Benefit in Radiation After Breast Cancer Surgery

By DENISE GRADY

From http://www.nytimes.com/

 

Radiation treatment after surgery for breast cancer significantly lowers the risk that the disease will recur in the breast or spread lethally to other parts of the body over the next 10 to 15 years, researchers say.

The new findings mean that radiation prevents recurrences for a longer time and saves more lives than was generally recognized, said Sarah C. Darby, a professor of medical statistics at the University of Oxford and an author of the report.

These reassuring results, which were reported Wednesday in the British journal The Lancet, are based on an analysis of 17 studies involving 10,801 women in Europe, Canada and the United States. All had cancers small enough to be treated with breast-conserving surgery, meaning a lumpectomy or other procedure to excise the cancer without removing the entire breast. Women were picked at random to receive radiation therapy, or not, and followed for a median of 9.5 years. Some were tracked for as long as 20 years.

Over all, radiation reduced the risk of a recurrence during the first 10 years after surgery to 19.3 percent from 35 percent, and reduced the risk of death from breast cancer to 21.4 percent from 25.2 percent in the first 15 years.

“It’s only been relatively recently realized that radiation has such a big effect on mortality,” Dr. Darby said, explaining that this positive outcome was at first not recognized because it takes five years to show up.

“These data reinforce the fact that the recurrence rate is reduced for the whole of the first decade,” she said. “That’s not been so clear. It’s not just for a year or the first few, but substantially reduced for a full decade.”

A researcher who was not part of the study, Dr. Thomas A. Buchholz, head of radiation oncology at the University of Texas M.D. Anderson Cancer Center, said: “The findings are extremely important. The group from Oxford are some of the most important breast cancer investigators. They’ve been able to get data from almost every single randomized controlled trial, both from the United States and Europe. The power is, you can combine the data to get very large sample sizes and answer fundamental questions.”

Earlier research by the Oxford group also found that radiation could prevent recurrence and increase survival, Dr. Buchholz said.

“Now, they’re confirming, with very long-term follow-up, the importance of radiation not just in preventing recurrences but in increasing your chance of being cured,” he said. “This is some of the most important data we have with respect to breast cancer treatment.”

The theory behind giving radiation after surgery for breast cancer is to kill any stray cancer cells that may have been left behind and to prevent them from growing into another tumor or spreading to vital organs.

But studies were needed to find out if the theory held up, especially since radiation has side effects like skin burns and fatigue.

Some researchers questioned whether radiation was needed, reasoning that even if cancer did recur in the breast, additional surgery would get rid of it, and that a recurrence did not necessarily mean the disease would spread. The new findings challenge that reasoning.

“If somebody has a local recurrence, yes, you can treat it, but before that happens, some of that residual cancer will have spread,” Dr. Darby said.

Some researchers thought that if a cancer had the tendency to spread, it would have done so even before the first operation, so radiation would be too late to stop it — another idea dispelled by the new findings.

Dr. Darby’s analysis found that after 15 years, for every four recurrences prevented, one death was prevented.

Most of the women in the studies — 7,287 — had no cancer in their lymph nodes, which is generally a favorable sign. In 1,050 others, there were positive nodes, and in 2,464 there was no information on the nodes. Some women took tamoxifen, a hormone-blocking drug given to women whose tumors may be fed by estrogen. And many of the women with cancerous lymph nodes also got chemotherapy. Regardless of what other treatments they received, all the women still benefited from radiation.
In women with clear lymph nodes, radiation cut the 10-year recurrence risk in half, to 15.6 percent from 31 percent, and cut the 15-year risk of death to 17.2 percent from 20.5 percent. In women with diseased lymph nodes, radiation cut the recurrence rate to 42.5 percent from 63.7 percent, and cut the death risk to 42.8 percent from 51.3 percent.

Earlier studies had found that radiation for breast cancer could harm the heart and increase a woman’s risk of dying from heart disease. But techniques have improved in recent years to avoid exposing the heart and lungs to radiation, and Dr. Darby’s study found no significant differences between women who did or did not receive radiation when it came to death rates from diseases other than breast cancer.

A version of this article appeared in print on October 20, 2011, on page A23 of the New York edition with the headline: Radiation Therapy After Breast Cancer Surgery Cuts Recurrence, Study Says.

The Dutch Way: Bicycles and Fresh Bread

Robin Utrecht/Agence France-Presse — Getty Images

In the Netherlands, respect for bicycles is hard-wired into the culture.

By RUSSELL SHORTO

From http://www.nytimes.com/

Russell Shorto is the author of “The Island at the Center of the World” and a contributing writer at The New York Times Magazine. He is working on a book about Amsterdam.

Amsterdam

AS an American who has been living here for several years, I am struck, every time I go home, by the way American cities remain manacled to the car. While Europe is dealing with congestion and greenhouse gas buildup by turning urban centers into pedestrian zones and finding innovative ways to combine driving with public transportation, many American cities are carving out more parking spaces. It’s all the more bewildering because America’s collapsing infrastructure would seem to cry out for new solutions.

Geography partly explains the difference: America is spread out, while European cities predate the car. But Boston and Philadelphia have old centers too, while the peripheral sprawl in London and Barcelona mirrors that of American cities.

More important, I think, is mind-set. Take bicycles. The advent of bike lanes in some American cities may seem like a big step, but merely marking a strip of the road for recreational cycling spectacularly misses the point. In Amsterdam, nearly everyone cycles, and cars, bikes and trams coexist in a complex flow, with dedicated bicycle lanes, traffic lights and parking garages. But this is thanks to a different way of thinking about transportation.

To give a small but telling example, pointed out to me by my friend Ruth Oldenziel, an expert on the history of technology at Eindhoven University, Dutch drivers are taught that when you are about to get out of the car, you reach for the door handle with your right hand — bringing your arm across your body to the door. This forces a driver to swivel shoulders and head, so that before opening the door you can see if there is a bike coming from behind. Likewise, every Dutch child has to pass a bicycle safety exam at school. The coexistence of different modes of travel is hard-wired into the culture.

This in turn relates to lots of other things — such as bread. How? Cyclists can’t carry six bags of groceries; bulk buying is almost nonexistent. Instead of shopping for a week, people stop at the market daily. So the need for processed loaves that will last for days is gone. A result: good bread.

There are also in the United States certain perceptions associated with both cycling and public transportation that are not the case here. In Holland, public buses aren’t considered last-resort forms of transportation. And cycling isn’t seen as eco-friendly exercise; it’s a way to get around. C.E.O.’s cycle to work, and kids cycle to school.

It’s true that public policy reinforces the egalitarianism. With mandatory lessons and other fees, getting a driver’s license costs more than $1,000. And taxi fares are kept deliberately high: a trip from the airport may cost $80, while a 20-minute bus ride sets you back about $3.50. But the egalitarianism — or maybe better said a preference for simplicity — is also rooted in the culture. A 17th-century French naval commander was shocked to see a Dutch captain sweeping out his own quarters. Likewise, I used to run into the mayor of Amsterdam at the supermarket, and he wasn’t engaged in a populist stunt (mayors aren’t elected here but are government appointees); he was shopping.

For American cities to think outside the car would seem to require a mental sea change. Then again, Americans, too, are practical, no-nonsense people. And Zef Hemel, the chief planner for the city of Amsterdam, reminded me that sea changes do happen. “Back in the 1960s, we were doing the same thing as America, making cities car-friendly,” he said. Funnily enough, it was an American, Jane Jacobs, who changed the minds of European urban designers. Her book “The Death and Life of Great American Cities” got European planners to shift their focus from car-friendliness to overall livability.

When I noted that Manhattan’s bike lanes seem to be used more for recreation than transport — cyclists in Amsterdam are dressed in everything from jeans to cocktail dresses, while those in Manhattan often look like spandex cyborgs — Mr. Hemel told me to give it time. “Those are the pioneers," he said. “You have to start somewhere.”

What he meant was, “You start with bike lanes” — that is, with the conviction that urban planning can bring about beneficial cultural changes. But that points up another mental difference: the willingness of Europeans to follow top-down social planning. America’s famed individualism breeds an often healthy distrust of the elite. I’m as quick as any other red-blooded American to bristle at European technocrats telling me how to live. (Try buying a light bulb or a magazine after 6 p.m. in Amsterdam, where the political elite have decreed that workers’ well-being requires that shops be open only during standard office hours, precisely when most people can’t shop.)

But while many Americans see their cars as an extension of their individual freedom, to some of us owning a car is a burden, and in a city a double burden. I find the recrafting of the city in order to lessen — or eliminate — the need for cars to be not just grudgingly acceptable, but, yes, an expansion of my individual freedom. So I say (in this case, at least): Go, social-planning technocrats! If only America’s cities could be so free.

A version of this op-ed appeared in print on July 31, 2011, on page SR5 of the New York edition with the headline: The Dutch Way: Bicycles and Fresh Bread.

NY Times: Inside the Chinese Knockoff-Tennis-Shoe Factory

Andrew Bettles for The New York Times (Shoes provided by Immigration and Customs Enforcement)

By NICHOLAS SCHMIDLE

In southern China, making fake shoes has become a very big business. Chinese authorities are slow to enforce the law, and it's becoming harder and harder to tell which shoes are genuine.
Click here for http://www.nytimes.com/

Struggling States Look to Unorthodox Taxes

By JESSE McKINLEY

Published: February 28, 2009

In his 11 years in the Washington Legislature, Representative Mark Miloscia says he has supported all manner of methods to fill the state’s coffers, including increasing fees on property owners to help the homeless and taxes on alcohol and cigarettes, most of which, he said, passed “without a peep.”

And so it was last month that Mr. Miloscia, a Democrat, decided he might try to “find a new tax source” — pornography.

The response, however, was a turn-off.

“People came down on me like a ton of bricks,” said Mr. Miloscia, who proposed an 18.5 percent sales tax on items like sex toys and adult magazines. “I didn’t quite understand. Apparently porn is right up there with Mom and apple pie.”

Mr. Miloscia’s proposal died at the committee level, but he is far from the only legislator floating unorthodox ideas as more than two-thirds of the states face budget shortfalls.

“The most common phrase you hear from the states is, ‘Everything is on the table,’ ” said Arturo Perez, a fiscal analyst with National Conference of State Legislatures, who predicted the worst financial year for states since the end of World War II.

Nowhere is that more true than California, where Assemblyman Tom Ammiano, a freshman from San Francisco, made a proposal intended to increase revenue, and, no doubt, appetite: legalizing and taxing marijuana, a major — if technically illegal — crop in the state. “We’re all jonesing now for money,” Mr. Ammiano said. “And there’s this enormous industry out there.”

In Nevada, State Senator Bob Coffin said he would introduce legislation to tax the state’s legal brothels, a fee that would be “based on the amount of activities.” And unlike the Washington porn proposal, which drew the ire of the adult entertainment industry, Mr. Coffin’s plan has the backing of the potential taxpayers, in this case brothel owners who employ women as independent contractors.

“I think they figure if they become part of the tax stream, the less vulnerable they will be to some shift in mores,” he said.

Hawaiian legislators were also considering capitalizing on another potential shift in public attitudes when they proposed legalizing same-sex unions, which supporters say could help the slumping tourism trade.

In Massachusetts, meanwhile, state legislators have introduced a proposal to build two resort-style casinos, including one in Boston. A similar push died last year in the State House of Representatives. But Representative Martin J. Walsh, a Dorchester Democrat and co-author of the new casino bill, said a $2 billion budget deficit might have changed some minds.

“Every state in the nation, including Massachusetts, needs to figure out a way of raising revenues,” Mr. Walsh said. “So we need to be creative.”

Scott Pattison, executive director of the National Association of State Budget Officers, said many lawmakers were loath to tap more traditional tax sources during a downturn. “What’s pushing it is this incredible desire to raise revenue,” Mr. Pattison said. “But it’s coupled with the desire not to raise the general and sales and income taxes.”

Whether such proposals can pass is another issue, though each idea has its supporters. Betty Yee, chairwoman of the California Board of Equalization, the state’s tax collector, said that legal marijuana could raise nearly $1 billion per year via a $50-per-ounce fee charged to retailers. An additional $400 million could be raised through sales tax on marijuana sold to buyers.

The law would also establish a smoking age — 21 — effectively putting marijuana in a similar regulatory class as alcohol or tobacco. Marijuana advocates argue that legalization could also decrease pressure on the state’s overburdened prison system and law enforcement officers.

All of which, Ms. Yee said, at least makes the proposal worth talking about in a state with chronic budget problems and a law already on the books allowing the medical use of the drug.

“We know the product is out there, and we know marijuana is available to young people as well, but there’s no regulatory structure in place,” Ms. Yee said. “I think it’s an opportunity to begin the debate.”

Such a debate, of course, does not always favor tax innovators. Several law enforcement groups have already objected to the idea of legal marijuana, which would conflict with federal law.

John Lovell, a lobbyist for several groups of California law enforcement officials, said the plan would create a large, illicit — and thus untaxed — black market, in addition to magnifying substance abuse problems. “The last thing we need is yet another legal substance that is mind-altering,” Mr. Lovell said.

Having taxes on illegal activities, like a seldom-collected tax on marijuana sales in Nevada, also has its drawbacks, said Robert MacCoun, a professor of law and public policy at the University of California, Berkeley, who has researched drug policy.

“It is very hard to tax illegal vices unless one is comfortable with contradiction,” Mr. MacCoun said. “How can you collect the taxes without documenting the behavior? And how can you document the behavior without making an arrest?”

In Washington State, Mr. Miloscia said he had also received criticism from an array of residents and business owners, who accused him of attacking the First Amendment and other sacred institutions with his pornography proposal.

“I had people call up saying their marriages would fall apart,” said Mr. Miloscia, who represents a suburban district between Tacoma and Seattle. “I didn’t know how passionate people are about this stuff.”

Brazilian "Land of Twins" May Be Caused By Nazi Eugenics

By ALEXEI BARRIONUEVO

CÂNDIDO GODÓI, Brazil — High atop a hill behind his family’s home, Derli Grimm knelt and took a sip from a thin black tube leading from a natural spring.

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André Vieira for The New York Times

Darlene and Darles Volkweis. Most of the twins are fraternal.

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André Vieira for The New York Times

Tatiane, left, and Fabiane Grimm, of the São Pedro area.

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André Vieira for The New York Times

Tânia Moelmann holding Kiara, left, and Yasmin.

The New York Times

Cândido Godói is a farm town.

Like so many in this farming town, populated almost entirely by German-speaking immigrants, Mr. Grimm, 19, believes that something in the water — a mysterious mineral, perhaps — is responsible for the town’s unusual concentration of twins.

“It can’t all be explained by genetics,” said Mr. Grimm, himself a twin.

Geneticists would like to disagree with him, but even they have no solid explanation for the 38 pairs of twins among about 80 families living in a one-and-a-half-square-mile area.

The mystery has persisted for decades, attracting international attention and inspiring books and investigations by geneticists. It is one reason locals are in no hurry to try to prove their water theory. They are too busy posing for journalists and marketing their town to tourists as the “twins capital of the world.”

Some researchers have suggested the darker possibility that Josef Mengele, the Nazi physician known as the Angel of Death, was involved. Mengele, residents say, roamed this region of southern Brazil, posing as a veterinarian, in the 1960s, about the time the twins explosion began. In a book published last year, an Argentine journalist, Jorge Camarasa, suggested that Mengele conducted experiments with women here that resulted in the higher rate of twins, many of them with blond hair and light-colored eyes. The experiments, locals said, may have involved new types of drugs and preparations, or even the artificial insemination Mengele claimed to know about, regarding cows and humans.

But neither Mr. Camarasa nor any other adherent of the Mengele theory has been able to prove the escaped Nazi conducted any experiments here. Mengele, who died in Brazil in 1979, was notorious for his often deadly experiments on twins at Auschwitz, ostensibly in an effort to produce a master Aryan race for Hitler.

“People who are speculating about Mengele are doing so to sell books,” said Paulo Sauthier, a historian who runs a museum here. “He studied the twins phenomenon in Germany, not here.”

A sign at the entrance to Cândido Godói says, “Garden City and Land of Twins.” More than 80 percent of its 6,700 residents are of German descent. They began arriving around World War I, lured by the prospect of cheap land, an agreeable farming climate and incentives from the Brazilian government to colonize the area.

The twins phenomenon is centered in the 300-person settlement of São Pedro, the part of Cândido Godói where the Grimms live. Mr. Sauthier, a twin, was born here in 1964. His mother, a Grimm, comes from one of the eight original families to settle São Pedro in 1918.

Even today they live a relatively isolated existence. Oxen still drag farm machinery. Residents speak a German dialect to one another.

It was in the early 1990s that the high proportion of twins was widely noticed. Soon, camera crews were rolling in from all over. Town leaders declared São Pedro to have the highest concentration of twins in the world. (A spokesman for Guinness World Records could not confirm that claim, saying Guinness did not keep track of the category.)

Today, residents relish the attention. Last year, at São Pedro’s sixth biennial twins party, they erected a statue of a woman holding a boy in one arm and his twin sister in the other, and installed a moat-like “fertility spring” that lights up at night.

Like many twins here, Fabiane and Tatiane Grimm, 22, have been posing for twins-seekers since they were babies. When a journalist and a photographer showed up unannounced, their mother ushered them from a barn into the house to shower before posing for pictures.

“It’s not too much of a mystery to me,” said Fabiane, whose family has five pairs of twins. “My brother married his third cousin. There are lots of cases like that, people marrying their cousins or other close family members.”

But to some, the mystery remains. A decade ago, Anencir Flores da Silva, a town doctor and former mayor of Cândido Godói, set out to solve it, and he has since interviewed more than 100 people. He said he believed that people were holding back information about Mengele.

“In a region full of Nazis, there are some that remain silent, who are scared,” Dr. da Silva said. “It is important that we discover the truth.”

A book he helped write about the twins, published in 2007, tells of several visits Mengele made to the region, using false names.

“I am convinced that Mengele was in the region and was observing the twins phenomenon,” Dr. da Silva said. He said a man identifying himself as Rudolf Weiss attended women with varicose veins and sometimes performed dental work. And some residents told him a German man was driving from home to home in a mobile laboratory, collecting samples and ministering to women.

Mr. Sauthier, the historian, said that the assertions lacked proof and that the German community did not deserve to be associated with “a criminal like Mengele.”

“There are no Nazi sympathizers in this region,” he said, although he acknowledged a historical interest in Nazi artifacts, including a 1937 metal milk can with a swastika in his museum and a 1936 photo of schoolchildren in Cândido Godói holding swastika flags that was included in Dr. da Silva’s book.

Geneticists say the most likely explanation for the twins is genetic isolation and inbreeding. Ursula Matte, a geneticist in Porto Alegre, found that from 1990 to 1994, 10 percent of the births in São Pedro were twins, compared with 1.8 percent for the state of Rio Grande do Sul.

There was no evidence of the use of contraceptives or fertility drugs among the women, nor of any genetic mixing with people of African origin, who have higher twinning rates than caucasians, Dr. Matte said. But the rate of identical twins here, at 47 percent of all twin births, is far higher than the 30 percent that is expected in the general population, she found.

While identical twins are generally thought to occur randomly in the population, independent of genetic factors, the remarkable discrepancy in the frequency of identical twins has led Dr. Matte to conclude that Sao Pedro is an "isolated phenomenon" where unknown genetic factors must be at work.

So the speculation continues.

Mr. Sauthier said he believed private water sources like the one Derli Grimm enjoys contain a mineral that affects ovulation. “To this day, no one has tested that water,” he said, noting that in the past decade the town switched to underground well water, a possible explanation for a recent decline in twin births.

Testing the spring sources would be expensive and, Dr. Matte said, would require some hypothesis about what the research was looking for. She doubts the town will ever push seriously to do a study. “They like to maintain the mystery,” she said.

This article has been revised to reflect the following correction:

Correction: February 25, 2009
The Cândido Godói Journal article on Monday, about the unexplained proliferation of twins born in the farming town of Cândido Godói in southern Brazil, misstated the type of twins usually associated with a genetic tendency of the mother. They are fraternal twins — like a majority of those born in the town. They are not identical twins, which are generally believed to be conceived by chance.