Study finds mammograms lead to unneeded treatment

Mammograms have done surprisingly little to catch deadly breast cancers before they spread, a big U.S. study finds. At the same time, more than a million women have been treated for cancers that never would have threatened their lives, researchers estimate.

Up to one-third of breast cancers, or 50,000 to 70,000 cases a year, don't need treatment, the study suggests.

It's the most detailed look yet at overtreatment of breast cancer, and it adds fresh evidence that screening is not as helpful as many women believe. Mammograms are still worthwhile, because they do catch some deadly cancers and save lives, doctors stress. And some of them disagree with conclusions the new study reached.

But it spotlights a reality that is tough for many Americans to accept: Some abnormalities that doctors call "cancer" are not a health threat or truly malignant. There is no good way to tell which ones are, so many women wind up getting treatments like surgery and chemotherapy that they don't really need.

Men have heard a similar message about PSA tests to screen for slow-growing prostate cancer, but it's relatively new to the debate over breast cancer screening.

"We're coming to learn that some cancers — many cancers, depending on the organ — weren't destined to cause death," said Dr. Barnett Kramer, a National Cancer Institute screening expert. However, "once a woman is diagnosed, it's hard to say treatment is not necessary."

He had no role in the study, which was led by Dr. H. Gilbert Welch of Dartmouth Medical School and Dr. Archie Bleyer of St. Charles Health System and Oregon Health & Science University. Results are in Thursday's New England Journal of Medicine.

Breast cancer is the leading type of cancer and cause of cancer deaths in women worldwide. Nearly 1.4 million new cases are diagnosed each year. Other countries screen less aggressively than the U.S. does. In Britain, for example, mammograms are usually offered only every three years and a recent review there found similar signs of overtreatment.

The dogma has been that screening finds cancer early, when it's most curable. But screening is only worthwhile if it finds cancers destined to cause death, and if treating them early improves survival versus treating when or if they cause symptoms.

Mammograms also are an imperfect screening tool — they often give false alarms, spurring biopsies and other tests that ultimately show no cancer was present. The new study looks at a different risk: Overdiagnosis, or finding cancer that is present but does not need treatment.

Researchers used federal surveys on mammography and cancer registry statistics from 1976 through 2008 to track how many cancers were found early, while still confined to the breast, versus later, when they had spread to lymph nodes or more widely.

The scientists assumed that the actual amount of disease — how many true cases exist — did not change or grew only a little during those three decades. Yet they found a big difference in the number and stage of cases discovered over time, as mammograms came into wide use.

Mammograms more than doubled the number of early-stage cancers detected — from 112 to 234 cases per 100,000 women. But late-stage cancers dropped just 8 percent, from 102 to 94 cases per 100,000 women.

The imbalance suggests a lot of overdiagnosis from mammograms, which now account for 60 percent of cases that are found, Bleyer said. If screening were working, there should be one less patient diagnosed with late-stage cancer for every additional patient whose cancer was found at an earlier stage, he explained.

"Instead, we're diagnosing a lot of something else — not cancer" in that early stage, Bleyer said. "And the worst cancer is still going on, just like it always was."

Researchers also looked at death rates for breast cancer, which declined 28 percent during that time in women 40 and older — the group targeted for screening. Mortality dropped even more — 41 percent — in women under 40, who presumably were not getting mammograms.

"We are left to conclude, as others have, that the good news in breast cancer — decreasing mortality — must largely be the result of improved treatment, not screening," the authors write.

The study was paid for by the study authors' universities.

"This study is important because what it really highlights is that the biology of the cancer is what we need to understand" in order to know which ones to treat and how, said Dr. Julia A. Smith, director of breast cancer screening at NYU Langone Medical Center in New York. Doctors already are debating whether DCIS, a type of early tumor confined to a milk duct, should even be called cancer, she said.

Another expert, Dr. Linda Vahdat, director of the breast cancer research program at Weill Cornell Medical College in New York, said the study's leaders made many assumptions to reach a conclusion about overdiagnosis that "may or may not be correct."

"I don't think it will change how we view screening mammography," she said.

A government-appointed task force that gives screening advice calls for mammograms every other year starting at age 50 and stopping at 75. The American Cancer Society recommends them every year starting at age 40.

Dr. Len Lichtenfeld, the cancer society's deputy chief medical officer, said the study should not be taken as "a referendum on mammography," and noted that other high-quality studies have affirmed its value. Still, he said overdiagnosis is a problem, and it's not possible to tell an individual woman whether her cancer needs treated.

"Our technology has brought us to the place where we can find a lot of cancer. Our science has to bring us to the point where we can define what treatment people really need," he said.

___

Online:

Study: http://www.nejm.org/doi/full/10.1056/NEJMoa1206809

Screening advice: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm

___

Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP

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Sandy victims cheered by NYC's Thanksgiving parade

NEW YORK (AP) — Victims of Superstorm Sandy in New York and elsewhere in the Northeast were comforted Thursday by kinder weather, free holiday meals and — for some — front row seats to the annual Macy's Thanksgiving Day Parade.

"It means a lot," said Karen Panetta, of the hard-hit Broad Channel section of Queens, as she sat in a special viewing section set aside for New Yorkers displaced by the storm.

"We're thankful to be here and actually be a family and to feel like life's a little normal today," she said.

The popular Macy's parade, attended by more than 3 million people and watched by 50 million on TV, included such giant balloons as Elf on a Shelf and Papa Smurf, a new version of Hello Kitty, Buzz Lightyear, Sailor Mickey Mouse and the Pillsbury Doughboy. Real-life stars included singer Carly Rae Jepsen and Rachel Crow of "The X Factor."

The young, and the young at heart, were delighted by the sight and sound of marching bands, performers and, of course, the giant balloons. The sunny weather quickly surpassed 50 degrees.

Alan Batt and his 11-year-old twins, Kyto and Elina, took in the parade at the end of the route, well away from the crowd and seemingly too far away for a good view. But they had an advantage: Two tall stepladders they hauled over from their apartment eight blocks away — one for each twin.

"We're New Yorkers," the 65-year-old Batt said. "We know what we're doing."

With the height advantage, "I get to see everything!" Kyto said.

At nearby Greeley Square, social worker Lowell Herschberger, 40, of Brooklyn, sought in vain to tear his sons, 8-year-old Logan and 6-year-old Liam, from a foosball table set up in the tiny park as the balloons crept by on the near horizon.

"Hey, guys — there's Charlie Brown," he said, pointing at the old standby balloon.

The boys didn't look up.

"I guess they're over it," the father said with a shrug.

Mayor Michael Bloomberg was reflective Thursday as he praised police, firefighters, armed services personnel, sanitation workers and volunteers involved in the storm response. His office was coordinating the distribution of 26,500 meals at 30 sites in neighborhoods affected by Sandy, and other organizations also were pitching in.

The disaster zones on Staten Island were flooded — this time with food and volunteers from Glen Rock, N.J. organized using social media.

"We had three carloads of food," said volunteer Beth Fernandez. "The whole town of Glen Rock pitched in. ... It's really cool. It's my best, my favorite Thanksgiving ever."

On Long Island, the Long Beach nonprofit Surf For All hosted a Thanksgiving event that fed 1,200 people. Carol Gross, 72, a Long Beach native, said she went to volunteer but was turned away because of a surplus of helpers.

"A lot of people like me, old-timers, we've never seen anything like this horror," she said, recalling the destruction.

Gross' brother, Jerry, who moved to Arizona in the 1960s, was stunned by what he saw when he returned for Thanksgiving.

"To come back and see the boardwalk all devastated like it is, it's like going to Manhattan and finding Times Square gone," he said.

George Alvarez, whose Toms River, N.J., home suffered moderate damage when Sandy hit the coast, said his family usually does "the traditional big dinner" on Thanksgiving. But this year, they chose to attend a community dinner held at an area church.

"This storm not only impacted us, it impacted a lot of our friends, our community, our psyche," Alvarez said shortly before his family headed out for their meal. "We could have had our usual dinner here at home, but this year it felt like we should be with others who are experiencing the same concerns we are. We made it through this devastating storm, and that's something to celebrate."

Across the country, other cities offered a mix of holiday cheer and acts of charity.

Thousands of people made the most of the mild, sunny fall weather to watch Detroit's Thanksgiving parade, hours ahead of the Lions' annual home game.

Floats and marching bands poured down Woodward Avenue on Thursday morning, with many spectators forgoing the cold-weather gear of past parades. Detroit's temperature hit 52 degrees at 11 a.m., with a warm wind blowing from the South.

Parade participants also included NASCAR driver Brad Keselowski, a 28-year-old Rochester Hills native and the first Michigan-born driver to win the Sprint Cup Series.

In San Francisco, lines of the homeless and less fortunate began forming late Wednesday outside a church in the city's tough Tenderloin district that expected to serve more than 5,000 meals, said the Rev. Cecil Williams.

"We must make sure people can overcome all adversities," Williams said. "You can, you will and you must."

___

AP radio correspondent Julie Walker, AP video journalist Ted Shaffrey and Associated Press writers Kiley Armstrong and Karen Matthews in New York, Alison Barnwell on Long Island, Bruce Shipkowski in New Jersey and Terry Collins in San Francisco contributed to this report.

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3 bomb blasts kill 6 in 2 main Pakistani cities

QUETTA, Pakistan (AP) — A bomb blast targeting an army vehicle killed three soldiers and two civilians in the southwestern city of Quetta on Wednesday, police said.

Hours later, two bombs went off minutes apart outside a Shiite mosque in the southern city of Karachi, killing at least one person and wounding several others.

The explosions demonstrated the underlying tensions in Pakistan between insurgents and security forces on the one hand Sunni and Shiite Muslims on the other. The relatively low level of attacks does not appear to be endangering the nation's stability.

In the first attack, an improvised explosive device was used to detonate the bomb by remote control in Quetta, police commissioner Qambar Dashti said. He said eight people were wounded in the attack, some critically.

There was no immediate claim of responsibility for the bombing.

Quetta is the provincial capital of Baluchistan. The province has long been a scene of low-level insurgency by nationalist groups demanding more of a share in the region's natural resources.

Taliban and the al-Qaida-linked Pakistani militant group Lashkar-e-Jhangvi has also been active in Baluchistan, mainly focusing on targeting Shiite Muslims, whom it considers heretics.

Also Wednesday, two bombs exploded outside a Shiite mosque in the southern city of Karachi, killing one person and wounding seven people, senior police official Javed Odho said. He said the first appeared to be a suicide attack.

As the security forces and rescue workers were transporting victims of the first attack in Karachi to hospitals, a second bomb exploded at the same place, wounding several people, including security forces, rescue workers and journalists, senior police officer Omer Khitab said.

The twin bombings came as minority Shiites were celebrating the holy month of Muharram.

Pakistan has a long history of sectarian violence by extremist Sunni and Shiite Muslims in Karachi and other parts of the country.

The Sunni-Shiite schism over the true heir to Islam's Prophet Muhammad dates back to the seventh century.

___

Associated Press Writer Adil Jawad contributed to this report from Karachi.

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Ex-'Price is Right' model gets $7.7M in damages

LOS ANGELES (AP) — A jury has awarded a former model on "The Price is Right" more than $7.7 million in punitive damages after determining the show discriminated against her because of her pregnancy.

The decision Wednesday came one day after the panel determined producers discriminated against Brandi Cochran. They awarded her nearly $777,000 in actual damages.

The show's producers, FremantleMedia North America and The Price is Right Productions, vow to appeal the verdict and say they expect to be vindicated.

Cochran said she was rejected by the game show's producers when she tried to return from maternity leave in 2010.

Producers said they were satisfied with the five models they had when the 41-year-old sought to return.

Cochran says she is humbled by the award and hopes it raises issues of pregnancy discrimination in all workplaces.

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Study finds mammograms lead to unneeded treatment

Mammograms have done surprisingly little to catch deadly breast cancers before they spread, a big U.S. study finds. At the same time, more than a million women have been treated for cancers that never would have threatened their lives, researchers estimate.

Up to one-third of breast cancers, or 50,000 to 70,000 cases a year, don't need treatment, the study suggests.

It's the most detailed look yet at overtreatment of breast cancer, and it adds fresh evidence that screening is not as helpful as many women believe. Mammograms are still worthwhile, because they do catch some deadly cancers and save lives, doctors stress. And some of them disagree with conclusions the new study reached.

But it spotlights a reality that is tough for many Americans to accept: Some abnormalities that doctors call "cancer" are not a health threat or truly malignant. There is no good way to tell which ones are, so many women wind up getting treatments like surgery and chemotherapy that they don't really need.

Men have heard a similar message about PSA tests to screen for slow-growing prostate cancer, but it's relatively new to the debate over breast cancer screening.

"We're coming to learn that some cancers — many cancers, depending on the organ — weren't destined to cause death," said Dr. Barnett Kramer, a National Cancer Institute screening expert. However, "once a woman is diagnosed, it's hard to say treatment is not necessary."

He had no role in the study, which was led by Dr. H. Gilbert Welch of Dartmouth Medical School and Dr. Archie Bleyer of St. Charles Health System and Oregon Health & Science University. Results are in Thursday's New England Journal of Medicine.

Breast cancer is the leading type of cancer and cause of cancer deaths in women worldwide. Nearly 1.4 million new cases are diagnosed each year. Other countries screen less aggressively than the U.S. does. In Britain, for example, mammograms are usually offered only every three years and a recent review there found similar signs of overtreatment.

The dogma has been that screening finds cancer early, when it's most curable. But screening is only worthwhile if it finds cancers destined to cause death, and if treating them early improves survival versus treating when or if they cause symptoms.

Mammograms also are an imperfect screening tool — they often give false alarms, spurring biopsies and other tests that ultimately show no cancer was present. The new study looks at a different risk: Overdiagnosis, or finding cancer that is present but does not need treatment.

Researchers used federal surveys on mammography and cancer registry statistics from 1976 through 2008 to track how many cancers were found early, while still confined to the breast, versus later, when they had spread to lymph nodes or more widely.

The scientists assumed that the actual amount of disease — how many true cases exist — did not change or grew only a little during those three decades. Yet they found a big difference in the number and stage of cases discovered over time, as mammograms came into wide use.

Mammograms more than doubled the number of early-stage cancers detected — from 112 to 234 cases per 100,000 women. But late-stage cancers dropped just 8 percent, from 102 to 94 cases per 100,000 women.

The imbalance suggests a lot of overdiagnosis from mammograms, which now account for 60 percent of cases that are found, Bleyer said. If screening were working, there should be one less patient diagnosed with late-stage cancer for every additional patient whose cancer was found at an earlier stage, he explained.

"Instead, we're diagnosing a lot of something else — not cancer" in that early stage, Bleyer said. "And the worst cancer is still going on, just like it always was."

Researchers also looked at death rates for breast cancer, which declined 28 percent during that time in women 40 and older — the group targeted for screening. Mortality dropped even more — 41 percent — in women under 40, who presumably were not getting mammograms.

"We are left to conclude, as others have, that the good news in breast cancer — decreasing mortality — must largely be the result of improved treatment, not screening," the authors write.

The study was paid for by the study authors' universities.

"This study is important because what it really highlights is that the biology of the cancer is what we need to understand" in order to know which ones to treat and how, said Dr. Julia A. Smith, director of breast cancer screening at NYU Langone Medical Center in New York. Doctors already are debating whether DCIS, a type of early tumor confined to a milk duct, should even be called cancer, she said.

Another expert, Dr. Linda Vahdat, director of the breast cancer research program at Weill Cornell Medical College in New York, said the study's leaders made many assumptions to reach a conclusion about overdiagnosis that "may or may not be correct."

"I don't think it will change how we view screening mammography," she said.

A government-appointed task force that gives screening advice calls for mammograms every other year starting at age 50 and stopping at 75. The American Cancer Society recommends them every year starting at age 40.

Dr. Len Lichtenfeld, the cancer society's deputy chief medical officer, said the study should not be taken as "a referendum on mammography," and noted that other high-quality studies have affirmed its value. Still, he said overdiagnosis is a problem, and it's not possible to tell an individual woman whether her cancer needs treated.

"Our technology has brought us to the place where we can find a lot of cancer. Our science has to bring us to the point where we can define what treatment people really need," he said.

___

Online:

Study: http://www.nejm.org/doi/full/10.1056/NEJMoa1206809

Screening advice: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm

___

Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP

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Silent skies over Gaza after cease-fire

The rockets and missiles fell silent over Gaza for the first time in eight days today, but gunfire erupted in the crowded streets of the Palestinian enclave to celebrate the announcement of a ceasefire in the bloody conflict between Israel and Hamas.

The two sides fired final salvos at one another up until the final moments before the 2 p.m. ET cease-fire deadline. At least one Israeli missile landed at 1:57 p.m. ET in Gaza, and four rockets were launched toward the Israeli province of Beer Sheva at 1:59 p.m. ET.

After 2 p.m. ET, however, the sky was finally empty of munitions.

The eight days of fighting left 130 Palestinans and five Israelis dead, and badly damaged many of Gaza's buildings. A bomb that exploded on a bus in Tel Aviv earlier today left an additional 10 Israelis wounded.

The fighting came to an end after a meeting between Egyptian President Mohammed Morsi and U.S. Secretary of State Hillary Clinton.

"This is a critical moment for the region," Clinton said after the meeting, standing next to Egyptian Foreign Minister Mohamed Kamel Amr to announce the deal.

"The people of this region deserve a chance to live free of fear and violence and today's agreement is a step" in that direction, Clinton said. "Now we have to focus on reaching a durable outcome."

Clinton said that Egypt and the U.S. would help support the peace process going forward.

"Ultimately every step must move us toward a comprehensive peace for people of the region," she said.

Israeli Prime Minister Benjamin Netanyahu confirmed the cease-fire from Tel Aviv after Clinton's announcement.

"I agree that that it was a good idea to give an opportunity to the cease-fire... in order to enable Israeli citizens to return to their day to day lives," Netanyahu said.

He reiterated that it was vital to Israel's security to "prevent smuggling of arms to terrorist organizations" in the future.

An Israeli official told ABC News that the ceasefire would mean a "quiet for quiet" deal, in which both sides stop shooting and "wait and see what happens."

"Who knows if the ceasefire will even last two minutes," the official said. The official said that any possible agreement on borders and blockades on the Gaza/Israel border would come only after a period of quiet.

Clinton and Morsi met for three hours in Cairo today to discuss an end to the violence. The secretary of state met with Netanyahu Tuesday night for more than two hours, saying she sought to "de-escalate the situation in Gaza."

The fighting dragged on Tuesday night and Wednesday morning despite Hamas officials declaring publicly Tuesday afternoon that they expected a cease-fire would be announced Tuesday night, after Clinton and Netanyahu's talks.

The airstrikes by the Israeli Defense Forces overnight hit government ministries, underground tunnels, a banker's empty villa and a Hamas-linked media office. At least four strikes within seconds of each other pulverized a complex of government ministries the size of a city block, rattling nearby buildings and shattering windows.

Hours later, clouds of acrid dust still hung over the area and smoke still rose from the rubble. Gaza health officials said there were no deaths or injuries.

On Wednesday morning, the IDF said they had destroyed 50 underground rocket launching sites in Gaza. They also said that Israel's "Iron Dome" missile shield intercepted two rockets from Gaza into Israel overnight as well.

Around 12 p.m. in Israel, however, a bomb exploded on a public bus near the nation's military headquarters in Tel Aviv, in one of the city's busiest areas. Israel police said the explosion was a terrorist attack, the first in Israel since 2006.

Upon landing in Cairo to meet with Morsi, Clinton released a statement condemning the attack.

"The United States strongly condemns this terrorist attack and our thoughts and prayers are with the victims and the people of Israel. As I arrive in Cairo, I am closely monitoring reports from Tel Aviv, and we will stay in close contact with Prime Minister Netanyahu's team. The United States stands ready to provide any assistance that Israel requires," she said.

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Afghan revolving door: 5 US generals, 5 years

KABUL, Afghanistan (AP) — For former CIA director David Petraeus, it was a one-year stint as top U.S. commander in Afghanistan. His replacement is scheduled to leave next year after 18 months in the job.

And now the sex scandal that draws them together — Petraeus' career toppled and Marine Gen. John Allen's possibly on hold — also has placed greater attention to the quick turnover of American battlefield chiefs in the 11-year war.

Nearly two dozen generals have commanded troops from the United States and the NATO-led International Security Assistance Force, or ISAF, since the American invasion in late 2001 — with five U.S. generals running both commands in the past five years alone.

There is no firm evidence the Pentagon's revolving door in Afghanistan has posed any significant obstacles for U.S. troops, but some military analysts suggest the frequent changes at the top create potential breaks in continuity in the critical cooperation with the Afghan political leadership and security officials.

"The learning curve is pretty steep," said retired Lt. Gen. David Barno, who commanded U.S. forces in Afghanistan in 2003 and 2004. "One of the critical coins of the realm in being effective in this kind of environment is relationships among your allies, relationships with the host nation, and with the Afghans."

Iraq also had regular command changes, including Petraeus in charge during the U.S. troop "surge" in 2007 that helped dislodge insurgent control from key areas. But the war strategy in Afghanistan has, at many times, been even more complex as fronts shift and Taliban fighters regain strength.

"Rotating top commanders on an annual basis makes no management sense," Thomas E. Ricks, a senior fellow at the Center for a New American Security, wrote in an opinion piece published recently in The New York Times.

"Imagine trying to run a corporation by swapping the senior executives every year," he continued. "Or imagine if, at the beginning of 1944, six months before D-Day, Gen. George C. Marshall, the Army chief of staff, told Gen. Dwight D. Eisenhower, the supreme allied commander, that it was time to give someone else a chance to lead."

Petraeus, a four-star general, took over the Afghan command in July 2010 to fill a void after Gen. Stanley A. McChrystal was fired because of scathing remarks about America's civilian leadership. McChrystal's predecessor, Gen. David McKiernan, was ousted on May 11, 2009, a year before his term as commander was set to end because newly elected President Barack Obama wanted a new war policy. He had succeeded Gen. Dan McNeill, who served in 2007-08.

Petraeus completed a one-year term and retired to become CIA director in September 2011.

He resigned Nov. 9 after he had an extramarital affair with his biographer. Allen, who also has four stars, is under investigation following revelations that he exchanged thousands of emails with a Florida socialite also involved in the Petraeus case, including a few which were found to be of a questionable nature.

Some analysts and former military officers say that rotating generals so quickly creates a disconnect between the commanders and their Afghan allies, including the mercurial President Hamid Karzai. Commanders also have to deal with billions of dollars in funds and the complexities of handing over security to the Afghans by the end of 2014, including building an army and police of 352,000 almost from scratch.

Gen. Mohammad Zahir Azimi, a spokesman for the Afghan Ministry of Defense, said the longer a NATO commander stays in the job, the more chance he has to really understand Afghanistan.

"For us, an Afghan army corps commander should stay in his position for at least three years," he said.

Jawed Kohistani, military analyst in Kabul, said he thinks a constant changeover of senior NATO commanders or Afghan military leaders hampers coordination of the two forces. Staying longer, he believes, allows a commander to know insurgents and their weaknesses.

"It gives an opportunity for the enemy to use this gap — the time between the leaving of one commander and the arrival of another — to their advantage," Kohistani said. "There should be enough time for a NATO commander to get to know the Afghan president, vice presidents, security ministers and assess the situation. If he doesn't have enough time to do all these things, it has a negative effect on the security situation."

Obama sped up the confirmation hearing last week for Gen. Joseph Dunford to become the 15th ISAF commander and replace Allen, who was to leave in the spring after 18 months at the helm for a new job as U.S. European Command chief and NATO supreme allied commander. But Allen's confirmation has been postponed until an investigation into his role is concluded.

There have also been about a half-dozen U.S. generals who only commanded American combat troops in the first years of the conflict.

By comparison, the command tours of generals in Iraq "averaged almost twice as long as ISAF's," said Stephen Biddle, a professor of political science and international affairs at George Washington University.

Given the huge funds involved in the war effort, running the Afghan campaign has been as complicated as managing a multibillion dollar corporation.

Anthony Cordesman, a national security expert at the Center for Strategic and International Studies, said the lack of continuity includes both the military and civilian presence in Afghanistan, including the State Department and other agencies.

"What the Afghans see is constant change at every level," he said. "They constantly see people come and go. They have no reason to establish lasting relationships. People leave at the point where they're becoming most effective."

He added that "this constant rotation is a problem everybody recognizes, but no one has really been willing to address."

The Pentagon also has a number of senior leaders — ranging from the chairman of the joint chiefs of staff and defense secretary to the commander of U.S. Central Command — who also play key roles in the war strategy and provide some continuity.

"There is no doubt that the frequent changeover is tough. There is a learning curve each time a new man takes the helm,"

"The good aspect to this is that it brings a fresh set of eyes," said Michael O'Hanlon, a fellow at the Brookings Institution in Washington. "It's not realistic to have commanders serve a whole lot longer than, say, Gen. Allen ... as these folks get tired."

___

Baldor reported from Washington. Associated Press writers Rahim Faiez and Deb Riechmann in Kabul contributed to this report.

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Ex-'Price is Right' model wins suit against show

LOS ANGELES (AP) — Jurors awarded nearly $777,000 Tuesday to a former "The Price is Right" model who claimed she was discriminated against by producers because of her pregnancy.

Brandi Cochran, 41, said she was rejected by the game show's producers when she tried to return to work in early 2010 after taking maternity leave.

The Superior Court jury determined her pregnancy was the reason she wasn't rehired and awarded Cochran $776,944 in the suit against producers FremantleMedia North America and The Price is Right Productions.

In their defense, producers said they were satisfied with the five models working on the show at the time Cochran sought to return.

A second phase of the trial will determine whether Cochran should be awarded punitive damages. Cochran's attorneys had asked for more than $8 million, City News Service reported.

Jurors began deliberations Thursday, telling Judge Kevin Brazile several times that they were deadlocked before reaching the verdict.

In a statement, FremantleMedia said it expects to be "fully vindicated" after an appeal, adding that it stands behind executive producer Mike Richards and the show's staff.

"We believe the verdict in this case was the result of a flawed process in which the court, among other things, refused to allow the jury to hear and consider that 40 percent of our models have been pregnant," and further "important" evidence, FremantleMedia said.

A call seeking comment from Cochran's attorney wasn't immediately returned Tuesday.

The verdict is a rare one for a program that has seen other lawsuits. Longtime host Bob Barker, who retired in 2007, was sued by some of the show's hostesses for sexual harassment and wrongful termination.

Most of the cases involving "Barker's Beauties" — the nickname given the gown-wearing women who presented prizes to contestants — ended with out-of-court settlements.

Comedian-actor Drew Carey followed Barker as the show's host.

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OB/GYNs back over-the-counter birth control pills

WASHINGTON (AP) — No prescription or doctor's exam needed: The nation's largest group of obstetricians and gynecologists says birth control pills should be sold over the counter, like condoms.

Tuesday's surprise opinion from these gatekeepers of contraception could boost longtime efforts by women's advocates to make the pill more accessible.

But no one expects the pill to be sold without a prescription any time soon: A company would have to seek government permission first, and it's not clear if any are considering it. Plus there are big questions about what such a move would mean for many women's wallets if it were no longer covered by insurance.

Still, momentum may be building.

Already, anyone 17 or older doesn't need to see a doctor before buying the morning-after pill — a higher-dose version of regular birth control that can prevent pregnancy if taken shortly after unprotected sex. Earlier this year, the Food and Drug Administration held a meeting to gather ideas about how to sell regular oral contraceptives without a prescription, too.

Now the influential American College of Obstetricians and Gynecologists is declaring it's safe to sell the pill that way.

Wait, why would doctors who make money from women's yearly visits for a birth-control prescription advocate giving that up?

Half of the nation's pregnancies every year are unintended, a rate that hasn't changed in 20 years — and easier access to birth control pills could help, said Dr. Kavita Nanda, an OB/GYN who co-authored the opinion for the doctors group.

"It's unfortunate that in this country where we have all these contraceptive methods available, unintended pregnancy is still a major public health problem," said Nanda, a scientist with the North Carolina nonprofit FHI 360, formerly known as Family Health International.

Many women have trouble affording a doctor's visit, or getting an appointment in time when their pills are running low — which can lead to skipped doses, Nanda added.

If the pill didn't require a prescription, women could "pick it up in the middle of the night if they run out," she said. "It removes those types of barriers."

Tuesday, the FDA said it was willing to meet with any company interested in making the pill nonprescription, to discuss what if any studies would be needed.

Then there's the price question. The Obama administration's new health care law requires FDA-approved contraceptives to be available without copays for women enrolled in most workplace health plans.

If the pill were sold without a prescription, it wouldn't be covered under that provision, just as condoms aren't, said Health and Human Services spokesman Tait Sye.

ACOG's opinion, published in the journal Obstetrics & Gynecology, says any move toward making the pill nonprescription should address that cost issue. Not all women are eligible for the free birth control provision, it noted, citing a recent survey that found young women and the uninsured pay an average of $16 per month's supply.

The doctors group made clear that:

—Birth control pills are very safe. Blood clots, the main serious side effect, happen very rarely, and are a bigger threat during pregnancy and right after giving birth.

—Women can easily tell if they have risk factors, such as smoking or having a previous clot, and should avoid the pill.

—Other over-the-counter drugs are sold despite rare but serious side effects, such as stomach bleeding from aspirin and liver damage from acetaminophen.

—And there's no need for a Pap smear or pelvic exam before using birth control pills. But women should be told to continue getting check-ups as needed, or if they'd like to discuss other forms of birth control such as implantable contraceptives that do require a physician's involvement.

The group didn't address teen use of contraception. Despite protests from reproductive health specialists, current U.S. policy requires girls younger than 17 to produce a prescription for the morning-after pill, meaning pharmacists must check customers' ages. Presumably regular birth control pills would be treated the same way.

Prescription-only oral contraceptives have long been the rule in the U.S., Canada, Western Europe, Australia and a few other places, but many countries don't require a prescription.

Switching isn't a new idea. In Washington state a few years ago, a pilot project concluded that pharmacists successfully supplied women with a variety of hormonal contraceptives, including birth control pills, without a doctor's involvement. The question was how to pay for it.

Some pharmacies in parts of London have a similar project under way, and a recent report from that country's health officials concluded the program is working well enough that it should be expanded.

And in El Paso, Texas, researchers studied 500 women who regularly crossed the border into Mexico to buy birth control pills, where some U.S. brands sell over the counter for a few dollars a pack. Over nine months, the women who bought in Mexico stuck with their contraception better than another 500 women who received the pill from public clinics in El Paso, possibly because the clinic users had to wait for appointments, said Dr. Dan Grossman of the University of California, San Francisco, and the nonprofit research group Ibis Reproductive Health.

"Being able to easily get the pill when you need it makes a difference," he said.

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Online:

OB/GYN group: http://www.acog.org

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Clinton’s high-profile swan song

Secretary of State Hillary Rodham Clinton at a meeting with President Barack Obama, second from left, and Japan's …Secretary of State Hillary Rodham Clinton was supposed to be heading for the exit, even as the fight over who should succeed her escalated. Instead, America's top diplomat sped Tuesday to the Middle East on an urgent mission to douse flaring violence between Israel and Hamas, the Islamist Palestinian group that controls Gaza.

Amid early, disputed reports of a possible truce, Clinton had several major goals: Ease the violence, bolster Egyptian President Mohammed Morsi, and avoid an appearance of giving Hamas any sort of legitimacy on the world stage. The U.S. regards Hamas as a terrorist group and deals only with the Palestinian Authority of President Mahmoud Abbas, which controls the West Bank but has been relegated to the sidelines of the latest deadly clashes.

As Clinton winged her way to the troubled region, President Barack Obama—en route to Washington from a trip to Asia—spoke by telephone to Morsi from Air Force One, their third such conversation in 24 hours.

Obama "commended President Morsi's efforts to pursue a de-escalation," Deputy National Security Adviser Ben Rhodes told reporters aboard the presidential plane. "And he also underscored that President Morsi's efforts reinforce the important role that President Morsi and Egypt play on behalf of regional security and the pursuit of broader peace between the Palestinians and Israelis."

Morsi, whose country shares a peace accord with Israel and a border with Gaza, is thought to have sway with Hamas.

Clinton was to stop in Jerusalem for talks with Israeli Prime Minister Benjamin Netanyahu, in Ramallah to meet with Abbas and in Cairo for discussions with Morsi. State Department spokeswoman Victoria Nuland said Clinton aimed for a "de-escalation of violence and a durable outcome that ends the rocket attacks on Israeli cities and towns and restores a broader calm."

American officials have been leery of using the term "cease-fire," preferring variations on "de-escalation" of the conflict.

Clinton's visit came as the political battle over the Sept. 11 terrorist attack on the American compound in Benghazi, Libya, clouded the debate over who will succeed her.

Republicans have accused the Obama administration of covering up the role of suspected extremists in the assault, and questioned whether Clinton's State Department correctly handled requests for more security at the site. The president's foes have targeted Susan Rice, the U.S. ambassador to the United Nations, who at the request of the White House in several television interviews incorrectly tied the attack to protests sparked by an Internet video that ridiculed Islam.

The Benghazi strike claimed the lives of Ambassador Chris Stevens and three other Americans. It has also highlighted the uncertain fate of so-called Arab spring countries—like Egypt—where popular movements swept aside decades-old authoritarian regimes.

Ahead of Clinton's visit, the White House renewed its support for Israel's military operations but hinted at disapproval of a possible ground offensive. Netanyahu's government has called up thousands of troops in what could be preparations for such an onslaught.

Rhodes told reporters the U.S. would prefer to see the Israelis work "diplomatically and peacefully" to resolve the crisis, noting both Palestinian and Israeli civilians would be at risk in the event of a ground assault.

Clinton's stop in Ramallah underscored a diplomatic peculiarity of her trip: Top U.S. officials regard the Palestinian Authority as such minor players in the current crisis, neither Obama nor Clinton have spoken to Abbas since the violence escalated nearly a week ago.

While Clinton by Monday had reached out to leaders—including Jordan's King Abdullah; the foreign ministers of Israel, Egypt, France and Turkey; Egypt's prime minister; and U.N. Secretary-General Ban Ki-moon—she had not spoken to Abbas.

By refusing to deal directly with Hamas and reaching out to the Palestinian Authority instead, Clinton appeared to be trying to resolve the conflict without involving one of the key participants.

Rhodes on Tuesday reiterated U.S. conditions for dealing directly with Hamas: The group must renounce terrorism and recognize Israel's right to exist.

He also defended Clinton's trip to Ramallah, calling it a worthwhile investment "both as it relates to what's happening in Gaza and our efforts going forward to improve the situation in Gaza, but also in terms of our broader efforts to pursue peace between the Israelis and Palestinians."

Rhodes's message was implicit but unmistakable:  If the Palestinians want a lasting peace deal, they should align with the Palestinian Authority and not with Hamas or other extremist groups.

The U.S. has for years been steadfast in its posture toward Hamas. Massachusetts Sen. John Kerry, a top contender for Clinton's job, did not talk to Hamas when he made a surprise visit to Gaza in January 2009.

Clinton headed to the Middle East after traveling to Asia with Obama on what aides to both expected would be their final joint trip overseas, including a history-making stop in Myanmar.

Aboard Air Force One on a flight between Rangoon and Cambodia, the one-time political rivals sat in Obama's private office sharing memories of their work together.

"As the president said, it wasn't just the last four years; they have been through a lot together over the last five or six years," Rhodes said. "But right now there is urgent business to be done."

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