced breast cancer has increased slightly among young women, a 34-year analysis suggests. The disease is still uncommon among women younger than 40, and the small change has experts scratching their heads about possible reasons.

The results are potentially worrisome because young women's tumors tend to be more aggressive than older women's, and they're much less likely to get routine screening for the disease.

Still, that doesn't explain why there'd be an increase in advanced cases and the researchers and other experts say more work is needed to find answers.

It's likely that the increase has more than one cause, said Dr. Rebecca Johnson, the study's lead author and medical director of a teen and young adult cancer program at Seattle Children's Hospital.

"The change might be due to some sort of modifiable risk factor, like a lifestyle change" or exposure to some sort of cancer-linked substance, she said.

Johnson said the results translate to about 250 advanced cases diagnosed in women younger than 40 in the mid-1970s versus more than 800 in 2009. During those years, the number of women nationwide in that age range went from about 22 million to closer to 30 million — an increase that explains part of the study trend "but definitely not all of it," Johnson said.

Other experts said women delaying pregnancy might be a factor, partly because getting pregnant at an older age might cause an already growing tumor to spread more quickly in response to pregnancy hormones.

Obesity and having at least a drink or two daily have both been linked with breast cancer but research is inconclusive on other possible risk factors, including tobacco and chemicals in the environment. Whether any of these explains the slight increase in advanced disease in young women is unknown.

There was no increase in cancer at other stages in young women. There also was no increase in advanced disease among women older than 40.

Overall U.S. breast cancer rates have mostly fallen in more recent years, although there are signs they may have plateaued.

Some 17 years ago, Johnson was diagnosed with early-stage breast cancer at age 27, and that influenced her career choice to focus on the disease in younger women.

"Young women and their doctors need to understand that it can happen in young women," and get checked if symptoms appear, said Johnson, now 44. "People shouldn't just watch and wait."

The authors reviewed a U.S. government database of cancer cases from 1976 to 2009. They found that among women aged 25 to 39, breast cancer that has spread to distant parts of the body — advanced disease — increased from between 1 and 2 cases per 100,000 women to about 3 cases per 100,000 during that time span.

The study was published Tuesday in the Journal of the American Medical Association.

About one in 8 women will develop breast cancer in their lifetime, but only 1 in 173 will develop it by age 40. Risks increase with age and certain gene variations can raise the odds.

Routine screening with mammograms is recommended for older women but not those younger than 40.

Dr. Len Lichtenfeld, the American Cancer Society's deputy chief medical officer, said the results support anecdotal reports but that there's no reason to start screening all younger women since breast cancer is still so uncommon for them.

He said the study "is solid and interesting and certainly does raise questions as to why this is being observed." One of the most likely reasons is probably related to changes in childbearing practices, he said, adding that the trend "is clearly something to be followed."

Dr. Ann Partridge, chair of the federal Centers for Disease Control and Prevention's advisory committee on breast cancer in young women, agreed but said it's also possible that doctors look harder for advanced disease in younger women than in older patients. More research is needed to make sure the phenomenon is real, said Partridge, director of a program for young women with breast cancer at the Harvard-affiliated Dana-Farber Cancer Institute.

The study shouldn't cause alarm, she said. Still, Partridge said young women should be familiar with their breasts and see the doctor if they notice any lumps or other changes.

Software engineer Stephanie Carson discovered a large breast tumor that had already spread to her lungs; that diagnosis in 2003 was a huge shock.

"I was so clueless," she said. "I was just 29 and that was the last thing on my mind."

Carson, who lives near St. Louis, had a mastectomy, chemotherapy, radiation and other treatments and she frequently has to try new drugs to keep the cancer at bay.

Because most breast cancer is diagnosed in early stages, there's a misconception that women are treated, and then get on with their lives, Carson said. She and her husband had to abandon hopes of having children, and she's on medical leave from her job.

"It changed the complete course of my life," she said. "But it's still a good life."

____

Online:

JAMA: http://jama.ama-assn.org

CDC: http://www.cdc.gov/cancer/breast/index.htm

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India Ink: Narmada Devi, the Housewife from Uttar Pradesh

Why do millions of people, from entire Indian villages to urbane middle managers to foreign tourists, brave the crowds at the Kumbh Mela? During this year’s 55-day pilgrimage, to Allahabad, Uttar Pradesh, an estimated 100 million Hindus and others are expected to take a holy dip in the Ganges River to wash away their sins. India Ink interviewed some of them.

Narmada Devi, 45, a housewife from Varanasi, Uttar Pradesh, was one among them. This is what she had to say.

Why did you come to the Kumbh Mela this year? Is it your first time?

This is my fifth time. I came with family. We had a tough year last year. We wonder if it is because of the sins we have committed. We came here to wash them away.

How have you found it so far?

I love the excitement here. I am also fortunate that I am here on Mauni Amavasya, one of the main royal bathing days. They say that if we manage to take a dip today, we would be internally cleansed.

Describe your journey to the Kumbh. Did you travel alone? How long did it take?

We traveled in a horrible bus from Benaras. It took us longer than it should have. I don’t know how much time we spent on that bus, but it was an awful journey. I threw up the whole time.

Do you consider yourself a religious person?

We are Hindus. We follow Hinduism and worship Hindu gods. We have a pandit, or priest, in our town who we believe in, and we do whatever he asks us to – with respect to our profession, our future, etc. Apart from that, I don’t know what you mean by being religious.

Who do you think is going to win the 2014 election?

We don’t care if it is the Bahujan Samaj Party or the Samajwadi Party. We just want good governance. I can’t tell you how much we have suffered because of bad administration. Higher crime rates, not enough good education for my sons and my husband’s shop was also looted. No authorities came to our rescue.

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Cheers! Hollywood Toasts the Oscars

From Elton John's celebrated bash to Vanity Fair's annual soiree, see how George & Stacy, Adele, Jennifer Lawrence and more marked Hollywood's biggest night

Credit: Kevin Mazur/VF13/WireImage

Updated: Monday Feb 25, 2013 | 11:30 AM EST
By: Kiran Hefa & Kate Hogan

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Koop, who transformed surgeon general post, dies

With his striking beard and starched uniform, former Surgeon General Dr. C. Everett Koop became one of the most recognizable figures of the Reagan era — and one of the most unexpectedly enduring.

His nomination in 1981 met a wall of opposition from women's groups and liberal politicians, who complained President Ronald Reagan selected Koop, a pediatric surgeon and evangelical Christian from Philadelphia, only because of his conservative views, especially his staunch opposition to abortion.

Soon, though, he was a hero to AIDS activists, who chanted "Koop, Koop" at his appearances but booed other officials. And when he left his post in 1989, he left behind a landscape where AIDS was a top research and educational priority, smoking was considered a public health hazard, and access to abortion remained largely intact.

Koop, who turned his once-obscure post into a bully pulpit for seven years during the Reagan and George H.W. Bush administrations and who surprised both ends of the political spectrum by setting aside his conservative personal views on issues such as homosexuality and abortion to keep his focus sharply medical, died Monday at his home in Hanover, N.H. He was 96.

An assistant at Koop's Dartmouth College institute, Susan Wills, confirmed his death but didn't disclose its cause.

Dr. Richard Carmona, who served as surgeon general a decade ago under President George W. Bush, said Koop was a mentor to him and preached the importance of staying true to the science even if it made politicians uncomfortable.

"He set the bar high for all who followed in his footsteps," Carmona said.

Although the surgeon general has no real authority to set government policy, Koop described himself as "the health conscience of the country" and said modestly just before leaving his post that "my only influence was through moral suasion."

A former pipe smoker, Koop carried out a crusade to end smoking in the United States; his goal had been to do so by 2000. He said cigarettes were as addictive as heroin and cocaine. And he shocked his conservative supporters when he endorsed condoms and sex education to stop the spread of AIDS.

Chris Collins, a vice president of amFAR, the Foundation for AIDS Research, said many people don't realize what an important role Koop played in the beginning of the AIDS epidemic.

"At the time, he really changed the national conversation, and he showed real courage in pursuing the duties of his job," Collins said.

Even after leaving office, Koop continued to promote public health causes, from preventing childhood accidents to better training for doctors.

"I will use the written word, the spoken word and whatever I can in the electronic media to deliver health messages to this country as long as people will listen," he promised.

In 1996, he rapped Republican presidential hopeful Bob Dole for suggesting that tobacco was not invariably addictive, saying Dole's comments "either exposed his abysmal lack of knowledge of nicotine addiction or his blind support of the tobacco industry."

Although Koop eventually won wide respect with his blend of old-fashioned values, pragmatism and empathy, his nomination met staunch opposition.

Foes noted that Koop traveled the country in 1979 and 1980 giving speeches that predicted a progression "from liberalized abortion to infanticide to passive euthanasia to active euthanasia, indeed to the very beginnings of the political climate that led to Auschwitz, Dachau and Belsen."

But Koop, a devout Presbyterian, was confirmed after he told a Senate panel he would not use the surgeon general's post to promote his religious ideology. He kept his word.

In 1986, he issued a frank report on AIDS, urging the use of condoms for "safe sex" and advocating sex education as early as third grade.

He also maneuvered around uncooperative Reagan administration officials in 1988 to send an educational AIDS pamphlet to more than 100 million U.S. households, the largest public health mailing ever.

Koop personally opposed homosexuality and believed sex should be saved for marriage. But he insisted that Americans, especially young people, must not die because they were deprived of explicit information about how HIV was transmitted.

Koop further angered conservatives by refusing to issue a report requested by the Reagan White House, saying he could not find enough scientific evidence to determine whether abortion has harmful psychological effects on women.

Koop maintained his personal opposition to abortion, however. After he left office, he told medical students it violated their Hippocratic oath. In 2009, he wrote to Senate Majority Leader Harry Reid, urging that health care legislation include a provision to ensure doctors and medical students would not be forced to perform abortions. The letter briefly set off a security scare because it was hand delivered.

Koop served as chairman of the National Safe Kids Campaign and as an adviser to President Bill Clinton's health care reform plan.

At a congressional hearing in 2007, Koop spoke about political pressure on the surgeon general post. He said Reagan was pressed to fire him every day, but Reagan would not interfere.

Koop, worried that medicine had lost old-fashioned caring and personal relationships between doctors and patients, opened his institute at Dartmouth to teach medical students basic values and ethics. He also was a part-owner of a short-lived venture, drkoop.com, to provide consumer health care information via the Internet.

Koop was born in the New York City borough of Brooklyn, the only son of a Manhattan banker and the nephew of a doctor. He said by age 5 he knew he wanted to be a surgeon and at age 13 he practiced his skills on neighborhood cats.

He attended Dartmouth, where he received the nickname Chick, short for "chicken Koop." It stuck for life.

Koop received his medical degree at Cornell Medical College, choosing pediatric surgery because so few surgeons practiced it.

In 1938, he married Elizabeth Flanagan, the daughter of a Connecticut doctor. They had four children, one of whom died in a mountain climbing accident when he was 20.

Koop was appointed surgeon-in-chief at Children's Hospital in Philadelphia and served as a professor at the University of Pennsylvania School of Medicine.

He pioneered surgery on newborns and successfully separated three sets of conjoined twins. He won national acclaim by reconstructing the chest of a baby born with the heart outside the body.

Although raised as a Baptist, he was drawn to a Presbyterian church near the hospital, where he developed an abiding faith. He began praying at the bedside of his young patients — ignoring the snickers of some of his colleagues.

Koop's wife died in 2007, and he married Cora Hogue in 2010.

He was by far the best-known surgeon general and for decades afterward was still a recognized personality.

"I was walking down the street with him one time" about five years ago, recalled Dr. George Wohlreich, director of the College of Physicians of Philadelphia, a medical society with which Koop had longstanding ties. "People were yelling out, 'There goes Dr. Koop!' You'd have thought he was a rock star."

___

Ring reported from Montpelier, Vt. Cass reported from Washington. AP Medical Writers Lauran Neergaard in Washington and Mike Stobbe in New York contributed to this report.

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India Ink: Laliji, the Octogenarian from Bihar

Why do millions of people, from entire Indian villages to urbane middle managers to foreign tourists, brave the crowds at the Kumbh Mela? During this year’s 55-day pilgrimage, to Allahabad, Uttar Pradesh, an estimated 100 million Hindus and others are expected to take a holy dip in the Ganges River to wash away their sins. India Ink interviewed some of them.

Laliji, 80, from Chhapra, Bihar, was one among them. This is what she had to say.

Why did you come to the Kumbh Mela this year? Is it your first time?

I have come to the Kumbh before, but this is the first time my son brought me here. It was his way of showing his gratitude.

How have you found it so far?

I like it, especially since all my friends and fellow-villagers are here. We are celebrating it. The dip was memorable, though the water was cold. But I am enjoying.

Describe your journey to the Kumbh. Did you travel alone? How long did it take?

We took a bus from our house to the district headquarters, from where the village leaders had promised to arrange transport for us. But that seemed to be a crowded option, hence we decided to take another bus and come here.

Do you consider yourself a religious person?

I am very religious, and have brought up my eight sons that way. We are God-fearing people. We think twice before we can hurt anyone or anything. It’s not for nothing that we are respected in our village.

Who do you think is going to win the 2014 election?

I don’t understand politics. Last year, someone paid us to vote for them — we did.

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FDA approves new targeted breast cancer drug

WASHINGTON (AP) — The Food and Drug Administration has approved a first-of-a-kind breast cancer medication that targets tumor cells while sparing healthy ones.

The drug Kadcyla from Roche combines the established drug Herceptin with a powerful chemotherapy drug and a third chemical linking the medicines together. The chemical keeps the cocktail intact until it binds to a cancer cell, delivering a potent dose of anti-tumor poison.

Cancer researchers say the drug is an important step forward because it delivers more medication while reducing the unpleasant side effects of chemotherapy.

"This antibody goes seeking out the tumor cells, gets internalized and then explodes them from within. So it's very kind and gentle on the patients — there's no hair loss, no nausea, no vomiting," said Dr. Melody Cobleigh of Rush University Medical Center. "It's a revolutionary way of treating cancer."

Cobleigh helped conduct the key studies of the drug at the Chicago facility.

The FDA approved the new treatment for about 20 percent of breast cancer patients with a form of the disease that is typically more aggressive and less responsive to hormone therapy. These patients have tumors that overproduce a protein known as HER-2. Breast cancer is the second most deadly form of cancer in U.S. women, and is expected to kill more than 39,000 Americans this year, according to the National Cancer Institute.

The approval will help Roche's Genentech unit build on the blockbuster success of Herceptin, which has long dominated the breast cancer marketplace. The drug had sales of roughly $6 billion last year.

Genentech said Friday that Kadcyla will cost $9,800 per month, compared to $4,500 per month for regular Herceptin. The company estimates a full course of Kadcyla, about nine months of medicine, will cost $94,000.

FDA scientists said they approved the drug based on company studies showing Kadcyla delayed the progression of breast cancer by several months. Researchers reported last year that patients treated with the drug lived 9.6 months before death or the spread of their disease, compared with a little more than six months for patients treated with two other standard drugs, Tykerb and Xeloda.

Overall, patients taking Kadcyla lived about 2.6 years, compared with 2 years for patients taking the other drugs.

FDA specifically approved the drug for patients with advanced breast cancer who have already been treated with Herceptin and taxane, a widely used chemotherapy drug. Doctors are not required to follow FDA prescribing guidelines, and cancer researchers say the drug could have great potential in patients with earlier forms of breast cancer

Kadcyla will carry a boxed warning, the most severe type, alerting doctors and patients that the drug can cause liver toxicity, heart problems and potentially death. The drug can also cause severe birth defects and should not be used by pregnant women.

Kadcyla was developed by South San Francisco-based Genentech using drug-binding technology licensed from Waltham, Mass.-based ImmunoGen. The company developed the chemical that keeps the drug cocktail together and is scheduled to receive a $10.5 million payment from Genentech on the FDA decision. The company will also receive additional royalties on the drug's sales.

Shares of ImmunoGen Inc. rose 2 cents to $14.32 in afternoon trading. The stock has ttraded in a 52-wek range of $10.85 to $18.10.

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Stock futures advance, Barnes & Noble up early

NEW YORK (Reuters) - Stock index futures rose on Monday, suggesting the recent rally for equities remains intact in spite of concerns that the U.S. Federal Reserve could curtail its stimulus sooner than many expected.

* Stocks have been strong performers so far this year, with the S&P 500 jumping 6.2 percent in 2013. Pullbacks have generally been slight, with investors using any dip as a buying opportunity. While the S&P fell last week, the decline was a slight 0.3 percent and it was the first weekly drop after a seven-week streak of gains.

* The gains have come on strong corporate earnings, as well as a backdrop of stimulus from the Federal Reserve. Last week's decline came when some Fed officials seemed to suggest the stimulus may be curtailed faster than many expected, though subsequent comments seemed to allay those concerns.

* Another test for equities will come with the looming debate over massive U.S. government budget cuts that will take effect if lawmakers fail to reach an agreement over spending and taxes. On Sunday, the White House issued more dire warnings about the harm the cuts are expected to do to the economy if enacted.

* More government-related uncertainty came from Italy, where a close election left questions about how the country would handle its three-year debt crisis. Last year, inconclusive Greek elections sparked a protracted selloff and a period of uncertainty in U.S. equity markets as well.

* Still, European shares <.fteu3> were higher on Monday, rising 0.6 percent after a smooth Italian debt auction.

* S&P 500 futures rose 6.4 points and were above fair value, a formula that evaluates pricing by taking into account interest rates, dividends and time to expiration on the contract. Dow Jones industrial average futures added 39 points and Nasdaq 100 futures rose 17.25 points.

* In company news, the Wall Street Journal reported that Barnes & Noble Inc Chairman Leonard Riggio is considering a bid for the company's bookstore business. The stock jumped 18 percent to $16 in premarket trading.

* Lowe's Cos Inc reported earnings that beat expectations, helped by rebuilding efforts after Hurricane Sandy in the United States.

* Other companies scheduled to report quarterly results include Autodesk Inc and FirstEnergy .

* Fourth-quarter earnings for S&P 500 companies are estimated to have risen 6 percent, according to Thomson Reuters data, above a 1.9 percent forecast at the start of the earnings season.

* U.S. stocks closed higher on Friday, boosted by strong results from Hewlett-Packard Co , as well as allayed concerns over Fed policy.

(Editing by Chizu Nomiyama)

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Insurgents Launch 4 Attacks in Afghanistan

KABUL — Afghan intelligence agents on Sunday shot and killed a man in a sport utility vehicle that officials said had been packed with explosives, foiling what they described as an attempt to set off a massive explosion in a neighborhood of narrow streets lined with foreign embassies.

At about the same time, Taliban suicide attackers set off three separate car bombs in two provinces near the capital. But the bombs did minimal damage,  officials said, and the toll from the Sunday violence was low. In addition to the two attackers and the suspect, two security guards and a police officer were also killed and five other people wounded, including one attacker who managed to flee.

A spokesman for the Taliban, Zabiullah Mujahid, said the insurgents were behind the three successful bombings. But he disavowed knowledge of the attempt in Kabul, saying Taliban commanders in the city had no plans for an attack on Sunday.

While it is not unusual for the Taliban to deny having a hand in a failed attack, much about the attempted bombing Sunday remained murky, with officials hailing Afghan security forces for acting quickly but offering only the barest details about how the man identified as a bomber was spotted.

The police chief of Kabul, Gen. Mohammed Ayoub Salangi, said the suspect was in a Toyota sport utility vehicle and was trying to pass through a checkpoint when he was recognized by agents from the country’s intelligence service, the National Directorate of Security.

The man “was gunned down,” General Salangi said. The agents had to act quickly, he added, saying that there was no time to inspect the vehicle or question the suspect because that would have given him the chance to detonate the explosives.

General Salangi, who in an earlier statement said there were two men in the car, did not say how or why the agents recognized the man. But he added that the car bomb was quickly defused and carted away.

The bombing attempt, in the Wazir Akbar Khan neighborhood, led some embassies to did briefly lock down the streets on which they are located and on which they control security. The spot where the man was shot were was less than a mile from the United States Embassy and the headquarters of the American-led coalition, neither of which offered any comment.

Earlier in the day, in Jalalabad, a city in eastern Afghanistan, a single bomber in a Toyota Corolla directly targeted the Security Directorate, officials said, detonating his explosive-laden vehicle outside a building used by the intelligence agency. Two guards were killed and a third was wounded, said Hazrat Mohammad Mashraqiwal, a police spokesman in Jalalabad.

Later on Sunday, two people in another car laden with explosives tried to enter the district governor’s compound in Baraki Barak district of Logar Province, south of Kabul. But they were stopped by police officers guarding the compound, prompting one man to jump and make a run for it and the other to set off the car bomb, said Abdul Rahim Amin, the governor.

One police officer was wounded in the attack, along with the man who fled.

Earlier in Logar, around dawn, a minivan packed with explosives was set off at a police post near the provincial capital, Pul-e-Alam. One officer was killed and two others wounded, an official said.

Sharifullah Sahak contributed reporting.

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See the Mini Balenciaga Bag Kim Kardashian Gifted Niece Penelope

Mom & Babies
Celebrity Baby Blog

02/22/2013 at 05:00 PM ET

Mom Kourtney Kardashian has one! Aunts Kim and Khloé own one too. And now Penelope Disick is the latest family member to add Balenciaga‘s chic city tote to her closet.

“Penelope is wearing the little Balenciaga bag that I got her for Christmas!” Kim posted on Instagram Friday, along with an adorable photo of the mom-to-be with her 7½-month-old niece and her mini yellow handbag.

Is Kim gearing up for her little one? If she has a little girl, we have no doubt her wardrobe will be the envy of the playground. Although the expectant reality star recently revealed that if it’s up to dad-to-be Kanye West, their baby will be wearing lots of “big chains and leather pants.”

And to be fair, Penelope wasn’t the only Kardashian-Jenner kid to receive luxe fashions for Christmas. Kylie and Kendall also scored during the holidays.

Courtesy Kim Kardashian; Inset: Rex USA

– Shanelle Rein-Olowokere

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FDA approves new targeted breast cancer drug

WASHINGTON (AP) — The Food and Drug Administration has approved a first-of-a-kind breast cancer medication that targets tumor cells while sparing healthy ones.

The drug Kadcyla from Roche combines the established drug Herceptin with a powerful chemotherapy drug and a third chemical linking the medicines together. The chemical keeps the cocktail intact until it binds to a cancer cell, delivering a potent dose of anti-tumor poison.

Cancer researchers say the drug is an important step forward because it delivers more medication while reducing the unpleasant side effects of chemotherapy.

"This antibody goes seeking out the tumor cells, gets internalized and then explodes them from within. So it's very kind and gentle on the patients — there's no hair loss, no nausea, no vomiting," said Dr. Melody Cobleigh of Rush University Medical Center. "It's a revolutionary way of treating cancer."

Cobleigh helped conduct the key studies of the drug at the Chicago facility.

The FDA approved the new treatment for about 20 percent of breast cancer patients with a form of the disease that is typically more aggressive and less responsive to hormone therapy. These patients have tumors that overproduce a protein known as HER-2. Breast cancer is the second most deadly form of cancer in U.S. women, and is expected to kill more than 39,000 Americans this year, according to the National Cancer Institute.

The approval will help Roche's Genentech unit build on the blockbuster success of Herceptin, which has long dominated the breast cancer marketplace. The drug had sales of roughly $6 billion last year.

Genentech said Friday that Kadcyla will cost $9,800 per month, compared to $4,500 per month for regular Herceptin. The company estimates a full course of Kadcyla, about nine months of medicine, will cost $94,000.

FDA scientists said they approved the drug based on company studies showing Kadcyla delayed the progression of breast cancer by several months. Researchers reported last year that patients treated with the drug lived 9.6 months before death or the spread of their disease, compared with a little more than six months for patients treated with two other standard drugs, Tykerb and Xeloda.

Overall, patients taking Kadcyla lived about 2.6 years, compared with 2 years for patients taking the other drugs.

FDA specifically approved the drug for patients with advanced breast cancer who have already been treated with Herceptin and taxane, a widely used chemotherapy drug. Doctors are not required to follow FDA prescribing guidelines, and cancer researchers say the drug could have great potential in patients with earlier forms of breast cancer

Kadcyla will carry a boxed warning, the most severe type, alerting doctors and patients that the drug can cause liver toxicity, heart problems and potentially death. The drug can also cause severe birth defects and should not be used by pregnant women.

Kadcyla was developed by South San Francisco-based Genentech using drug-binding technology licensed from Waltham, Mass.-based ImmunoGen. The company developed the chemical that keeps the drug cocktail together and is scheduled to receive a $10.5 million payment from Genentech on the FDA decision. The company will also receive additional royalties on the drug's sales.

Shares of ImmunoGen Inc. rose 2 cents to $14.32 in afternoon trading. The stock has ttraded in a 52-wek range of $10.85 to $18.10.

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