The Lede Blog: Clinton Testifies on Benghazi Attacks

The Lede followed Secretary of State Hillary Rodham Clinton’s testimony Wednesday before the House Foreign Affairs Committee and Senate Foreign Relations Committee about the Sept. 11, 2012, attacks on the American Consulate in the eastern city of Benghazi, Libya, that killed Ambassador Chris Stevens and three other Americans.

At a House Committee hearing last October investigating the attack, as reported on The Lede, State Department officials and security experts who served on the ground offered conflicting assessments about what resources were requested and made available to deal with growing security concerns in Tripoli and Benghazi.

Mrs. Clinton had been scheduled to testify before Congress last month, but an illness, a concussion and a blood clot near her brain forced her to postpone her appearance.

As our colleagues Michael R. Gordon and Eric Schmitt reported, four State Department officials were removed from their posts on last month after an independent panel criticized the “grossly inadequate” security at a diplomatic compound in Benghazi.

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Gadgetwise Blog: A New Kind of Holster for iPhone

Unless you carry a Bushmaster Adaptive Combat Rifle around, the Sector 5 Black Ops iPhone cover from Element Case is likely to be the most polarizing accessory you own.

The case is made from a resin called G10 and designed by a company best known for its premium handgun grips, VZ Grips.

The back of the case bears a checkering pattern common to handguns, and it has a rim of machined aluminum that is anodized with a nonreflective coating.

They even throw in a back knurled power button and “tactical holster” for affixing your phone to your belt.

Like many Element Case products, the cost is high: $200. Element Case has made a business of creating expensive covers from premium and exotic materials, like its $200 Ronin case made with a bumper of resin-impregnated wood.

The weaponized iPhone case certainly courts controversy, but thanks to the remarkably grippy pattern on the Black Ops model, you may not give it up until they pry it from you cold, dead hands.

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Well: Long Term Effects on Life Expectancy From Smoking

It is often said that smoking takes years off your life, and now a new study shows just how many: Longtime smokers can expect to lose about 10 years of life expectancy.

But amid those grim findings was some good news for former smokers. Those who quit before they turn 35 can gain most if not all of that decade back, and even those who wait until middle age to kick the habit can add about five years back to their life expectancies.

“There’s the old saw that everyone knows smoking is bad for you,” said Dr. Tim McAfee of the Centers for Disease Control and Prevention. “But this paints a much more dramatic picture of the horror of smoking. These are real people that are getting 10 years of life expectancy hacked off — and that’s just on average.”

The findings were part of research, published on Wednesday in The New England Journal of Medicine, that looked at government data on more than 200,000 Americans who were followed starting in 1997. Similar studies that were done in the 1980s and the decades prior had allowed scientists to predict the impact of smoking on mortality. But since then many population trends have changed, and it was unclear whether smokers today fared differently from smokers decades ago.

Since the 1960s, the prevalence of smoking over all has declined, falling from about 40 percent to 20 percent. Today more than half of people that ever smoked have quit, allowing researchers to compare the effects of stopping at various ages.

Modern cigarettes contain less tar and medical advances have cut the rates of death from vascular disease drastically. But have smokers benefited from these advances?

Women in the 1960s, ’70s and ’80s had lower rates of mortality from smoking than men. But it was largely unknown whether this was a biological difference or merely a matter of different habits: earlier generations of women smoked fewer cigarettes and tended to take up smoking at a later age than men.

Now that smoking habits among women today are similar to those of men, would mortality rates be the same as well?

“There was a big gap in our knowledge,” said Dr. McAfee, an author of the study and the director of the C.D.C.’s Office on Smoking and Public Health.

The new research showed that in fact women are no more protected from the consequences of smoking than men. The female smokers in the study represented the first generation of American women that generally began smoking early in life and continued the habit for decades, and the impact on life span was clear. The risk of death from smoking for these women was 50 percent higher than the risk reported for women in similar studies carried out in the 1980s.

“This sort of puts the nail in the coffin around the idea that women might somehow be different or that they suffer fewer effects of smoking,” Dr. McAfee said.

It also showed that differences between smokers and the population in general are becoming more and more stark. Over the last 20 years, advances in medicine and public health have improved life expectancy for the general public, but smokers have not benefited in the same way.

“If anything, this is accentuating the difference between being a smoker and a nonsmoker,” Dr. McAfee said.

The researchers had information about the participants’ smoking histories and other details about their health and backgrounds, including diet, alcohol consumption, education levels and weight and body fat. Using records from the National Death Index, they calculated their mortality rates over time.

People who had smoked fewer than 100 cigarettes in their lifetimes were not classified as smokers. Those who had smoked at least 100 cigarettes but had not had one within five years of the time the data was collected were classified as former smokers.

Not surprisingly, the study showed that the earlier a person quit smoking, the greater the impact. People who quit between 25 and 34 years of age gained about 10 years of life compared to those who continued to smoke. But there were benefits at many ages. People who quit between 35 and 44 gained about nine years, and those who stopped between 45 and 59 gained about four to six years of life expectancy.

From a public health perspective, those numbers are striking, particularly when juxtaposed with preventive measures like blood pressure screenings, colorectal screenings and mammography, the effects of which on life expectancy are more often viewed in terms of days or months, Dr. McAfee said.

“These things are very important, but the size of the benefit pales in comparison to what you can get from stopping smoking,” he said. “The notion that you could add 10 years to your life by something as straightforward as quitting smoking is just mind boggling.”

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Well: Long Term Effects on Life Expectancy From Smoking

It is often said that smoking takes years off your life, and now a new study shows just how many: Longtime smokers can expect to lose about 10 years of life expectancy.

But amid those grim findings was some good news for former smokers. Those who quit before they turn 35 can gain most if not all of that decade back, and even those who wait until middle age to kick the habit can add about five years back to their life expectancies.

“There’s the old saw that everyone knows smoking is bad for you,” said Dr. Tim McAfee of the Centers for Disease Control and Prevention. “But this paints a much more dramatic picture of the horror of smoking. These are real people that are getting 10 years of life expectancy hacked off — and that’s just on average.”

The findings were part of research, published on Wednesday in The New England Journal of Medicine, that looked at government data on more than 200,000 Americans who were followed starting in 1997. Similar studies that were done in the 1980s and the decades prior had allowed scientists to predict the impact of smoking on mortality. But since then many population trends have changed, and it was unclear whether smokers today fared differently from smokers decades ago.

Since the 1960s, the prevalence of smoking over all has declined, falling from about 40 percent to 20 percent. Today more than half of people that ever smoked have quit, allowing researchers to compare the effects of stopping at various ages.

Modern cigarettes contain less tar and medical advances have cut the rates of death from vascular disease drastically. But have smokers benefited from these advances?

Women in the 1960s, ’70s and ’80s had lower rates of mortality from smoking than men. But it was largely unknown whether this was a biological difference or merely a matter of different habits: earlier generations of women smoked fewer cigarettes and tended to take up smoking at a later age than men.

Now that smoking habits among women today are similar to those of men, would mortality rates be the same as well?

“There was a big gap in our knowledge,” said Dr. McAfee, an author of the study and the director of the C.D.C.’s Office on Smoking and Public Health.

The new research showed that in fact women are no more protected from the consequences of smoking than men. The female smokers in the study represented the first generation of American women that generally began smoking early in life and continued the habit for decades, and the impact on life span was clear. The risk of death from smoking for these women was 50 percent higher than the risk reported for women in similar studies carried out in the 1980s.

“This sort of puts the nail in the coffin around the idea that women might somehow be different or that they suffer fewer effects of smoking,” Dr. McAfee said.

It also showed that differences between smokers and the population in general are becoming more and more stark. Over the last 20 years, advances in medicine and public health have improved life expectancy for the general public, but smokers have not benefited in the same way.

“If anything, this is accentuating the difference between being a smoker and a nonsmoker,” Dr. McAfee said.

The researchers had information about the participants’ smoking histories and other details about their health and backgrounds, including diet, alcohol consumption, education levels and weight and body fat. Using records from the National Death Index, they calculated their mortality rates over time.

People who had smoked fewer than 100 cigarettes in their lifetimes were not classified as smokers. Those who had smoked at least 100 cigarettes but had not had one within five years of the time the data was collected were classified as former smokers.

Not surprisingly, the study showed that the earlier a person quit smoking, the greater the impact. People who quit between 25 and 34 years of age gained about 10 years of life compared to those who continued to smoke. But there were benefits at many ages. People who quit between 35 and 44 gained about nine years, and those who stopped between 45 and 59 gained about four to six years of life expectancy.

From a public health perspective, those numbers are striking, particularly when juxtaposed with preventive measures like blood pressure screenings, colorectal screenings and mammography, the effects of which on life expectancy are more often viewed in terms of days or months, Dr. McAfee said.

“These things are very important, but the size of the benefit pales in comparison to what you can get from stopping smoking,” he said. “The notion that you could add 10 years to your life by something as straightforward as quitting smoking is just mind boggling.”

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Media Decoder Blog: Adding Subscribers, Netflix Posts Surprise Profit

Netflix on Wednesday announced a surprise profit in the fourth quarter of 2012 and a new total of 27 million streaming subscribers in the United States, a jump of more than two million from the third quarter.

The company also added nearly two million new subscribers in other countries, though it continued to lose money overseas, as expected. Overall, however, the company reported $8 million in net income and $945 million in revenue. Analysts had expected a slight loss, not a profit, due to the rising costs of acquiring must-see streaming content.

Netflix’s fourth-quarter earnings exceeded not just Wall Street’s expectations but also its own, as the chief executive, Reed Hastings, and chief financial officer, David Wells, noted in a letter to investors. Revenues, they said, were driven in part by holiday season sales of new tablets and television sets.

Investors cheered the news, and at one point sent Netflix shares soaring more than 30 percent in after-hours trading.

The growth spurt in the fourth quarter attested to the popularity of on-demand libraries of television shows and movies. Streaming services by Amazon, Hulu, and Redbox are competing on the same playing field as Netflix, but for now Netflix is the biggest such service by far.

“The fact that our growth remains this strong despite intensifying competition, and our already substantial U.S. market penetration, underlines the large opportunity ahead,” Mr. Hastings and Mr. Wells wrote.

Netflix ended 2012 with 27.1 million streaming subscribers in the United States and 6.1 million elsewhere. On Wednesday it predicted that it would end the first quarter of 2013 with somewhere between 28.5 and 29.2 million in the United States and somewhere between 6.6 and 7.3 million elsewhere.

Net income will be about in line with the fourth quarter, Netflix said, since the revenue from new subscribers will be offset by licensing expenses and continuing declines in its DVD-by-mail business.

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France and Germany Celebrate 50th Anniversary of Élysée Treaty





BERLIN — France and Germany recently issued a joint postage stamp as part of a yearlong celebration of the 50th anniversary of the Élysée Treaty, the landmark agreement between the two former enemies.




The stamp is identical, except for one telling difference. In each country, it bears a picture of a man and woman, side by side, peering through lenses colored in blue-white-red and black-red-gold. But the French stamp costs 80 euro cents, while its German twin sells for only 75.


In a year loaded with symbolic gestures and 4,000 events, including Tuesday’s joint session of Parliament, joint cabinet dinner and a concert, that 5-cent disparity is a reminder that despite the decades of friendship and enormous day-to-day cooperation, significant, often devilish, differences persist.


De Gaulle once described Europe as “a coach with horses, with Germany the horse and France the coachman.” Since he signed the treaty with Konrad Adenauer in 1963, successive governments in both countries have struggled to overcome, or overlook, what divides them.


But the relationship has never been as close as some hoped. While the German news media celebrated Tuesday’s anniversary of a treaty that has been a cornerstone for the European Union and German prosperity, the tone from France was harsher. Le Figaro called it “a friendship broken down,” foundering on “diplomatic and economic tensions,” while Le Monde called the event “a festival of hypocrisy.”


The critical matter, however, is that war between the two peoples, who murdered each other for centuries, seems as inconceivable now as the Spanish Inquisition.


“Coming from a long history of conflict and war, they have succeeded in intertwining themselves so closely that today one can no longer imagine it any other way than both partners working closely together,” said Georg Link, the German foreign minister’s commissioner for Franco-German cooperation.


Chancellor Angela Merkel, a conservative, and President François Hollande, a Socialist, began the festivities on Monday here, with a question-and-answer session with university students from both countries. Sitting side by side, they appeared at ease for the first time since Mr. Hollande came to power last May, exchanging jokes and using first names — a public first, and a telling shift.


Yet, even if the two succeed in establishing a better relationship, the tensions between centralized, statist France and federal Germany are real and will persist. They involve European issues like the euro zone crisis and the failed merger of the aerospace giants EADS and BAE Systems, as well as foreign policy matters, like the obvious disagreements over military engagements in Libya and now Mali.


French officials say the two leaders get on decently, agree on fundamental questions and maintain a daily web of contacts and relationships at all levels. They argue that former President Nicolas Sarkozy of France, a conservative, deferred too much to Ms. Merkel to the detriment of the euro and economic growth, and that Mr. Hollande and Ms. Merkel have gotten more done through compromise.


Honest about their differences, Mr. Hollande cited as examples of the new relationship a “pact for growth” to go alongside a fiscal discipline treaty, championed by Ms. Merkel, and the ability to come to agreement on the single banking supervisory system for the euro zone. Ms. Merkel said they planned to meet in May to work out a joint position on economic cooperation, growth and competitiveness ahead of the next European Union summit in June.


The French have sought to “rebalance” the power structures within the European Union by working closely with the Spanish and Italian leaders, and softened the quasi-religious quality of the German prescription of budget discipline and debt reduction.


But it remains true in European Union affairs that Ms. Merkel’s words carry more weight than those of any other leader — and not just because of Germany’s demographic and economic power. There is an understanding that nothing works in the bloc without German agreement, and that France, weaker economically and more saddled with debt, plays a more junior role.


A survey of 25,000 people on either side of the border released ahead of Tuesday’s festivities showed that while 80 percent of Germans and 70 percent of French hold the other in high regard, stereotypes persist.


The French still see themselves as Europe’s center of policy creativity, but view Germany as the overly cautious, and increasingly begrudging, paymaster. The Germans, however, consider their caution one of their greatest assets, and grumble at French reluctance to reform their social-welfare system and reduce their dependence on nuclear energy.


With an active military and a seat on the Security Council, the French also see themselves as playing a far more important diplomatic role globally, while Germany seems to have regressed in its willingness to use force.


As France has moved to engage militarily in Mali, for instance, responding quickly to a cry for help from an ally, French officials note that while Britain was quick to offer air transport help, Berlin initially pledged only political support. The Germans have since offered two cargo planes.


On Tuesday the chancellor gave no indication of German eagerness to join the fight, thanking French troops for their efforts “for all of us.”


One enduring bond between Paris and Berlin is a belief in the importance of the European Union as an anchor for peace and prosperity. The leaders have acknowledged that the strength of their bond has often proved troubling for their European partners, as seen in British efforts to renegotiate its terms for membership.


“Europeans have a special view of German-French relations,” Mr. Hollande told a group of students, with a smile. “When we get along, they are afraid it will be to their detriment. And when we do not get along, they realize then that it is to their detriment.”


The chancellor, seated beside him, nodded vigorously.


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Google Profit Exceeds Expectations





Although Google is scrambling to meet consumers as they flock to mobile devices, the question is whether it is moving fast enough.




When Google announced its fourth-quarter earnings on Tuesday, investors were watching closely for positive signals of Google’s progress in the evolution to a mobile world.


There was some evidence that Google was making progress on a crucial challenge: a decrease in the price that advertisers pay Google each time someone clicks on an ad, known as cost per click. The trend has been driven by the increasing use of Google on mobile devices — where advertisers largely pay less for ads — at the expense of the desktop computer.


On Tuesday, Google said the price per click rose 2 percent from the previous quarter, though it was still 6 percent lower than in the year-ago quarter, making it the fifth consecutive quarter of year-over-year decline.


The earnings report was greeted warmly by investors in after-hours trading, though analysts emphasized that the results were mixed. The company exceeded their expectations on profit, but disappointed on revenue. That was at least in part because analysts are still figuring out how to account for Motorola Mobility, the struggling cellphone maker that Google acquired last year.


Larry Page, Google’s chief executive and co-founder, was optimistic in a statement.


“In today’s multi-screen world we face tremendous opportunities as a technology company focused on user benefit,” he said. “It’s an incredibly exciting time to be at Google.”


The company reported fourth-quarter revenue of $14.42 billion, an increase of 36 percent over the year-ago quarter. Net revenue, which excludes payments to the company’s advertising partners, was $11.34 billion, up from $8.13 billion.


Net income rose 13 percent to $10.65 a share.


The fourth quarter is generally Google’s brightest because it makes much of its money on retail ads that run during the holiday shopping season. Analysts had expected revenue of $10.47 a share, on revenue of $12.3 billion. Google warned last week that analysts’ expectations were off target because Google sold Motorola’s set-top box division during the quarter so it did not include it in the quarterly results. Still, even including that division of Motorola, Google’s revenue would have missed expectations.


Shares of Google, which fell slightly during the day, were up 4 percent in after-hours trading. “This is supposed to be Google’s quarter to shine, the December quarter, and we’re going to have it all mucked up by Motorola,” said Colin Gillis, an analyst at BGC Partners.


This holiday season was the first that Google charged e-commerce companies to be included in its comparison shopping engine, and these so-called product listing ads contributed to its bottom line.


“Q4 retail is absolutely crucial for Google’s earnings,” said Sid Shah, director of business analytics at Adobe, which handles $2 billion in annual advertising spending. “Despite talk about retail having a weak season, Google’s product listing ad program has taken off quite successfully.”


Nonetheless, Google’s mobile challenge overhung even its usual holiday shopping sparkle. Consumers are increasingly shopping on phones and tablets, yet Google and other companies have not yet figured out how best to profit from mobile users.


“You would expect Google to be a key player benefiting from mobile, but that hasn’t played out in the last year,” said Jordan Rohan, an analyst at Stifel Nicolaus.


One problem is that advertisers pay about half as much for an ad on a mobile device, in part because they are not yet sure how effective mobile ads can be.


Another challenge for Google is that consumers increasingly use apps, like Yelp or Kayak, to search on mobile devices instead of using Google. Even when consumers use Google for mobile searches, they are often doing so on Apple devices like iPhones, for which Google has to pay Apple a fee.


This shift is happening as Google’s biggest, most lucrative business — desktop search — is slowing. The share of clicks on Google results that happen on desktop computers has fallen to 73 percent from 77 percent in the last six months, while the share of clicks on tablets and smartphones has increased to 27 percent from 23 percent, according to data from Adobe.


Meanwhile, Google has a new competitor in search: Facebook, which last week introduced a new form of personalized social search on the site.


Google has also recently become a maker of mobile devices, both by acquiring Motorola and by producing the line of Nexus devices with manufacturer partners. In the fourth quarter, Google sold about 1.5 million Nexus phones and tablets, not including those sold by other retailers, according to estimates from JPMorgan.


In the fourth quarter, a weight was lifted from Google when the Federal Trade Commission closed its antitrust investigation of Google’s search practices. But it remains under investigation in Europe, where the outcome is expected to be harsher.


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The Well Column: Facing Cancer, a Stark Choice

In the 1970s, women’s health advocates were highly suspicious of mastectomies. They argued that surgeons — in those days, pretty much an all-male club — were far too quick to remove a breast after a diagnosis of cancer, with disfiguring results.

But today, the pendulum has swung the other way. A new generation of women want doctors to take a more aggressive approach, and more and more are asking that even healthy breasts be removed to ward off cancer before it can strike.

Researchers estimate that as many as 15 percent of women with breast cancer — 30,000 a year — opt to have both breasts removed, up from less than 3 percent in the late 1990s. Notably, it appears that the vast majority of these women have never received genetic testing or counseling and are basing the decision on exaggerated fears about their risk of recurrence.

In addition, doctors say an increasing number of women who have never had a cancer diagnosis are demanding mastectomies based on genetic risk. (Cancer databases don’t track these women, so their numbers are unknown.)

“We are confronting almost an epidemic of prophylactic mastectomy,” said Dr. Isabelle Bedrosian, a surgical oncologist at M. D. Anderson Cancer Center in Houston. “I think the medical community has taken notice. We don’t have data that say oncologically this is a necessity, so why are women making this choice?”

One reason may be the never-ending awareness campaigns that have left many women in perpetual fear of the disease. Improvements in breast reconstruction may also be driving the trend, along with celebrities who go public with their decision to undergo preventive mastectomy.

This month Allyn Rose, a 24-year-old Miss America contestant from Washington, D.C., made headlines when she announced plans to have both her healthy breasts removed after the pageant; both her mother and her grandmother died from breast cancer. The television personality Giuliana Rancic, 37, and the actress Christina Applegate, 41, also talked publicly about having double mastectomies after diagnoses of early-stage breast cancer.

“You’re not going to find other organs that people cut out of their bodies because they’re worried about disease,” said the medical historian Dr. Barron H. Lerner, author of “The Breast Cancer Wars” (2001). “Because breast cancer is a disease that is so emotionally charged and gets so much attention, I think at times women feel almost obligated to be as proactive as possible — that’s the culture of breast cancer.”

Most of the data on prophylactic mastectomy come from the University of Minnesota, where researchers tracked contralateral mastectomy trends (removing a healthy breast alongside one with cancer) from 1998 to 2006. Dr. Todd M. Tuttle, chief of surgical oncology, said double mastectomy rates more than doubled during that period and the rise showed no signs of slowing.

From those trends as well as anecdotal reports, Dr. Tuttle estimates that at least 15 percent of women who receive a breast cancer diagnosis will have the second, healthy breast removed. “It’s younger women who are doing it,” he said.

The risk that a woman with breast cancer will develop cancer in the other breast is about 5 percent over 10 years, Dr. Tuttle said. Yet a University of Minnesota study found that women estimated their risk to be more than 30 percent.

“I think there are women who markedly overestimate their risk of getting cancer,” he said.

Most experts agree that double mastectomy is a reasonable option for women who have a strong genetic risk and have tested positive for a breast cancer gene. That was the case with Allison Gilbert, 42, a writer in Westchester County who discovered her genetic risk after her grandmother died of breast cancer and her mother died of ovarian cancer.

Even so, she delayed the decision to get prophylactic mastectomy until her aunt died from an aggressive breast cancer. In August, she had a double mastectomy. (She had her ovaries removed earlier.)

“I feel the women in my family didn’t have a way to avoid their fate,” said Ms. Gilbert, author of the 2011 book “Parentless Parents,” about how losing a parent influences one’s own style of parenting. “Here I was given an incredible opportunity to know what I have and to do something about it and, God willing, be around for my kids longer.”

Even so, she said her decisions were not made lightly. The double mastectomy and reconstruction required an initial 11 1/2-hour surgery and an “intense” recovery. She got genetic counseling, joined support groups and researched her options.

But doctors say many women are not making such informed decisions. Last month, University of Michigan researchers reported on a study of more than 1,446 women who had breast cancer. Four years after their diagnosis, 35 percent were considering removing their healthy breast and 7 percent had already done so.

Notably, most of the women who had a double mastectomy were not at high risk for a cancer recurrence. In fact, studies suggest that most women who have double mastectomies never seek genetic testing or counseling.

“Breast cancer becomes very emotional for people, and they view a breast differently than an arm or a required body part that you use every day,” said Sarah T. Hawley, an associate professor of internal medicine at the University of Michigan. “Women feel like it’s a body part over which they totally have a choice, and they say, ‘I want to put this behind me — I don’t want to worry about it anymore.’ ”


We hope you’ll “Like” Well on Facebook, where you’ll find news and conversations about fitness, food and family health.

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The Well Column: Facing Cancer, a Stark Choice

In the 1970s, women’s health advocates were highly suspicious of mastectomies. They argued that surgeons — in those days, pretty much an all-male club — were far too quick to remove a breast after a diagnosis of cancer, with disfiguring results.

But today, the pendulum has swung the other way. A new generation of women want doctors to take a more aggressive approach, and more and more are asking that even healthy breasts be removed to ward off cancer before it can strike.

Researchers estimate that as many as 15 percent of women with breast cancer — 30,000 a year — opt to have both breasts removed, up from less than 3 percent in the late 1990s. Notably, it appears that the vast majority of these women have never received genetic testing or counseling and are basing the decision on exaggerated fears about their risk of recurrence.

In addition, doctors say an increasing number of women who have never had a cancer diagnosis are demanding mastectomies based on genetic risk. (Cancer databases don’t track these women, so their numbers are unknown.)

“We are confronting almost an epidemic of prophylactic mastectomy,” said Dr. Isabelle Bedrosian, a surgical oncologist at M. D. Anderson Cancer Center in Houston. “I think the medical community has taken notice. We don’t have data that say oncologically this is a necessity, so why are women making this choice?”

One reason may be the never-ending awareness campaigns that have left many women in perpetual fear of the disease. Improvements in breast reconstruction may also be driving the trend, along with celebrities who go public with their decision to undergo preventive mastectomy.

This month Allyn Rose, a 24-year-old Miss America contestant from Washington, D.C., made headlines when she announced plans to have both her healthy breasts removed after the pageant; both her mother and her grandmother died from breast cancer. The television personality Giuliana Rancic, 37, and the actress Christina Applegate, 41, also talked publicly about having double mastectomies after diagnoses of early-stage breast cancer.

“You’re not going to find other organs that people cut out of their bodies because they’re worried about disease,” said the medical historian Dr. Barron H. Lerner, author of “The Breast Cancer Wars” (2001). “Because breast cancer is a disease that is so emotionally charged and gets so much attention, I think at times women feel almost obligated to be as proactive as possible — that’s the culture of breast cancer.”

Most of the data on prophylactic mastectomy come from the University of Minnesota, where researchers tracked contralateral mastectomy trends (removing a healthy breast alongside one with cancer) from 1998 to 2006. Dr. Todd M. Tuttle, chief of surgical oncology, said double mastectomy rates more than doubled during that period and the rise showed no signs of slowing.

From those trends as well as anecdotal reports, Dr. Tuttle estimates that at least 15 percent of women who receive a breast cancer diagnosis will have the second, healthy breast removed. “It’s younger women who are doing it,” he said.

The risk that a woman with breast cancer will develop cancer in the other breast is about 5 percent over 10 years, Dr. Tuttle said. Yet a University of Minnesota study found that women estimated their risk to be more than 30 percent.

“I think there are women who markedly overestimate their risk of getting cancer,” he said.

Most experts agree that double mastectomy is a reasonable option for women who have a strong genetic risk and have tested positive for a breast cancer gene. That was the case with Allison Gilbert, 42, a writer in Westchester County who discovered her genetic risk after her grandmother died of breast cancer and her mother died of ovarian cancer.

Even so, she delayed the decision to get prophylactic mastectomy until her aunt died from an aggressive breast cancer. In August, she had a double mastectomy. (She had her ovaries removed earlier.)

“I feel the women in my family didn’t have a way to avoid their fate,” said Ms. Gilbert, author of the 2011 book “Parentless Parents,” about how losing a parent influences one’s own style of parenting. “Here I was given an incredible opportunity to know what I have and to do something about it and, God willing, be around for my kids longer.”

Even so, she said her decisions were not made lightly. The double mastectomy and reconstruction required an initial 11 1/2-hour surgery and an “intense” recovery. She got genetic counseling, joined support groups and researched her options.

But doctors say many women are not making such informed decisions. Last month, University of Michigan researchers reported on a study of more than 1,446 women who had breast cancer. Four years after their diagnosis, 35 percent were considering removing their healthy breast and 7 percent had already done so.

Notably, most of the women who had a double mastectomy were not at high risk for a cancer recurrence. In fact, studies suggest that most women who have double mastectomies never seek genetic testing or counseling.

“Breast cancer becomes very emotional for people, and they view a breast differently than an arm or a required body part that you use every day,” said Sarah T. Hawley, an associate professor of internal medicine at the University of Michigan. “Women feel like it’s a body part over which they totally have a choice, and they say, ‘I want to put this behind me — I don’t want to worry about it anymore.’ ”


We hope you’ll “Like” Well on Facebook, where you’ll find news and conversations about fitness, food and family health.

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DealBook: Can Britain Forge Looser Ties to Europe Without Losing Influence?

LONDON — Last year, Prime Minister David Cameron of Britain used his appearance at the World Economic Forum to vent frustration with the European Union, listing some of the policies he would ditch if he could throw off Europe’s regulatory shackles.

“In the name of social protection, the E.U. has promoted unnecessary measures that impose burdens on businesses and governments, and can destroy jobs,” he argued, adding a list of directives that he would like to scrap.

One year later, Mr. Cameron is following through on that pledge. He is promising to renegotiate Britain’s ties to the 27-nation bloc, forge a new and looser relationship, and probably put the outcome of those talks to a referendum.

A speech on Europe, planned for last week, was postponed because of the crisis in Algeria. It has been rescheduled for Wednesday, ahead of a possible visit by Mr. Cameron to Davos, Switzerland.

It was unclear whether Mr. Cameron would attend Davos this year and speak on the same theme. But his tough line on Europe echoes growing British disenchantment with a bloc whose single currency union, which the British never joined, has been in crisis for three years.

Yet, supposing Mr. Cameron were to succeed in scaling down Britain’s involvement, some central questions will arise. Can Britain play a more limited role in Brussels and still retain significant influence there? And what might that mean for Britain’s full participation in one of the world’s biggest single markets?

In their 40-year history of engagement with a unifying Europe, Britons have never embraced the ideal of unity; instead they have seen their ties to the Continent in pragmatic terms. Increasingly, London’s conclusion seems to be that the costs in terms of regulatory burdens and financial contributions are not outweighed by clear benefits.

Mr. Cameron argues that to stabilize support for the European Union in Britain, the relationship must be loosened and focused more on the bloc’s single market of almost 500 million people.

Britain, which is in the second tier of European Union membership, not only stayed out of the euro — and unlike most of the others on the sidelines has no intention of joining — but also does not participate in Europe’s Schengen passport-free travel zone. The British government also announced last year that it would opt out of a range of justice and security policy areas.

A group of Conservative lawmakers argued last week for five treaty changes, including those that would allow any country to block new European Union legislation on financial services, and would repatriate social and employment laws to national capitals. Britain’s euro skeptics are also blunt in their criticism of the bloc’s agricultural, fisheries and regional aid programs

Many would ideally like to keep just one element of European Union membership, access to the single market, though achieving such status looks highly improbable.

Even those who sympathize with Mr. Cameron’s stance argue that a more detached position comes at the price of reduced influence, though they contend the cost of not changing would be higher. They also argue that leverage in some of the policy areas is of limited value anyway.

“There is a trade-off, there is no doubt,” said Mats Persson, director of Open Europe, a research organization that favors a change in Britain’s relationship with the union. “If you reduce the level of E.U. influence in the British economy and society, you will lose some influence over some policy areas.”

But Mr. Persson argues that “if there is no change in Britain’s E.U. relationship, its membership is in question, which would really reduce its influence.”

Others worry that Britain is weakening its own position. Charles Grant, director of the Center for European Reform, a research institute in London, says that already “British influence in Brussels is at its lowest level in the 25 years I have been following the E.U.”

And critics argue that standing back from more policy arenas would increase the country’s sense of alienation from the bloc and fuel popular sentiment that things are stacked against Britain. A more detached relationship could also prove a disadvantage in the deal-making culture that prevails in Brussels.

Officially, decisions on legislation in Brussels are made by national governments under a complex series of rules before going to the European Parliament, whose approval is also required. In some cases, like tax policy, all 27 national governments need to agree, though in many others a weighted majority is required.

But relatively few decisions are actually put to a vote by governments. In practice, countries strike informal agreements and compromises, often trading support on one issue for a reciprocal agreement, sometimes in an unrelated area of policy.

For example, Britain once supported Germany, which wanted to water down planned rules on takeovers, in exchange for help from Berlin to soften new European Union legislation on workers’ rights.

The fewer areas in which a country participates, the less influence it has to barter.

Something similar affects another area of unofficial influence: control of crucial positions in Brussels. When the last round of top European Union jobs was decided, Tony Blair, a former British prime minister, was a contender to become the president of the European Council, the body in which national governments meet. But Britain’s absence from the euro currency and the Schengen zone made this a nonstarter.

The prime minister at the time, Gordon Brown, wanted a top economic post for Britain in the European Commission, the executive of the bloc. Instead, he got a foreign policy position for Catherine Ashton, reflecting the fact that Britain remained an engaged player in that area.

The euro has dominated the agenda in Brussels for the last three years, but Britons have reduced prospects of making big careers in this policy area because London has no power to lobby for them.

“If you are in the Treasury in London, why the hell would you go to Brussels?” said one European Union official not authorized to speak publicly.

That trend now looks likely to extend to justice and security policy. Britain recently held the most senior position in the justice and home affairs directorate of the European Commission, partly because the British used to be enthusiastic about cooperation in that forum. A Briton, Rob Wainwright, is currently the director of Europol, the bloc’s law enforcement agency.

But given the government’s decision to distance itself, it will be harder for Britons to get such top jobs in the future.

Declining career prospects for British officials are reflected in staff recruitment figures, released in April 2011. They showed that the European Commission now employed more Poles than Britons, though Britain has a larger population and joined the European Union’s forerunner more than 30 years before Polish accession in 2004.

Britain has fewer than half France’s number of European Commission officials, and the situation seems destined to deteriorate because relatively few Britons are applying for entry-level jobs.

All this risks creating a downward spiral in British influence, which the country would need to counter by being more effective in the areas in which it remains.

“I think Britain still could have clout in more limited areas if it keeps friends and allies,” Mr. Grant said. “But the fact that we are not, for example, so engaged in justice and home affairs weakens our bargaining power across policy areas and weakens the career prospects of British officials.”

Mr. Grant added, “There has been a steady diminution in the last few years, which you could plot on a graph: the more you distance yourself the less influence you have.”

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