Health-Related Quality of Life, Comorbidities, and Lifestyle Behaviors Among Survivors of Obesity-Related and Non-Obesity-Related Cancer Types.

1. Introduction

The CDC has identified 13 cancers strongly associated with excess body weight [ 1 , 2 ]. In the United States (US), 40.3% of adults are obese and are therefore at increased risk of developing ORCs [ 3 , 4 ]. Consistent with rising obesity prevalence, the incidence of ORCs has increased in recent decades, while the incidence of non-ORCs remained stable [ 5 ]. Given this rising burden, characterizing the health and survivorship profiles of ORC survivors is critical for identifying their distinct needs and informing targeted prevention, treatment, and survivorship care strategies.

Most survivorship research has treated cancer survivors as a homogeneous group or has focused on obesity as a risk factor, rather than distinguishing between survivors of ORCs and survivors of non-ORCs [ 6 , 7 , 8 , 9 ]. As a result, remains unclear whether survivors of ORCs differ from survivors of non-ORCs regarding lifestyle behaviors, comorbidities, and HRQoL, given that a cancer diagnosis compounds obesity-related risk for these same factors. This gap in knowledge is especially concerning for Hispanic/Latino populations, who experience a higher burden of obesity and related conditions in the US. Among Hispanic/Latino adults in the US, obesity prevalence is estimated at 44.8%, slightly higher than that of non-Hispanic White adults (44.2%) [ 10 ]. Moreover, adults living in Puerto Rico have an estimated prevalence of 36.2% [ 11 ], one of the highest in the US. Data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) report that Puerto Ricans have the highest obesity incidence rate and risk for ORC among Hispanic/Latino groups [ 12 , 13 ]. In addition, national data suggest that ORCs are disproportionately common among Hispanic/Latino adults with metabolic syndrome [ 14 ], further underscoring the need to examine the survivorship experience of ORC survivors, given that a cancer diagnosis compounds pre-existing risk for comorbidities associated with obesity-related disease processes, particularly among Hispanic/Latino cancer survivors.

Despite the growing evidence of the detrimental impact of obesity on health outcomes among cancer survivors, virtually no data are currently available on the experiences of survivors of ORCs compared to non-obesity-related cancers (non-ORCs). Specifically, while obesity itself has been linked to diminished health-related quality of life (HRQoL) and a higher prevalence of comorbidities [ 8 , 9 , 15 , 16 , 17 ], little is known about the unique health risks among survivors of ORCs [ 18 ].

The paucity of research on health outcomes during ORC survivorship is even more marked for high-risk subgroups like Hispanic/Latino survivors. Existing work has focused on the link between obesity and worse physical health and higher prevalence of comorbidities in Hispanic/Latino cancer survivors [ 6 , 19 , 20 , 21 , 22 ]; however, to date, no studies have directly compared comorbidities and HRQoL by ORC status among Hispanic/Latino survivors. For example, a multinational study recently estimated that 33.4% of cancer patients had one or more comorbidities [ 23 ]. Another study based in the US reported that 43.4% of Hispanic/Latino cancer patients had at least one comorbidity [ 24 ]. These studies included at least one ORC (colorectal cancer) but did not differentiate between ORC and non-ORC survivors in their findings. Notable for carrying the highest risk of developing ORCs of all Hispanic/Latino subgroups, Puerto Ricans also navigate unique social and structural conditions including high levels of poverty, a fragile healthcare infrastructure, and longstanding economic constraints that influence their health outcomes [ 25 ]. In a recent study of Puerto Rican women with gynecologic cancers, 90.1% reported at least one comorbidity, 39.5% reported poor general physical health, and 33.9% experienced frequent physical distress [ 26 ]. Notably, the majority (75.1%) of these cancers were ORCs (endometrial or ovarian cancers), yet no comparisons were made with survivors of non-ORCs. To date, no studies have directly compared comorbidities and HRQoL between survivors of ORC and non-ORC in Puerto Rico.

These patterns highlight the importance of assessing health outcomes among cancer survivors living in Puerto Rico, where cancer survivors navigate a unique healthcare and sociocultural context that may influence survivorship outcomes, face elevated chronic disease risk [ 25 ], and may benefit from tailored survivorship interventions. Understanding differences between ORC and non-ORC survivors is therefore essential not only for developing culturally responsive survivorship strategies that address behavioral and clinical needs, but also for generating hypotheses to guide future research into the mechanisms underlying these differences.

2. Methods

2.1. Data Source

This cross-sectional study analyzed data from 871 eligible participants enrolled in the Impact of Social Determinants of Health on the Cancer Care Continuum in Cancer Survivors in Puerto Rico (START-PR) project, conducted between November 2023 and August 2025 [ 27 ]. The primary aim of START-PR is to evaluate the association between social determinants of health and access to care across the cancer care continuum. All participants were informed about study procedures before enrollment in accordance with protocols approved by the University of Puerto Rico Comprehensive Cancer Center Institutional Review Board (UPRCCC IRB; protocol #2411004025). They completed an anonymous 15–20 min questionnaire designed to collect information on social, clinical, and demographic characteristics. The survey, administered in person or online, was available in both Spanish and English; in-person participants were able to elect either tablet- or paper-based versions.

Eligible participants were adults aged ≥21 years residing in Puerto Rico who had received cancer treatment within the past 12 months. For this study, participants with a primary cancer diagnosis were eligible. Multiple recruitment strategies were used, including in-person study promotion by trained research assistants in collaborating oncology clinics in the San Juan Metropolitan area; outreach efforts during community health activities and professional meetings; social media; referrals from providers; and flyers in waiting rooms. For this secondary data analysis, we excluded participants with missing information on sex and age ( n = 7), inconclusive cancer type ( n = 26), missing cancer type ( n = 16), and multiple cancer types ( n = 250).

Among participants with breast cancer, those with missing age at diagnosis were excluded because they could not be classified as ORC or non-ORC ( n = 4). The final analytic sample comprised 569 participants. Figure S1 displays the flow diagram of analytic sample derivation. This study is a secondary analysis of an existing cohort with a fixed sample size; accordingly, no a priori power calculation was performed, and we report 95% confidence intervals for all effect estimates [ 28 ].

2.2. Measures

2.2.1. Obesity-Related Cancer

Participants were classified as having an obesity-related cancer (ORC) if their primary tumor site corresponded to one of the 13 cancer types that the CDC identifies as being associated with obesity. These include postmenopausal breast, colorectal, endometrial, esophageal adenocarcinoma, gallbladder, kidney, liver, ovarian, pancreatic, stomach, thyroid, multiple myeloma, and meningioma [ 1 , 2 ]. All other cancer types were classified as non-ORCs. Table S1 presents the distribution of individual cancer types among participants with ORCs and non-ORCs.

2.2.2. HRQoL and HRQoL Sub-Scales

HRQoL was assessed using the Functional Assessment of Cancer Therapy-General (FACT-G) instrument [ 29 ], a validated 27-item questionnaire designed to measure four domains of HRQoL in cancer patients: Physical Well-Being (PWB), Social/Family Well-Being (SWB), Emotional Well-Being (EWB), and Functional Well-Being (FWB). Items are scored on a 5-point Likert scale ranging from 0 to 4, with higher scores indicating better well-being. Reverse-coded items were recoded according to instrument guidelines before subscale scoring [ 29 ]. Participants were categorized as having low versus high HRQoL based on the total FACT-G score. A score ≤ 70 was classified as having low HRQoL. Subscale-specific thresholds were used to identify low well-being in each domain: PWB ≤ 18, SWB ≤ 19, EWB ≤ 15, and FWB ≤ 14. Scores above these thresholds were classified as high. These thresholds correspond to the group-level cutoff scores established by Pearman et al. in a large adult cancer sample, derived as one-half standard deviation below the mean [ 30 ].

2.2.3. Comorbidities

Comorbidities were grouped according to chronic diseases commonly assessed in national surveys of adult cancer survivors [ 31 ]. Participants were classified into four comorbidity burden categories: no chronic conditions (0), one chronic condition (1), two chronic conditions (2), or three or more chronic conditions (3+) based on self-report of the following: hypertension, diabetes, stroke, heart disease, chronic obstructive pulmonary disease, asthma, kidney disease, liver disease, hepatitis, arthritis. Diabetes and hypertension were also presented individually, as these cardiometabolic comorbidities align with the framework described by Maras et al. (2023) [ 24 ].

2.2.4. Lifestyle Behaviors

Lifestyle behaviors included self-reported alcohol use, physical activity, and smoking. Alcohol use was categorized as no drinking or moderate/exceeded moderate drinking according to the CDC definition of moderate alcohol use using sex-specific thresholds for average drinks consumed per drinking day and consistent with the American Cancer Society Nutrition and Physical Activity Guideline for Cancer Survivors [ 32 , 33 ]. The moderate and exceeded moderate drinking categories were combined because of the limited sample size in the exceeded moderate drinking group. Physical activity referred to any exercise or movement outside of regular work during the past 30 days. Smoking status was classified according to CDC definitions as never, former, or current smoker based on lifetime cigarette consumption (≥100 cigarettes) and current smoking status [ 34 ].

2.2.5. Covariates

Sociodemographic variables included age at cancer diagnosis (in years), sex assigned at birth (female or male), education level (less than high school, high school/some college/associate degree, or bachelor’s degree/higher), annual household income (<$20,000, $20,000–$40,000, >$40,000, or do not know/refused to report), marital status (married/living with partner or divorced/separated/widowed/single), birthplace (United States, Puerto Rico, other), self-reported residential area (urban/suburban or rural), health insurance type (private, Medicare/Medicare-Medicaid, or public), access to health care (yes/no), cancer stage (localized, regional, distant, unknown), and current cancer treatment (yes/no). Menopausal status at the time of breast cancer diagnosis was approximated using age at diagnosis, consistent with previous studies [ 35 , 36 ]. Participants diagnosed after age 50 were classified as having postmenopausal breast cancer, whereas those diagnosed at age 50 years or younger were classified as having premenopausal breast cancer. Covariates were selected a priori based on prior research examining social determinants of health [ 6 , 22 , 27 ] survivorship outcomes [ 8 , 9 , 15 , 16 , 17 ] and chronic disease [ 19 , 20 , 21 ] among cancer survivors.

2.3. Statistical Analysis

Descriptive statistics were used to summarize participant characteristics. Chi-square tests compared categorical variables, and independent t -tests assessed differences in continuous variables between ORC and non-ORC groups. Poisson regression models with robust standard errors estimated adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) for associations between ORC status and each outcome, including lifestyle behaviors (physical activity and alcohol use), HRQoL total and subscale scores. Smoking status (never, former, and current) and comorbidity burden (0, 1, 2, and 3+ comorbidities) were evaluated using multinomial logistic regression models to estimate adjusted relative risk ratios (aRRRs) and 95% CIs.

All models included a prespecified set of covariates including sex, age at diagnosis, education, and cancer stage, selected a priori based on prior research and clinical relevance [ 6 , 8 , 9 , 15 , 16 , 17 , 19 , 20 , 21 , 22 , 27 ]. Additional outcome-specific covariates were selected using stepwise regression with an entry criterion of p -value ≤ 0.05. This approach was used to develop parsimonious adjusted models for each outcome. Specifically, for smoking status, alcohol use was included; for alcohol use, comorbidity burden, smoking status, cancer treatment, income, health insurance, and birthplace were included. For physical activity, marital status, comorbidity burden, and income were included. For overall HRQoL, comorbidity burden and birthplace were included. For FWB and PWB, physical activity, comorbidity burden, and birthplace were added. For EWB, birthplace was included; and for SWB, comorbidity burden and marital status were included. For comorbidity burden, physical activity, marital status, HRQoL, and income were included.

Interaction terms between ORC status and age and ORC status and sex were evaluated using Wald tests. Where significant, the model was stratified and estimated within each stratum. Statistical significance was defined as a two-sided p -value < 0.05. All analyses were conducted using Stata/SE version 18 [ 37 ].

3. Results

3.1. Sample Demographics

Table 1 describes the 569 participants; 262 (46.05%) were diagnosed with ORCs and 307 (53.95%) with non-ORCs. ORC survivors were significantly older at cancer diagnosis (mean age: 59.29 ± 12.86 years) compared to non-ORC survivors (54.34 ± 14.99 years; p < 0.001). A higher proportion of women were diagnosed with ORCs (80.92%) than with non-ORCs (55.63%; p < 0.001). ORC survivors were more likely to be born in the US (11.45%) compared to non-ORC survivors (5.45%; p = 0.04). No significant differences were observed between groups for educational attainment, household income, marital status, physical activity, smoking status, HRQoL total and subscale scores, number of comorbidities, or active treatment ( p > 0.05 for all).

3.2. Multivariable Analyses

Multinomial logistic regression models indicated that ORC survivors had a significantly higher relative likelihood of reporting being former smokers relative to never smoking compared with non-ORC survivors (aRRR: 1.74, 95% CI: 1.02–2.96; Table 2 ) after adjusting for sex, education, age at diagnosis, cancer stage, and alcohol use. No significant association between ORC status and current smoking relative to never smoking was observed (aRRR: 1.09, 95% CI: 0.41–2.91). No significant differences by ORC status were observed for physical activity, alcohol use, or HRQoL total and subscale scores.

3.3. Interaction Analyses

The association between ORC status and alcohol use varied by sex ( p = 0.02; Figure 1 ). Among males, ORC survivors had a significantly lower prevalence of moderate/exceeded drinking than non-ORC survivors (aPR = 0.22, 95% CI: 0.07–0.68). In contrast, among females, ORC survivors had a higher, although not statistically significant, prevalence of moderate/exceeded drinking than non-ORC survivors (aPR = 1.27, 95% CI: 0.84–1.91).

Age at diagnosis also modified associations with EWB ( p = 0.01) and PWB ( p = 0.009; Figure 2 ). In age-stratified analyses, ORC survivors aged >60 years were less likely than their non-ORC counterparts to report low EWB (aPR = 0.59, 95% CI: 0.41–0.85) and low PWB (aPR = 0.74, 95% CI: 0.58–0.95). In contrast, ORC survivors aged 46–60 years had a significantly higher prevalence of low PWB (aPR = 1.35, 95% CI: 1.06–1.72), with no significant difference in EWB. No significant associations with EWB or PWB were identified among participants aged ≤45. Age-stratified linear regression analyses of HRQoL and its subdomains showed broadly similar patterns ( Table S2 ).

4. Discussion

This study is among the first to characterize the relationship between ORC status and survivorship outcomes—including HRQoL, comorbidities, and lifestyle behaviors—among cancer survivors living in Puerto Rico, addressing a critical gap in the literature on Hispanic/Latino populations. Overall, most outcomes examined did not differ significantly by ORC status, suggesting that ORC and non-ORC survivors share largely similar survivorship profiles in this population. Where significant differences did emerge, findings highlight a higher relative risk of former smoking (vs. never smoking) and a lower prevalence of moderate/exceeded drinking among ORC survivors compared with non-ORC survivors, along with additional sex- and age-specific patterns in alcohol use and emotional/physical well-being. Together, these findings suggest that behavioral risk factors, rather than comorbidities, represent the primary axis of difference between ORC and non-ORC survivors in this population, and may be particularly relevant targets for tailored survivorship care. Our findings align with prior research documenting associations between obesity and smoking among cancer survivors [ 38 , 39 ]. We observed a higher relative likelihood of reporting being a former smoker (vs. never smoking) among ORC survivors compared with non-ORC survivors (aRRR: 1.74, 95% CI: 1.02–2.96) [ 40 , 41 ]. A potential explanation for this pattern is that a cancer diagnosis often serves as a “teachable moment,” prompting increased motivation for health behavior change, including smoking cessation [ 42 , 43 ]; ORC survivors, whose treatment and survivorship care may place greater emphasis on lifestyle counseling to address modifiable cardiometabolic and recurrence risk factors, may be particularly likely to act on this opportunity to quit. No significant interactions were observed by age or sex, suggesting that this pattern is consistent across demographic groups in our sample. Further research is needed to understand the factors underlying this more favorable cessation pattern among ORC survivors, and whether they could be leveraged to support cessation efforts among non-ORC survivors as well.

Prior studies among cancer survivors have generally examined obesity itself, rather than ORC status, as a predictor of HRQoL, leaving the survivorship experience specific to ORC survivors comparatively understudied [ 9 , 44 ]. To address this, we examined whether HRQoL differed by ORC status in our sample of cancer survivors living in Puerto Rico. We found ORC survivors aged >60 years were significantly less likely to report low PWB and EWB, whereas those aged 46–60 years reported a higher prevalence of low PWB. These exploratory findings suggest that the relationship between ORC status and HRQoL may vary across the life course [ 45 , 46 ]. Although not directly evaluated in this study, two complementary hypotheses may help explain this pattern. Differences in EWB may reflect age-related shifts in emotion regulation: consistent with socioemotional selectivity theory, as time horizons narrow with age, older adults increasingly prioritize emotionally meaningful goals and interactions, which has been associated with better emotional well-being relative to younger and middle-aged adults [ 47 ]. Differences in PWB may partly reflect response shift, whereby survivors recalibrate their internal standards for physical health over time, such that comparable symptoms are rated as less burdensome with age or longer time since diagnosis [ 48 ]. Additional studies incorporating validated measures of emotion regulation and response shift in ORC survivors are warranted. If confirmed in future studies, these findings may have implications for lifestyle-focused interventions, including physical activity promotion and nutritional counseling.

We found no significant differences in physical activity by ORC status. However, our measure captured any exercise or movement outside of work during the past 30 days and did not assess whether participants met recommended levels of physical activity. This likely reflects the overall low physical activity observed in the sample, consistent with population-level estimates in Puerto Rico [ 49 ]. Environmental and structural barriers, such as limited access to safe recreational spaces, walkable neighborhoods, and community facilities, may play a larger role in shaping physical activity than ORC status [ 49 , 50 ]. Taken together with population-level evidence from Puerto Rico, these findings highlight the importance of continuing to understand physical activity patterns among cancer survivors. Future studies using guideline-based measures of physical activity are needed to better characterize differences by ORC status [ 19 , 24 , 51 ].

Exploratory analyses further identified a significant interaction by sex, indicating that this association was observed among males but not among females. Among males, ORC survivors had a lower prevalence of moderate/exceeded drinking than non-ORC survivors, whereas no significant differences were observed among females. Prior research using All of Us data found that males were more likely to engage in risky drinking behaviors, including binge and hazardous drinking in the past year [ 52 ] and that male cancer survivors had higher odds of current and binge drinking in the past year, with alcohol use varying by cancer types [ 53 ]. However, these studies did not examine whether the association between cancer type and alcohol use differed by sex. Sex-related factors may also contribute to these patterns, as men generally consume more alcohol and engage in heavier drinking than women, leaving greater room for behavioral change following a cancer diagnosis. In contrast, women tend to drink less and experience stronger social pressures to limit alcohol use, potentially resulting in less behavioral variation to detect differences by ORC status [ 54 ]. If confirmed in future studies, these findings may have implications for sex-specific behavioral counseling within survivorship care, particularly with respect to alcohol use among male survivors.

This study contributes to the cancer survivorship literature by addressing a critical gap in understanding ORC survivorship within Hispanic/Latino populations. However, several limitations should be considered. First, we could not adjust for obesity because obesity status at diagnosis was unavailable. Although obesity status at diagnosis would have allowed us to evaluate the independent role of obesity, the objective of this exploratory secondary analysis was to characterize survivorship profiles according to ORC status among cancer survivors in Puerto Rico. Future studies should incorporate obesity status at diagnosis to further investigate the relationship between obesity, ORC status, and health-related outcomes. Second, the exclusion of participants with multiple cancer diagnoses (29% of the eligible sample) may have introduced selection bias. Third, behavioral and comorbidity measures were self-reported, which may have introduced social desirability bias for behavioral variables such as alcohol use and smoking status, while comorbidity reporting may have been affected by recall bias. In addition, menopausal status was approximated using age at diagnosis (≥50 years), an imperfect proxy that may misclassify women whose natural menopause occurred earlier or later. However, this approximation is consistent with the average age at natural menopause among Puerto Rican women [ 36 ]. Finally, recruitment through clinical settings may overrepresent survivors who are more engaged with healthcare, potentially limiting generalizability to survivors less engaged in care. Despite these limitations, our study had several strengths, including the use of validated measures such as the FACT-G to assess HRQoL. Additionally, we adjusted for covariates informed by prior research on the social determinants of health among cancer survivors [ 6 , 8 , 9 , 15 , 16 , 17 , 19 , 22 , 27 ]. Our study is among the first to compare HRQoL, lifestyle behaviors, and comorbidities between ORC and non-ORC survivors in Puerto Rico, addressing an important gap in the literature.

Future research should incorporate prospective longitudinal designs with repeated assessments of HRQoL, comorbidities, and lifestyle behaviors, integrating objective adiposity measures and cancer registry linkages to more accurately characterize the association between ORC status and these outcomes over time.

5. Conclusions

In conclusion, ORC status was associated with smoking status, but not with overall HRQoL, physical activity, or comorbidities. Exploratory analyses suggested heterogeneity by age and sex, underscoring the need for tailored survivorship care strategies. These findings support public health efforts to characterize health outcomes unique to the ORC survivorship experience. Survivorship experiences in this group are shaped not only by obesity and cancer type, but also by age, sex, and broader structural factors associated with health. Considering these factors, there is a particular need to more accurately characterize ORC survivors living in Puerto Rico. Improving our understanding of ORC survivors in Puerto Rico is essential for informing clinicians, guiding culturally responsive follow-up care, and supporting policymakers and community programs in developing interventions that address the unique needs of this population. Such efforts are critical for reducing differences in cancer outcomes across Hispanic/Latino communities.

Acknowledgments

We thank the START-PR research assistants for their valuable support with participant recruitment. We also thank Stephanie Cameron-Maldonado for her contributions to data management and data quality, and Mariela Bournigal-Feliciano for her work on the development of data collection instruments, database design, and study implementation. We further thank the Scientific Editing and Communications Core at the University of Puerto Rico Comprehensive Cancer Center for their assistance in reviewing and editing the manuscript.

Abbreviations

The following abbreviations are used in this manuscript:

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/cancers18172817/s1 , Figure S1. Flow diagram of analytic sample derivation. Table S1. Distribution of ORC and non-ORC types. Table S2. Linear regression of HRQoL and subdomains by ORC status, stratified by age.

Author Contributions

Conceptualization, W.H., G.R.-O., C.T.S.-D., L.G.-S., C.M.P. and M.S.-S.; Methodology, W.H., G.R.-O. and C.T.S.-D.; Software, L.G.-S.; Validation, W.H., G.R.-O. and C.T.S.-D.; Formal analysis, W.H., G.R.-O. and C.T.S.-D.; Investigation, L.G.-S. and M.S.-S.; Resources: L.G.-S. and M.S.-S.; Data curation, L.G.-S. and M.S.-S.; Writing—original draft preparation, W.H.; Writing—review and editing, G.R.-O., C.T.S.-D., L.G.-S., C.M.P. and M.S.-S.; Visualization, W.H., G.R.-O. and C.T.S.-D.; Supervision, G.R.-O., C.T.S.-D., L.G.-S., C.M.P. and M.S.-S.; Project administration, L.G.-S. and M.S.-S.; Funding acquisition, M.S.-S. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

This study protocol was approved by the Institutional Review Board of the University of Puerto Rico Comprehensive Cancer Center (UPRCCC IRB# 2411004025, approved on 9 November 2023) and was conducted in accordance with the Declaration of Helsinki.

Informed Consent Statement

The UPRCCC IRB approved the use of an informative sheet instead of an informed consent form because our study involves minimal risk to participants; the patients who participated in this study were informed of this study using the informative sheet.

Data Availability Statement

The data supporting this study are available from M.S.-S. upon request.

Conflicts of Interest

The authors declare no conflicts of interest.

Funding Statement

This research was funded by the National Cancer Institute (NCI) Cancer Prevention and Control (CAPAC) Program (grant number R25CA240120). Additional support was provided by the Office of Cancer Research Training and Education Coordination (CRTEC) of the University of Puerto Rico Comprehensive Cancer Center, the National Institute for General Medical Sciences (NIGMS)-funded Alliance for Clinical and Translational Research (grant number U54GM133807), and Bristol Myers Squibb (grant number 93918763). FACT-G is a copyrighted instrument owned by David Cella, Ph.D. and administered by FACIT.org. Permission to use the instrument was obtained prior to the study. The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Institutes of Health.

Footnotes

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Associated Data

Supplementary Materials

Data Availability Statement

The data supporting this study are available from M.S.-S. upon request.