Surgeon infected patients during heart procedure, Cedars-Sinai admits

A heart surgeon at Cedars-Sinai Medical Center unwittingly infected five patients during valve replacement surgeries earlier this year, causing four of the patients to need a second operation.

The infections occurred after tiny tears in the latex surgical gloves routinely worn by the doctor allowed bacteria from a skin inflammation on his hand to pass into the patients' hearts, according to the hospital. The patients survived the second operation and are still recovering, hospital officials said.

The outbreak led to investigations by the hospital and both the L.A. County and California departments of public health. The federal Centers for Disease Control and Prevention was also consulted.

Hospital officials called it a "very unusual occurrence" probably caused by an unfortunate confluence of events: the nature of the surgery, the microscopic rips in the gloves and the surgeon's skin condition. Valve replacement requires the surgeon to use thick sutures and tie more than 100 knots, which can cause extra stress on the gloves, they said.

Nevertheless, the hospital's goal is to have zero infections, said Harry Sax, vice chairman of the hospital's department of surgery. "Any hospital-acquired infection is unacceptable," he said.

The infections raise questions about what health conditions should prevent a surgeon from operating and how to get the best protection from surgical gloves. Surgeons with open sores or known infections aren't supposed to operate, but there is no national standard on what to do if they have skin inflammation, said Rekha Murthy, medical director of the hospital's epidemiology department. She added that there were also no national standards on types of gloves used, whether to wear double gloves or how many times surgeons should change those gloves during a procedure.

Healthcare-acquired infections are very common throughout the United States. Each year, infections cause 99,000 deaths in the country, including about 12,000 in California. Hospitals in the state are required to report certain infections to the California Department of Public Health. That reporting makes the public more aware of the quality of care provided at local hospitals and is an important tool for reducing infections, said Debby Rogers, deputy director of the department's Center for Health Care Quality.

Cedars-Sinai has low rates for hospital-acquired infections compared with the state and national average but has not performed as well on other surgical quality measures recently, according to the Leapfrog Group, an employer-backed nonprofit focused on healthcare quality. The organization gave the hospital a C rating last month on its national report card, down from an A in June, though it was not related to the infection outbreak.

"Clearly this hospital is making attempts to reduce infections, but they have more work to do," said Leah Binder, Leapfrog's chief executive.

Cedars-Sinai Medical Center conducts about 360 valve replacement surgeries each year and said infections occur in fewer than 1% of its cases — lower than the national average.

The hospital learned about the problem in June after three patients who had undergone valve replacement surgery showed signs of infection. Doctors diagnosed the patients with an infection called endocarditis. Concerned there might be a connection among the cases, epidemiologists analyzed the bacteria, staphylococcus epidermidis, and determined that it was an identical strain and therefore must have come from a single source. "It led to the question of gee, I wonder where it came from?" Murthy said.

Epidemiologists homed in on the surgeon with the skin inflammation. The bacteria matched, and then they made a surprising discovery: microscopic tears in the gloves typically worn by surgeons after performing valve replacement surgery. The surgeon, whose name was not released, was not allowed to operate again until he healed. He is still a member of the medical staff but no longer performs surgeries at the hospital.

The hospital soon found the same infection in two more patients. Officials also reached out to 67 patients who had heart valve replacements with the same surgeon but didn't find any other cases. One of the five infected patients was treated with antibiotics, and the other four had new valve replacement surgeries. Sax said the hospital apologized to the patients and has continued to monitor their health. The hospital has also covered the cost of their care, including follow-up treatment and all the related surgeries.

All surgeons doing valve replacements are now required to change gloves more frequently, officials said. Some surgeons are wearing double gloves during the operations, Sax said.

Following the outbreak, Cedars-Sinai did the proper follow-up to ensure the safety of their patients, said Dawn Terashita, a medical epidemiologist with L.A. County, who was notified in September. What occurred at Cedars-Sinai was an unintentional consequence of the surgery, she said.

"There is no way to keep a room entirely sterile and all the people in it sterile," she said. "You will always have risk of infection."

anna.gorman@latimes.com

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15 Agonizing Automotive Atrocities

Yugo.

There, we got it out of the way. When you read the headline, of course an image of a tiny Cold War-era hatchback popped into your head. We bet you also shuddered at the thought of a Pontiac Aztek.

We love to poke fun at failure, and no failure made a punchline better than the Yugo. We found that out while talking with Jason Vuic, author of The Yugo: The Rise and Fall of the Worst Car in History. Vuic was aware that the Yugo fell far short of being a good car, but what truly amazed him was how many people who had never driven a Yugo knew just how bad it was. In failure, it became a wild viral marketing success.

Not all cars rose to level of infamy embodied by the Yugo. To paraphrase Shakespeare, some cars were born awful while others had awfulness thrust upon them. Some automotive atrocities were the result of automakers trying something new and falling far short of the mark, while other cars failed from a lack of effort. Still others were perfectly adequate cars but came to represent a regrettable moment in time.

Here we display all three kinds of auto-trocities, highlighting famous failures and digging deep to dredge up detritus better off forgotten. Yes, we know there are many, many more automotive atrocities and this list only scratches the surface of the heap. You’ll have a chance to list your favorite heaps tomorrow, so stay tuned.

Above: Peel Trident 1965-1966

Famous from appearances on Top Gear and Monster Garage, the Peel Trident was a “shopping car” built on the Isle of Man. Along with the bubblelicious BMW Isetta and the fiberglass Reliant Robin, the Trident was ridiculed for its small size and three wheels.

Photo: Casaflamingo/Flickr

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Quentin Tarantino: if you think “Django Unchained” is violent, try slavery

LOS ANGELES (TheWrap.com) – If you think “Django Unchained” is violent, Quentin Tarantino has a historical reality check for you: Try slavery.

The “Pulp Fiction” auteur is back with an Antebellum revenge flick that according to early screenings pours on the blood and gore. Tarantino told an audience of British Academy of Film and Television Arts members on Thursday that if anything he spared the lash in his depiction of slavery, according to the Guardian.

“We all intellectually ‘know’ the brutality and inhumanity of slavery,” Tarantino said, “but after you do the research it’s no longer intellectual any more, no longer just historical record – you feel it in your bones. It makes you angry and want to do something … I’m here to tell you, that however bad things get in the movie, a lot worse shit actually happened.”

Tarantino’s comments indicate that he anticipates the irreverent “Django Unchained” – which opens on Christmas Day – will court controversy for setting its story against the backdrop of the slave trade.

The film centers on a bounty hunter (Christoph Waltz) who partners with a freed slave (Jamie Foxx) to take down a plantation owner, Calvin Candie (Leonardo DiCaprio) who controls his wife. Candie, who speaks with Magnolia-scented menace in the trailers, owns a mixed-race club in Greenville, Miss., and deals in slave-fights.

Perhaps because the film features Tarantino’s trademark sardonic humor, some early viewers have compared “Django Unchained” to the works of Mel Brooks.

“Just watched what was basically a three-hour homage to BLAZING SADDLES,”@LouLumenick tweeted.

But despite the humor, in an interview with Howard Stern this week, Tarantino indicated that he took the responsibility of depicting slavery very seriously. In particular, he said that shooting a scene where a female slave is brutalized brought him to tears and deeply impacted the crew.

“It was early on in the production, and it was the first time we started officially dealing with that kind of ugliness,” Tarantino said. “We later got used to dealing with that kind of ugliness. But that first – it was traumatizing to everybody, none less because of the fact that we were doing it in the real slave area of a real plantation where the slaves lived.

“This actually happened on the grounds,” he added. “There was blood in that ground. Those trees had memories of everything that happened there. We could feel the spirits of the old slaves on the property.”

Of course, Tarantino has taken on controversial subjects before. He turned an ultra-violent and satiric eye at the Nazis and an SD colonel nicknamed the “Jew Hunter” and turned it into “Inglourious Basterds.” Dealing with charges of insensitivity, it nonetheless collected over $ 300 million worldwide and was nominated for a Best Picture Oscar.

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U.S. economy adds 146,000 jobs in November

The U.S. economy added 146,000 jobs in November and the unemployment rate fell to 7.7 percent, the lowest since December 2008. The government said Superstorm Sandy had only a minimal effect on the figures.

The Labor Department's report on Friday offered a mixed picture for the economy.

Hiring remained steady during the storm and in the face of looming tax increases. But the government said employers added 49,000 fewer jobs in October and September than initially estimated.

And the unemployment rate fell to a four-year low in November from 7.9 percent in October mostly because more people stopped looking for work and weren't counted as unemployed.

There were signs that the storm disrupted economic activity. Construction employment dropped 20,000. And weather prevented 369,000 people from getting to work — the most in almost two years. They were still counted as employed.

Stock futures jumped after the report. Dow Jones industrial average futures were down 20 points in the minutes before the report came out at 8:30 a.m., and just after were up 70 points.

As money moved into stocks, it moved out of safer bonds. The yield on the benchmark 10-year U.S. Treasury note, which moves opposite the price, rose to 1.63 percent from 1.58 percent just before the report.

Since July, the economy has added an average of 158,000 jobs a month. That's a modest pickup from 146,000 in the first six months of the year.

The increase suggests employers are not yet delaying hiring decisions because of the “fiscal cliff.” That's the combination of sharp tax increases and spending cuts that are set to take effect next year without a budget deal.

Retailers added 53,000 positions while temporary help companies added 18,000 and education and healthcare also gained 18,000.

Auto manufacturers added nearly 10,000 jobs.

Still, overall manufacturing jobs fell 7,000. That was pushed down by a loss of 12,000 jobs in food manufacturing that likely reflects the layoff of workers at Hostess.

Sandy forced restaurants, retailers and other businesses to close in late October and early November in 24 states, particularly in the Northeast.

The U.S. grew at a solid 2.7 percent annual rate in the July-September quarter. But many economists say growth is slowing to a 1.5 percent rate in the October-December quarter, largely because of the storm and threat of the fiscal cliff. That's not enough growth to lower the unemployment rate.

The storm held back consumer spending and income, which drive economic growth. Consumer spending declined in October and work interruptions caused by Sandy reduced wages and salaries that month by about $18 billion at an annual rate, the government said.

Still, many say economic growth could accelerate next year if the fiscal cliff is avoided. The economy is also expected to get a boost from efforts to rebuild in the Northeast after the storm.

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YouTube Makeover Offers Larger Videos

After months of experimenting with YouTube’s interface and serving limited trials to willing users, Google has launched a new look for the web’s biggest video-sharing site.

The new YouTube is reminiscent of Flickr’s redesign earlier this year — putting the content, in this case the videos, front and center. The new YouTube offers larger videos closer to the top of the page; the title is now below the video, just above the various sharing options.

The left of the page is home to YouTube’s new “Guide,” a list of all the YouTube channels you’re subscribed to, along with your history and video playlists. The YouTube Guide now comes with you across devices, offering up new videos and suggestions on everything from Android phones to Google TV.

The other notable change is that the page is no longer centered, it’s aligned to the left edge of the browser window. The result is a slightly less cluttered page with more emphasis on the video, though the dead space to the right looks a bit strange if you’ve got a large monitor.

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Jackson’s Hobbit: the journey begins

WELLINGTON (Reuters) – Film maker Peter Jackson wants to scare children with his latest movie – and perhaps even a few grown ups.

The first of the Hobbit movie trilogy – “The Hobbit: An Unexpected Journey” – is about to hit theatres, and Jackson says he’s tried to hold true to its roots as a children’s fantasy story, with scary bits.

“If they’re scared of the trolls great, if they’re scared of the goblins great, they know there are no goblins, they know there are no trolls, it’s a safe kind of danger,” he says.

The film, produced by MGM and Time Warner Inc, is the fourth in the Oscar-winning Jackson’s blockbuster “Lord of the Rings” film franchise, based on the books of author J.R.R. Tolkien.

It follows the journey of hobbit Bilbo Baggins, reluctantly pushed into travelling with 13 dwarves to steal treasure from a dragon and regain their homeland. During his travels, he comes by the ring that he later passes onto kinsman Frodo Baggins, which was at the core of the “Rings” trilogy.

Jackson says he’s worked to keep distance between the Hobbit, published in 1937, and the much darker Lord of the Rings, which came out nearly 20 years later.

“The Lord of the Rings has an apocalyptic sort of heavy themic end-of-the world quality to it, which the Hobbit doesn’t, which is one of the delights of it,” he said.

POMPOUS AND SMALL MINDED

The pointy eared, hairy footed hobbit Bilbo is played by British actor Martin Freeman, who says he’s tried to make Bilbo his own creation, a character audiences can root for despite his initial pomposity and small mindedness.

“You have to be able to follow him for the duration of the film, but I wanted him to be open and changeable and ready to be surprised,” Freeman said.

A key scene is an encounter in a cave between Bilbo and the creature Gollum, reprised in full computer generated splendor by Andy Serkis with the distinctive throaty whisper.

“It was a very rich experience,” he said, adding that playing Gollum again was “an absolute thrill”.

Such is the affection for the creature, who calls the magic ring “Precious”, that a 13 meter (42 feet) sculpture of Gollum hangs in the airport terminal at Wellington, which regards itself as the spiritual home of the Tolkien films and terms itself the “Middle of Middle Earth”.

Returning actors from the Rings trilogy, many of whom have only passing mention in the book, were no less enthusiastic. Ian McKellen returns for a leading role as the wispy-haired, grey bearded wizard, Gandalf, while Cate Blanchett is the elven queen Galadriel and Elijah Wood appears as Frodo Baggins.

“You couldn’t not come back, you had to come back,” says Hugo Weaving, the leader of the elves, Elrond.

HOBBIT – A FRAUGHT JOURNEY

The Hobbit film journey has not been without its setbacks.

Metro-Goldwyn-Mayer, owners of the film rights to the Tolkien books, had financial woes, prompting original director Guillermo del Toro to pull out and Jackson, already script writer and executive producer, to step in.

A major labor dispute prompted threats to move production out of New Zealand, and was solved by changing labor laws, while Jackson suffered a perforated ulcer and underwent surgery, delaying the film still further.

Though only two films were planned originally, Jackson has tapped Tolkien’s appendices to the Rings to make it into three.

Audiences are also getting more visual bangs for their buck, with the movies filmed in 3D and at 48 frames per second (fps), double the industry standard.

This delivers clearer pictures, but opinion is divided, with some critics calling it cartoon-like and jarring.

Jackson says he wants to drag the iPad generation back into theatres and the romance, excitement and mystery they offer.

“It’s more realistic, it’s more immersive. I almost feel a responsibility as a film maker to try to do my part at encouraging people to come to the movies, to watch the film in a cinema,” he said.

The second film “The Hobbit: The Desolation of Smaug” will be released in December next year, with the third “The Hobbit: There and Back Again” is due in mid-July 2014.

(Reporting by Gyles Beckford, editing by Elaine Lies)

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One toke over the line in Washington state, where pot is now legal

SEATTLE -- More than 100 hard-core tokers gathered under the Space Needle at the stroke of midnight Wednesday night to light one up in celebration of Washington state’s new marijuana law, which makes it legal for those 21 and older to possess an ounce or less of pot.

Voters in Washington and Colorado approved the nation’s first recreational marijuana laws in November, and though Colorado’s doesn’t take effect until January, the Washington initiative allows pot possession as of Thursday — though it’s still illegal for the moment to buy, sell or grow marijuana.

And smoking publicly remains against the law. That didn't stop the bandanna-clad crew puffing on pipes and joints under a chilly night sky early Thursday, and it appeared  the Seattle Police Department was not in the mood to arrest anyone on a night most seemed to take as celebratory.

"The Dude abides, and says, 'Take it inside!' " the SPD posted on its police blotter, under a photo of Jeff Bridges as "The Big Lebowski."

The department issued a bulletin to officers directing them "until further notice" to take no enforcement action, other than a verbal warning, against those violating the new law, known as Initiative 502.

"We had a city ordinance prior to this that said marijuana enforcement was our lowest enforcement priority," police department spokesman Jeff Kappel told the Los Angeles Times.

The state’s Liquor Control Board, tasked with setting up regulations to carry out the law, will over the next year draft a framework for licensing growers, handlers and retailers that initiative supporters hope will put black market drug dealers out of business.

The state's existing medical marijuana law remains unchanged.

"I think we have some ability to use our experience in regulating liquor, which is to me a similar public safety kind of product," the control board’s administrative director, Pat Kohler, said in an interview. "You want to ensure it doesn’t get in the hands of minors, and you want to make sure it doesn’t get in the wrong hands, where it can be used improperly."

State officials believe the hefty taxation on state-produced marijuana called for under the law could bring in $2 billion over the next five years.

Still unclear is what move may be next from the federal government, which still considers marijuana possession a felony.

The U.S. attorney’s office in Seattle issued a warning from the U.S. Justice Department on Wednesday that said it was taking its enforcement responsibility seriously.

"The department’s responsibility to enforce the Controlled Substances Act remains unchanged," the statement said. "Regardless of any changes in state law, including the change that will go into effect on Dec. 6 in Washington state, growing, selling or possessing any amount of marijuana remains illegal under federal law."

Likewise, it said, bringing pot onto any federal property, including national parks and forests, military installations and courthouses, would continue to be a poor idea.

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2012 Was the Year of the Drone in Afghanistan

The soldiers and marines are packing their bags. The pilots are sitting on the tarmac. But the armed robotic planes are busier than they’ve ever been: revised U.S. military statistics show a much, much larger drone war in Afghanistan than anyone suspected.

Last month, military stats revealed that the U.S. had launched some 333 drone strikes in Afghanistan thus far in 2012. That made Afghanistan the epicenter of U.S. drone attacks — not Pakistan, not Yemen, not Somalia. But it turns out those stats were off, according to revised ones released by the Air Force on Thursday morning. There have actually been 447 drone strikes in Afghanistan this year. That means drone strikes represent 11.5 percent of the entire air war — up from about 5 percent last year.

Never before in Afghanistan have there been so many drone strikes. For the past three years, the strikes have never topped 300 annually, even during the height of the surge. Never mind 2014, when U.S. troops are supposed to take a diminished role in the war and focus largely on counterterrorism. Afghanistan’s past year, heavy on insurgent-hunting robots, shows that the war’s future has already been on display.

It’s not just that the drone war in Afghanistan is so big. It’s that the broader air war is winding down. As the chart above shows, the Air Force flew fewer intelligence, surveillance and reconnaissance missions in 2012 than it did in 2011, although the number of spy missions in 2012 is still greater than in 2010 or 2009. This year has seen over 1,000 fewer aerial attacks, by manned and remotely piloted aircraft alike, than there were during the surge years of 2010 and 2011. Total sorties are even lower than their 2009 levels. The only exception to the downward slope: drone strikes.

That suggests a pattern that may endure through the next two years of troop reductions. As the humans leave, the robots take up the slack.

The U.S. and Afghanistan have begun negotiations on what a residual troop presence is supposed to look like. So far, it’s believed that the Pentagon wants to leave behind between 5,000 and 10,000 troops, to continue to train the Afghan military, hunt terrorists and generally ensure Afghanistan doesn’t collapse. And before the New Year, Gen. John Allen, the outgoing commander of the war, is supposed to recommend to President Obama how fast next year’s troop drawdowns ought to proceed. Pentagon officials insist nothing’s etched in stone.

But we might not have to wait for 2014 to see the future of the Afghanistan war. “We may well see the development of counterterrorism become more important as time goes on,” Allen told the Senate last year. This year proved Allen wasn’t blowing smoke. U.S. special operations forces underwent a major command overhaul and now operate out of a private base run by the company formerly known as Blackwater. Super-sizing the drone war is fully in line with that broader shift. This may have been the year of the drone in Afghanistan, but the drones aren’t going home any time soon.

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Latest James Bond movie breaks UK box office record

LONDON (Reuters) – “Skyfall“, the 23rd official James Bond movie, has become the most successful film in British box office history, earning 94.3 million pounds ($ 152 million), its producers said on Wednesday.

The tally, earned over 40 days, surpasses the previous record of 94.0 million pounds set by 2009 3D adventure film “Avatar” over its 11 month run in UK cinemas, although the figures do not take inflation into account.

Skyfall, which has been well received by critics, stars Daniel Craig in his third outing as 007, and is directed by Sam Mendes.

In it Bond and British spymaster M, played by Judi Dench, are pitted against technological wizard Silva (Javier Bardem) who is bent on revenge.

“We are very proud of this film and thank everybody, especially Daniel Craig and Sam Mendes, who have contributed to its success,” said co-producers Michael G. Wilson and Barbara Broccoli in a statement.

Globally, Skyfall has some way to go to match Avatar. It has earned $ 870 million in ticket sales around the world, according to movie tracking site Boxofficemojo.com, compared with Avatar’s record $ 2.8 billion.

According to the same website, Avatar’s adjusted box office total comes in at 14th in cinema history, with the 1939 classic “Gone With the Wind” in pole position.

(Reporting by Mike Collett-White, editing by Paul Casciato)

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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 might be taken for a longer duration as well.

“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 are in premenopausal women with estrogen receptor-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 10 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, compared with 0.4 percent in the control group.

“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.

“They don’t feel well on them, but it’s their safety net,” said Dr. Garber, who added that the news would be welcomed by many patients who would like to stay on the drug. “I have patients who agonize about this, people who are coming to the end of their tamoxifen.”

Emily Behrend, who is a few months from finishing her five years on tamoxifen, said she would definitely consider another five years. “If it can keep the cancer away, I’m all for it,” said Ms. Behrend, 39, a single mother in Tomball, Tex. She is taking the antidepressant Effexor to help control the night sweats and hot flashes caused by tamoxifen.

Cost is not considered a huge barrier to taking tamoxifen longer because the drug can be obtained for less than $200 a year.

The results, while answering one question, raise many new ones, including whether even more than 10 years of treatment would be better still.

Perhaps the most important question is what the results mean for postmenopausal women. Even many women who are premenopausal at the time of diagnosis will pass through menopause by the time they finish their first five years of tamoxifen, or will have been pushed into menopause by chemotherapy.

Postmenopausal patients tend to take aromatase inhibitors like anastrozole or letrozole, which are more effective than tamoxifen at preventing breast cancer recurrence, though they do not work for premenopausal women.

Mr. Peto said he thought the results of the Atlas study would “apply to endocrine therapy in general,” meaning that 10 years of an aromatase inhibitor would be better than five years. Other doctors were not so sure.

The Atlas study was paid for by various organizations including the United States Army, the British government and AstraZeneca, which makes the brand-name version of tamoxifen.

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