Well: Holding on for the Wedding

As my patient looked on, his wife took the framed photograph out of a nondescript manila mailer, the type with bubble wrap on the inside, and handed it to me gingerly. It was clear they both considered it to be precious cargo.

“You can see I made it to the wedding,” he said, smiling broadly, as I studied the image of him in a suit, locking arms with his granddaughter, the bride. The two of them were bordered by the opened doors of the church, stained glass windows on either side, his face bearing that familiar look of consuming love, joy and pride — along with a little fear, that at any moment he might start sobbing in front of all of his buddies and co-workers attending the ceremony. I have the same photograph in my own wedding album, of my father-in-law with my wife-to-be.

“You should have heard the gasp from everyone in the church when he came through those doors with our granddaughter,” his wife exclaimed. “I mean, no one thought he would even be there!”

“My granddaughter and I had been planning it for months, but we didn’t tell anyone,” my patient went on, explaining that he and his wife had raised the girl for several years while their daughter, who had gotten pregnant in her teens, could get back on her feet.

When it came to his health, my patient is the type of guy about whom you might say if he didn’t have bad luck, he wouldn’t have any luck at all. Years earlier, he was treated for colon cancer. Now, possibly as a result of that treatment, he had leukemia. But he also had a completely different type of bone cancer, and the kicker — advanced lung cancer.

He wasn’t the first patient I had ever treated with multiple cancers, and in general we approach people like him by going in order of treating the most serious cancers first, and working our way down to the less serious ones. In one respect, he was lucky: he looked a heck of a lot better than his medical chart. As leukemia and lung cancer often represent the worst of the worst, we tried treating both at the same time. The leukemia went into remission. The lung cancer didn’t.

Within oncology, it is taken as almost a truism that people die only after they have said their goodbyes to their immediate family, or achieved some life milestone. Countless times I have seen comatose patients linger until a child flies in from California, only to pass hours after that child’s arrival.

A study that appeared in The Journal of the American Medical Association in 2004 looked at whether people die soon after a milestone. In it, the authors analyzed death certificates from more than 300,000 people dying with cancer in Ohio from 1989 to 2000, and whether those people were more likely to die immediately after a birthday, Christmas or Thanksgiving. It turns out that these people were no more likely to die after these events than before, and the authors concluded that cancer patients are not able to postpone their deaths to survive such significant occasions.

The study was misguided, though: the authors asked the wrong question. The last time I looked forward to a birthday was half a lifetime ago when, for the first time, I could walk proudly into a bar without having to proffer my grungy fake I.D. And while I enjoy holidays, what motivates me to brave the traffic on I-80 with a car full of children and a DVD player on the fritz is not my enduring respect for pilgrims; it is the chance to be with the family I see far too infrequently.

“The weekend before the wedding was a close call,” my patient said. “I couldn’t move my leg or my arm, and that CT scan showed the lung cancer in my brain….” he trailed off.

“But that pill you prescribed really did the trick,” his wife picked up. “He could walk again after a few days.”

“Even if it hadn’t, if I’d had to tape my arm to my body and walk with a splint, I wouldn’t have missed it,” my patient said with a fierce look in his eyes.

I wanted to hang on to the photo, it represented such determination, but reluctantly handed it back. I said my goodbyes to them in clinic, then headed to the workroom, where one of the leukemia nurses approached me.

“When do you want to see him again — in four weeks or in five?” the nurse asked. I had the hardest time answering, and she gave me a knowing smile, understanding why I was hesitating.

“I don’t think it makes a difference, now that his granddaughter is married,” I answered.

He did come to clinic, just one more time. He was wearing a sweatshirt with the wedding photo silkscreened on the front, and underneath the caption, “Mission Accomplished.”

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Well: Holding on for the Wedding

As my patient looked on, his wife took the framed photograph out of a nondescript manila mailer, the type with bubble wrap on the inside, and handed it to me gingerly. It was clear they both considered it to be precious cargo.

“You can see I made it to the wedding,” he said, smiling broadly, as I studied the image of him in a suit, locking arms with his granddaughter, the bride. The two of them were bordered by the opened doors of the church, stained glass windows on either side, his face bearing that familiar look of consuming love, joy and pride — along with a little fear, that at any moment he might start sobbing in front of all of his buddies and co-workers attending the ceremony. I have the same photograph in my own wedding album, of my father-in-law with my wife-to-be.

“You should have heard the gasp from everyone in the church when he came through those doors with our granddaughter,” his wife exclaimed. “I mean, no one thought he would even be there!”

“My granddaughter and I had been planning it for months, but we didn’t tell anyone,” my patient went on, explaining that he and his wife had raised the girl for several years while their daughter, who had gotten pregnant in her teens, could get back on her feet.

When it came to his health, my patient is the type of guy about whom you might say if he didn’t have bad luck, he wouldn’t have any luck at all. Years earlier, he was treated for colon cancer. Now, possibly as a result of that treatment, he had leukemia. But he also had a completely different type of bone cancer, and the kicker — advanced lung cancer.

He wasn’t the first patient I had ever treated with multiple cancers, and in general we approach people like him by going in order of treating the most serious cancers first, and working our way down to the less serious ones. In one respect, he was lucky: he looked a heck of a lot better than his medical chart. As leukemia and lung cancer often represent the worst of the worst, we tried treating both at the same time. The leukemia went into remission. The lung cancer didn’t.

Within oncology, it is taken as almost a truism that people die only after they have said their goodbyes to their immediate family, or achieved some life milestone. Countless times I have seen comatose patients linger until a child flies in from California, only to pass hours after that child’s arrival.

A study that appeared in The Journal of the American Medical Association in 2004 looked at whether people die soon after a milestone. In it, the authors analyzed death certificates from more than 300,000 people dying with cancer in Ohio from 1989 to 2000, and whether those people were more likely to die immediately after a birthday, Christmas or Thanksgiving. It turns out that these people were no more likely to die after these events than before, and the authors concluded that cancer patients are not able to postpone their deaths to survive such significant occasions.

The study was misguided, though: the authors asked the wrong question. The last time I looked forward to a birthday was half a lifetime ago when, for the first time, I could walk proudly into a bar without having to proffer my grungy fake I.D. And while I enjoy holidays, what motivates me to brave the traffic on I-80 with a car full of children and a DVD player on the fritz is not my enduring respect for pilgrims; it is the chance to be with the family I see far too infrequently.

“The weekend before the wedding was a close call,” my patient said. “I couldn’t move my leg or my arm, and that CT scan showed the lung cancer in my brain….” he trailed off.

“But that pill you prescribed really did the trick,” his wife picked up. “He could walk again after a few days.”

“Even if it hadn’t, if I’d had to tape my arm to my body and walk with a splint, I wouldn’t have missed it,” my patient said with a fierce look in his eyes.

I wanted to hang on to the photo, it represented such determination, but reluctantly handed it back. I said my goodbyes to them in clinic, then headed to the workroom, where one of the leukemia nurses approached me.

“When do you want to see him again — in four weeks or in five?” the nurse asked. I had the hardest time answering, and she gave me a knowing smile, understanding why I was hesitating.

“I don’t think it makes a difference, now that his granddaughter is married,” I answered.

He did come to clinic, just one more time. He was wearing a sweatshirt with the wedding photo silkscreened on the front, and underneath the caption, “Mission Accomplished.”

Read More..

Apple to Resume U.S. Manufacturing

For the first time in years, Apple will manufacture computers in the United States, the chief executive of Apple, Timothy D. Cook, said in interviews with NBC and Bloomberg Businessweek.

“Next year, we will do one of our existing Mac lines in the United States,” he said in an interview to be broadcast Thursday on “Rock Center With Brian Williams” on NBC.

Apple, the biggest company in the world by market value, moved its manufacturing to Asia in the late 1990s. As an icon of American technology success and innovation, the California-based company has been criticized in recent years for outsourcing jobs abroad.

“I don’t think we have a responsibility to create a certain kind of job,” Mr. Cook said in the Businessweek interview. “But I think we do have a responsibility to create jobs.”

The company plans to spend $100 million on the American manufacturing in 2013, according to the interviews, a small fraction of its overall factory investments and an even tinier portion of its available cash.

In the interviews, Mr. Cook suggested the company would work with partners and that the manufacturing would be more than just the final assembly of parts. He noted that parts of the company’s ubiquitous iPhone, including the “engine” and the glass screen, were already made in America. The processor is manufactured by Samsung in Texas, while Corning makes the glass screen in Kentucky.

Over the last few years, sales of the iPhone, iPod and iPad have overwhelmed Apple’s line of Macinotsh computers, the basis of the company’s early business. Revenue from the iPhone alone made up 48 percent of the company’s total revenue for its fiscal fourth quarter ended Sept. 30.

But as recently as October, Apple introduced a new, thinner iMac, the product that pioneered the technique of building the computer innards inside the flat screen.

Mr. Cook did not say in the interviews where in the United States the new manufacturing would occur. But he did defend Apple’s track record in American hiring.

“When you back up and look at Apple’s effect on job creation in the United States, we estimate that we’ve created more than 600,000 jobs now,” Mr. Cook told Businessweek. Those jobs include positions at partners and suppliers.

Steve Dowling, a spokesman for Apple, declined on Thursday to provide additional details on Apple’s plans, referring to Mr. Cook’s interviews.

Apple has for years done the final assembly of some Macs in the United States, mainly systems that customers buy with custom configurations, like bigger hard drives and more memory than on standard machines.

Mr. Cook’s statements suggested Apple is planning to build more of the Mac’s ingredients here, although with partners. He told Businessweek that the plan “doesn’t mean that Apple will do it ourselves, but we’ll be working with people, and we’ll be investing our money.”

While Apple’s products are typically made in Asian factories owned by other companies, Apple itself often purchases the sophisticated manufacturing equipment required to make its cutting-edge designs, spending billions of dollars a year on such machines.

Foxconn Technology, which manufactures more than 40 percent of the world’s electronics, is one of Apple’s main overseas manufacturing contractors. Based in Taiwan, Foxconn is China’s largest private employer, with 1.2 million workers, and it has come under intense scrutiny over working conditions inside its factories.

In March, Foxconn pledged to sharply curtail the number of working hours and significantly increase wages. The announcement was a response to a far-ranging inspection by the Fair Labor Association, a monitoring group that found widespread problems — including numerous instances where Foxconn violated Chinese law and industry codes of conduct.

Apple, which recently joined the labor association, had asked the group to investigate plants manufacturing iPhones, iPads and other devices. A growing outcry over conditions at overseas factories prompted protests and petitions, and several labor rights organizations started scrutinizing Apple’s suppliers.

Almost all of the 70 million iPhones, 30 million iPads and 59 million other products Apple sold in 2011 were manufactured overseas. Apple employs 43,000 people in the United States and 20,000 overseas. An additional 700,000 people engineer, build and assemble iPads, iPhones and Apple’s other products, mostly abroad.

At a meeting with Silicon Valley executives in 2011, President Obama asked Steven P. Jobs, then the Apple chief executive, what it would take to make iPhones in the United States. Mr. Jobs, who died later that year, told the president, “Those jobs aren’t coming back.”

Nick Wingfield contributed reporting.

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Egyptian Forces Deploy Tanks as President Mohamed Morsi’s Backers Clash With Rivals

Tara Todras-Whitehill for The New York Times

Egyptian soldiers put up barbed wired fences near the presidential palace on Thursday in Cairo. More Photos »

CAIRO — An elite Egyptian unit deployed tanks outside the presidential palace on Thursday after a night of battles between Islamists and secular protesters that left five people dead and 450 wounded, spreading chaos in one of Cairo’s wealthiest suburbs and leaving streets littered with debris and burned-out cars.

Angry mobs of Islamists battled the secular protesters with fists, rocks and firebombs in the first major outbreak of violence between political factions here since the revolt against the ousted President Hosni Mubarak began nearly two years ago.

With at least 12 tanks drawn up near the palace, troops from the presidential guard hammered stakes into the ground to string barbed wire to separate Islamists camping outside the palace and secular protesters chanting slogans urging the guardsmen to choose “between the revolutionaries and the killers.” Other armored units were sent to guard the headquarters of state television, an important symbol of government power. The severity of the clashes — and their potential political impact — became apparent when three senior advisers to Mr. Mubarak’s successor, Mohamed Morsi, Egypt’s first freely elected president, resigned during the clashes Wednesday, blaming him for the bloodshed. Mr. Morsi’s prime minister implored both sides to pull back in order to make room for “dialogue.”

Graffiti on the walls of the presidential compound, mocking President Morsi, had been covered by Thursday morning with patches of white paint.

The scale of the fighting, in the affluent Heliopolis neighborhood just outside Mr. Morsi’s office in the presidential palace, raised the first doubts about Mr. Morsi’s effort to hold a referendum on Dec. 15 on a draft constitution approved by his Islamist allies over the objections of his secular opposition and the Coptic Christian Church.

Hundreds of Islamist supporters of Mr. Morsi spent the night outside the palace, and on Thursday some awoke with head bandages covering their wounds. Many said they were members of the Muslim Brotherhood from other provinces and they vowed to stay in Cairo until the draft constitution was approved.

They said they had come to defend Egypt’s democracy from a conspiracy by foreign powers, corrupt businessmen and cynical opposition leaders, insisting that their secular opponents were fighting for money, and not for sincere beliefs.

In a token of the deep suspicions since Egypt’s revolution, some maintained that Mr. Morsi could not rely on the police force to defend him and his palace because its leaders were holdovers from the old government trying to position themselves to be on the winning side of the political battle.

“We must take our freedom; it will not be given to us on a golden platter,” said Mohamed Hassan Awad Rashid, 54, a schoolteacher and member of the Muslim Brotherhood from Sharqiya in the Nile Delta who said he had arrived Wednesday and would stay until the referendum. “If we don’t complete our revolution now, then we are digging our own graves.”

In the early afternoon, the hundreds of Islamists supporting Mr. Morsi abruptly abandoned their encampment outside the presidential palace, possibly signaling a tactical shift by the president, who said through state media that he would address the nation later on Thursday.

State media also reported that in midafternoon, the presidential guard, which reports directly to the president, would clear the streets around the palace. Overnight, periodic gunshots could be heard at the front lines of the fight, and secular protesters displayed birdshot wounds and pellets. But it could not be determined whether the riot police or Islamists or the opposition had fired the guns.

Many in both camps brandished makeshift clubs, and on the secular side a few carried knives. Thousands joined the battle on each side. The riot police initially tried to fight off or break up the crowds with tear gas, but by midevening on Wednesday, the security forces had all but withdrawn. They continued to try to separate the two sides across one boulevard but stayed out of the battle that raged on all around.

In a city square on the Islamist side of the battle lines, a loudspeaker on the top of a moving car blared out exhortations that the fight was about more than politics or Mr. Morsi.

“This is not a fight for an individual, this is not a fight for President Morsi,” the speaker declared. “We are fighting for God’s law, against the secularists and liberals.”

Protesters reportedly set fire to Muslim Brotherhood political offices in the cities of Suez and Ismailia.

Mai Ayyad contributed reporting.

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To Fight Climate Change, College Students Take Aim at the Endowment Portfolio

SWARTHMORE, Pa. — A group of Swarthmore College students is asking the school administration to take a seemingly simple step to combat pollution and climate change: sell off the endowment’s holdings in large fossil fuel companies. For months, they have been getting a simple answer: no.

As they consider how to ratchet up their campaign, the students suddenly find themselves at the vanguard of a national movement.

In recent weeks, college students on dozens of campuses have demanded that university endowment funds rid themselves of coal, oil and gas stocks. The students see it as a tactic that could force climate change, barely discussed in the presidential campaign, back onto the national political agenda.

“We’ve reached this point of intense urgency that we need to act on climate change now, but the situation is bleaker than it’s ever been from a political perspective,” said William Lawrence, a Swarthmore senior from East Lansing, Mich.

Students who have signed on see it as a conscious imitation of the successful effort in the 1980s to pressure colleges and other institutions to divest themselves of the stocks of companies doing business in South Africa under apartheid.

A small institution in Maine, Unity College, has already voted to get out of fossil fuels. Another, Hampshire College in Massachusetts, has adopted a broad investment policy that is ridding its portfolio of fossil fuel stocks.

“In the near future, the political tide will turn and the public will demand action on climate change,” Stephen Mulkey, the Unity College president, wrote in a letter to other college administrators. “Our students are already demanding action, and we must not ignore them.”

But at colleges with large endowments, many administrators are viewing the demand skeptically, saying it would undermine their goal of maximum returns in support of education. Fossil fuel companies represent a significant portion of the stock market, comprising nearly 10 percent of the value of the Russell 3000, a broad index of 3,000 American companies.

No school with an endowment exceeding $1 billion has agreed to divest itself of fossil fuel stocks. At Harvard, which holds the largest endowment in the country at $31 billion, the student body recently voted to ask the school to do so. With roughly half the undergraduates voting, 72 percent of them supported the demand.

“We always appreciate hearing from students about their viewpoints, but Harvard is not considering divesting from companies related to fossil fuels,” Kevin Galvin, a university spokesman, said by e-mail.

Several organizations have been working on some version of a divestment campaign, initially focusing on coal, for more than a year. But the recent escalation has largely been the handiwork of a grass-roots organization, 350.org, that focuses on climate change, and its leader, Bill McKibben, a writer turned advocate. The group’s name is a reference to what some scientists see as a maximum safe level of carbon dioxide in the atmosphere, 350 parts per million. The level is now about 390, an increase of 41 percent since before the Industrial Revolution.

Mr. McKibben is touring the country by bus, speaking at sold-out halls and urging students to begin local divestment initiatives focusing on 200 energy companies. Many of the students attending said they were inspired to do so by an article he wrote over the summer in Rolling Stone magazine, “Global Warming’s Terrifying New Math.”

Speaking recently to an audience at the University of Vermont, Mr. McKibben painted the fossil fuel industry as an enemy that must be defeated, arguing that it had used money and political influence to block climate action in Washington. “This is no different than the tobacco industry — for years, they lied about the dangers of their industry,” Mr. McKibben said.

Eric Wohlschlegel, a spokesman for the American Petroleum Institute, said that continued use of fossil fuels was essential for the country’s economy, but that energy companies were investing heavily in ways to emit less carbon dioxide.

In an interview, Mr. McKibben said he recognized that a rapid transition away from fossil fuels would be exceedingly difficult. But he said strong government policies to limit emissions were long overdue, and were being blocked in part by the political power of the incumbent industry.

Mr. McKibben’s goal is to make owning the stocks of these companies disreputable, in the way that owning tobacco stocks has become disreputable in many quarters. Many colleges will not buy them, for instance.

Mr. McKibben has laid out a series of demands that would get the fuel companies off 350.org’s blacklist. He wants them to stop exploring for new fossil fuels, given that they have already booked reserves about five times as large as scientists say society can afford to burn. He wants them to stop lobbying against emission policies in Washington. And he wants them to help devise a transition plan that will leave most of their reserves in the ground while encouraging lower-carbon energy sources.

“They need more incentive to make the transition that they must know they need to make, from fossil fuel companies to energy companies,” Mr. McKibben said.

Most college administrations, at the urging of their students, have been taking global warming seriously for years, spending money on steps like cutting energy consumption and installing solar panels.

The divestment demand is so new that most administrators are just beginning to grapple with it. Several of them, in interviews, said that even though they tended to agree with students on the seriousness of the problem, they feared divisive boardroom debates on divestment.

That was certainly the case in the 1980s, when the South African divestment campaign caused bitter arguments across the nation.

Brent Summers contributed reporting from Burlington, Vt.

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Extended Use of Breast Cancer Drug Suggested

The widely prescribed drug tamoxifen already plays a major role in reducing the risk of death from breast cancer. But a new study suggests that women should be taking the drug for twice as long as is now customary, a finding that could upend the standard that has been in place for about 15 years.

In the study, patients who continued taking tamoxifen for 10 years were less likely to have the cancer come back or to die from the disease than women who took the drug for only five years, the current standard of care.

“Certainly, the advice to stop in five years should not stand,” said Prof. Richard Peto, a medical statistician at Oxford University and senior author of the study, which was published in The Lancet on Wednesday and presented at the San Antonio Breast Cancer Symposium.

Breast cancer specialists not involved in the study said the results could have the biggest impact on premenopausal women, who account for a fifth to a quarter of new breast cancer cases. Postmenopausal women tend to take different drugs, but some experts said the results suggest that those drugs as well might be taken for a longer duration.

“We’ve been waiting for this result,” said Dr. Robert W. Carlson, a professor of medicine at Stanford University. “I think it is especially practice-changing in premenopausal women because the results do favor a 10-year regimen.”

Dr. Eric P. Winer, chief of women’s cancers at the Dana-Farber Cancer Institute in Boston, said that even women who completed their five years of tamoxifen months or years ago might consider starting on the drug again.

Tamoxifen blocks the effect of the hormone estrogen, which fuels tumor growth in estrogen receptor-positive cancers that account for about 65 percent of cases in premenopausal women. Some small studies in the 1990s suggested that there was no benefit to using tamoxifen longer than five years, so that has been the standard.

About 227,000 cases of breast cancer are diagnosed each year in the United States, and an estimated 30,000 of them would be in premenopausal women with ER-positive cancer and prime candidates for tamoxifen. But postmenopausal women also take tamoxifen if they cannot tolerate the alternative drugs, known as aromatase inhibitors.

The new study, known as Atlas, included nearly 7,000 women with ER-positive disease who had completed five years of tamoxifen. They came from about three dozen countries. Half were chosen at random to take the drug another five years, while the others were told to stop.

In the group assigned to take tamoxifen for 10 years, 21.4 percent had a recurrence of breast cancer in the ensuing nine years, meaning the period 5 to 14 years after their diagnoses. The recurrence rate for those who took only five years of tamoxifen was 25.1 percent.

About 12.2 percent of those in the 10-year treatment group died from breast cancer, compared with 15 percent for those in the control group.

There was virtually no difference in death and recurrence between the two groups during the five years of extra tamoxifen. The difference came in later years, suggesting that tamoxifen has a carry-over effect that lasts long after women stop taking it.

Whether these differences are big enough to cause women to take the drug for twice as long remains to be seen.

“The treatment effect is real, but it’s modest,” said Dr. Paul E. Goss, director of breast cancer research at the Massachusetts General Hospital.

Tamoxifen has side effects, including endometrial cancer, blood clots and hot flashes, which cause many women to stop taking the drug. In the Atlas trial, it appears that roughly 40 percent of the patients assigned to take tamoxifen for the additional five years stopped prematurely.

Some 3.1 percent of those taking the extra five years of tamoxifen got endometrial cancer versus 1.6 percent in the control group. However, only 0.6 percent of those in the longer treatment group died from endometrial cancer or pulmonary blood clots.

“Over all, the benefits of extended tamoxifen seemed to outweigh the risks substantially,” Trevor J. Powles of the Cancer Center London, said in a commentary published by The Lancet.

Dr. Judy E. Garber, director of the Center for Cancer Genetics and Prevention at Dana-Farber, said many women have a love-hate relationship with hormone therapies.

Read More..

Extended Use of Breast Cancer Drug Suggested

The widely prescribed drug tamoxifen already plays a major role in reducing the risk of death from breast cancer. But a new study suggests that women should be taking the drug for twice as long as is now customary, a finding that could upend the standard that has been in place for about 15 years.

In the study, patients who continued taking tamoxifen for 10 years were less likely to have the cancer come back or to die from the disease than women who took the drug for only five years, the current standard of care.

“Certainly, the advice to stop in five years should not stand,” said Prof. Richard Peto, a medical statistician at Oxford University and senior author of the study, which was published in The Lancet on Wednesday and presented at the San Antonio Breast Cancer Symposium.

Breast cancer specialists not involved in the study said the results could have the biggest impact on premenopausal women, who account for a fifth to a quarter of new breast cancer cases. Postmenopausal women tend to take different drugs, but some experts said the results suggest that those drugs as well might be taken for a longer duration.

“We’ve been waiting for this result,” said Dr. Robert W. Carlson, a professor of medicine at Stanford University. “I think it is especially practice-changing in premenopausal women because the results do favor a 10-year regimen.”

Dr. Eric P. Winer, chief of women’s cancers at the Dana-Farber Cancer Institute in Boston, said that even women who completed their five years of tamoxifen months or years ago might consider starting on the drug again.

Tamoxifen blocks the effect of the hormone estrogen, which fuels tumor growth in estrogen receptor-positive cancers that account for about 65 percent of cases in premenopausal women. Some small studies in the 1990s suggested that there was no benefit to using tamoxifen longer than five years, so that has been the standard.

About 227,000 cases of breast cancer are diagnosed each year in the United States, and an estimated 30,000 of them would be in premenopausal women with ER-positive cancer and prime candidates for tamoxifen. But postmenopausal women also take tamoxifen if they cannot tolerate the alternative drugs, known as aromatase inhibitors.

The new study, known as Atlas, included nearly 7,000 women with ER-positive disease who had completed five years of tamoxifen. They came from about three dozen countries. Half were chosen at random to take the drug another five years, while the others were told to stop.

In the group assigned to take tamoxifen for 10 years, 21.4 percent had a recurrence of breast cancer in the ensuing nine years, meaning the period 5 to 14 years after their diagnoses. The recurrence rate for those who took only five years of tamoxifen was 25.1 percent.

About 12.2 percent of those in the 10-year treatment group died from breast cancer, compared with 15 percent for those in the control group.

There was virtually no difference in death and recurrence between the two groups during the five years of extra tamoxifen. The difference came in later years, suggesting that tamoxifen has a carry-over effect that lasts long after women stop taking it.

Whether these differences are big enough to cause women to take the drug for twice as long remains to be seen.

“The treatment effect is real, but it’s modest,” said Dr. Paul E. Goss, director of breast cancer research at the Massachusetts General Hospital.

Tamoxifen has side effects, including endometrial cancer, blood clots and hot flashes, which cause many women to stop taking the drug. In the Atlas trial, it appears that roughly 40 percent of the patients assigned to take tamoxifen for the additional five years stopped prematurely.

Some 3.1 percent of those taking the extra five years of tamoxifen got endometrial cancer versus 1.6 percent in the control group. However, only 0.6 percent of those in the longer treatment group died from endometrial cancer or pulmonary blood clots.

“Over all, the benefits of extended tamoxifen seemed to outweigh the risks substantially,” Trevor J. Powles of the Cancer Center London, said in a commentary published by The Lancet.

Dr. Judy E. Garber, director of the Center for Cancer Genetics and Prevention at Dana-Farber, said many women have a love-hate relationship with hormone therapies.

Read More..

Free-Messaging Apps Siphon Profits from Cellular Providers

For a long time, opening a cellphone bill was scary for the parents of teenagers. Charges for texting could reach hundreds of dollars a month, prompting many families to sign up for unlimited plans. But at perhaps $20 a month for each family member, that quickly added up, too.

Lucas Jackson/Reuters

A man uses his Apple iPhone in New York in September. Cellphone users are sending more text messages than ever, but increasingly they are free — thanks to the Internet.

Apps like Facebook Messenger, top, and WhatsApp, bottom, send their messages using the Internet rather than cellular networks. The shift could cost wireless companies billions of dollars.

Relief is on the way. Cellphone users are sending more text messages than ever, but increasingly they are free — thanks to the Internet. While that is good news for consumers, it could cost the world’s wireless companies tens of billions of dollars in lost revenue.

Standard texting, the kind where you send abbreviation-filled messages over a cellphone network, has been in decline in many parts of the world, and now appears to be shrinking in the United States. That is because smartphones can use free Internet-powered services that send messages over data networks instead, and those services are attracting millions of users.

The shift is opening an opportunity for big companies like Facebook and Apple and smaller start-ups like WhatsApp and Kik, which are making aggressive grabs at this market, aiming to put themselves at the center of how people communicate in the smartphone era.

Peter Deng, a product director at Facebook who oversees its Messenger software, said that text messaging was “ripe for innovation” because it had been held back by outdated technology.

“It’s limited to 160 characters,” Mr. Deng said, “and it’s not at all rich in its expression. People want to connect deeply with each other, and they don’t want to be constrained by various technical boundaries and decisions made 20 years ago.”

Unlike ordinary text messages, Facebook’s messaging service allows people to see when their friends are typing a reply and when messages are received, among other features, he said.

Standard texting is still popular. CTIA, the wireless industry trade group, said that in the first half of this year, Americans sent 1.107 trillion text messages. But that was down 2.6 percent from the 1.137 trillion messages sent in the first half of last year. Ovum, a mobile communications research firm, estimates that by 2016, Internet-based message services will have eaten up $54 billion in revenue that carriers could have made from text messaging.

For years, text messages have been a source of pure profit for carriers because it costs nearly nothing to deliver them. In response to the rise of Internet services, they have been overhauling their pricing plans to stay profitable.

Verizon Wireless and AT&T, for example, offer new plans that include unlimited texting and phone calls, while charging bigger fees for using Internet data, which is likely to be their main source of growth. (Internet messaging over a carrier’s data network does use up some of a customer’s monthly data allotment, but it is a tiny amount relative to, say, watching a video.)

John Walls, vice president for public affairs at CTIA, said carriers were always expanding their services by offering things like all-you-can-eat texting plans and the ability to donate to charity via text. He noted that 72,000 text messages were being sent every second of every day.

“I hardly think the end is in sight for texts,” Mr. Walls said.

For Internet companies, messaging will never be a cash cow. But they have other reasons to get excited about this market.

Facebook benefits if more people use its messaging service, because those people are likely to spend more time on its Web site and mobile apps, seeing more ads. On Tuesday the company said it would allow Android users in some countries to sign up for its messaging service with just a phone number, no Facebook account required, partly because this might eventually persuade non-Facebook users to cave in and sign up for an account. That feature will come to the United States at some point, Facebook said.

Apple’s free texting service, iMessage, comes installed on iPhones, iPads and iPod Touch devices, where it automatically routes messages over the Internet if they are being sent to another Apple device. The service also works with the Messages app on Apple’s computers. That could encourage people to continue buying Apple products to keep in touch with family and friends cheaply and easily. Even the design of iMessage makes people feel like they’re in a special clique: an iMessage shows up on an Apple device as a blue bubble, while a normal text message from a non-Apple phone is green.

Perhaps the most talked-about player in texting right now is the small start-up WhatsApp, based in Mountain View, Calif. The 30-person company, founded by Jan Koum and Brian Acton, two former Yahoo executives, says its service is used in more than 100 countries. Its app is one of the most popular in the world on iPhones and Android devices, and on the BlackBerry it is even bigger than Research in Motion’s own messaging service.

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Typhoon Kills Hundreds in Philippines

Erik De Castro/Reuters

Residents transported the body of victim in the southern Philippines on Wednesday.

MANILA — Rescue teams were trying to reach isolated villages in the southern Philippines on Wednesday after a powerful out-of-season typhoon tore through the region, leaving more than 270 people dead, officials said.

NASA

Typhoon Bopha moved toward the Philippines on Monday.

Karlos Manlupig/Associated Press

Relatives mourned in New Bataan on Wednesday.

Karlos Manlupig/Associated Press

Residents assessed the damage to their homes on the southern Philippine island of Mindanao on Tuesday after a typhoon struck.

Typhoon Bopha packed winds of up to 100 miles per hour when it struck Tuesday, bringing torrential rains that flattened entire villages, leaving thousands homeless, as well as washing out roads and bridges needed by rescue personnel trying to reach stricken regions.

A national disaster official, Benito Ramos, said at a news conference Wednesday afternoon that 274 deaths had been confirmed, with 339 people known to be injured and 279 missing.

The storm was weakening and leaving the Philippines on Wednesday. The Philippines is hit by more than 20 powerful tropical storms per year, but this typhoon struck remote communities off the usual storm path that are not accustomed to such strong storms.

In December of last year, Tropical Storm Washi killed more than 1,200 people and left hundreds of thousands homeless. Officials this year called for mandatory early evacuations of vulnerable communities.

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E.U. Financial Ministers Clash Over Banking Supervisor Plan

BRUSSELS — Finance ministers of the European Union locked horns Tuesday over the creation of a single banking supervisor for the euro area, which is supposed to be a key tool for avoiding future financial crises.

Thierry Charlier/Agence France-Presse — Getty Images

Germany's finance minister, Wolfgang Schäuble, voiced concerns about placing so much supervisory power with the European Central Bank.

The union’s leaders agreed in June to create the single regulator under the aegis of the European Central Bank. Shortly afterward, the European Commission proposed phasing in the system starting Jan. 1.

But sharp divisions have emerged among member states over how many of the 6,000 banks in the euro area should be covered by the new system; how to ensure that countries outside the system have a way to rebuff regulations they dislike; and how to ensure that the central bank keeps monetary policy separate from its decisions on bank supervision.

As ministers struggled to reach agreement during their regular monthly meeting here Tuesday, Wolfgang Schäuble, the German finance minister, refused to support one of the key demands of Britain — far-reaching changes to voting procedures on another banking body, the European Banking Authority, to ensure that lenders based in London continue to be governed by the British government.

Mr. Schäuble also underlined his concerns that placing so much supervisory power with the E.C.B. could lead the central bank to compromise its decisions on monetary policy.

“In the long run, you will damage the independence of the central bank,” warned Mr. Schäuble, who added that solutions still needed to be found to address the issue.

As the public deliberations drew to a close, finance ministers planned to reconvene Dec. 12 in order to continue their discussions on the single banking supervisor.

Germany has warned repeatedly that rushing ahead with creation of the single supervisor would risk creating additional regulatory loopholes in Europe. And the German domestic banking sector, in particular local savings banks, or Sparkassen, has recoiled at the prospect of more rigorous supervision by the central bank.

“I think it would be very difficult to get an approval by the German Parliament if you would leave the supervision for all the German banks to European banking supervision,” Mr. Schäuble said. “Nobody believes that any European institution will be capable to supervise 6,000 banks in Europe.”

That is not the view of Spain and France, which have sought to speed up creation of the new regulator and give it a broad mandate, and Spanish and French ministers warned Tuesday that foot-dragging could prompt a return of acute financial pressures in the euro area.

“If we are not able to deliver in the dates we have committed, this will not be neutral in terms of the stability of the markets,” Luis de Guindos, the Spanish economy minister, warned during the meeting. That sentiment was echoed by Pierre Moscovici, the French finance minister, who told the meeting that establishing the system was “essential to solve the euro crisis.”

French officials have stressed the need for a system that covers all euro-area banks rather than placing them mainly under national regulation with only occasional intervention from the central supervisor when required.

They have warned that any sudden intervention by the E.C.B. into the affairs of a bank under national regulation could raise alarm among investors and depositors and even lead to bank runs.

For Spain, stricter supervision was supposed to be the condition for using European funds to bail out its troubled banks directly and a way to avoid accumulating more sovereign debt.

But Germany is the biggest contributor to the bailout funds, and establishing the system could oblige Chancellor Angela Merkel to dip into that pot before national elections in Germany in September. Such aid could be an election issue because German citizens have grown weary of paying most of the bill for bailouts, and they are wary of using more money to help banks in vulnerable Southern European countries.

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