The Lede: Syrians Describes Apparent Missile Strikes on Aleppo

A Human Rights Watch video report on the aftermath of apparent missile strikes in Syria’s largest city, Aleppo.

Human Rights Watch investigators who visited Aleppo, Syria’s largest city, have concluded that the Syrian government fired at least four ballistic missiles into civilian neighborhoods there last week, killing more than 141 people, including 71 children. As my colleague Anne Barnard explained, the rights group released details of the four documented strikes, and a video report, on Tuesday.

On Wednesday, opposition activists added English subtitles to an emotional account of the devastation caused by one missile strike on Aleppo from a young boy who said he survived the bombing, but lost several family members and neighbors.

A video interview with a young boy who said that he had survived a missile attack on a civilian neighborhood in Aleppo, Syria’s largest city.

The original interview with the boy was posted on YouTube on Monday by Orient News, a private Syrian satellite channel that began broadcasting from Dubai before the anti-government uprising began. Within a week of the first protests in Syria, Ghassan Abboud, the Syrian businessman who owns the channel, told a Saudi broadcaster that senior government officials close to President Bashar al-Assad had threatened to kidnap his journalists if they did not stop covering the demonstrations.

The boy’s testimony was subtitled by the ANA New Media Association, a group of opposition video activists led by Rami Jarrah, who blogs as Alexander Page.

The new reports come weeks after experts told The Lede that video of a huge explosion at Aleppo University last month suggested that the campus had been hit by a ballistic missile.

When Liz Sly of the Washington Post visited Aleppo’s Ard al-Hamra neighborhood after two missile strikes, residents gave similarly graphic accounts of pulling the mangled bodies of victims from wrecked buildings. The scenes of devastation, she wrote, “more closely resembling those of an earthquake, with homes pulverized beyond recognition, people torn to shreds in an instant and what had once been thriving communities reduced to mountains of rubble.”

Ole Solvang, a Human Rights Watch researcher who helped document the damage in Aleppo, drew attention to video posted online by opposition activists, said to show the desperate search for survivors in the immediate aftermath of the strike on Ard al-Hamra.

Video said to show a neighborhood in Syria’s largest city, Aleppo, after a missile strike last week.

As Mr. Solvang assessed the wreckage in person on Thursday and Friday, he described the damage to Aleppo and a neighboring town in words and images posted on Twitter.

Visited a site of similar attack in Tel Rifat today. 25 houses destroyed and 3 killed last Monday. Unbelievable. http://t.co/FaFhNFiAsS

— Ole Solvang (@OleSolvang) 22 Feb 13

Today visited site of yesterday’s missile attack on Ard al Hamra in #Aleppo #Syria. Dozens houses destroyed. Unbelievable destruction. @hrw

— Ole Solvang (@OleSolvang) 23 Feb 13

Bodies are still under the rubble. 3 found during our 30 min visit. Casualty # still unclear. #Aleppo #Syria @hrw http://t.co/gaT7COpRT3

— Ole Solvang (@OleSolvang) 23 Feb 13

Late Tuesday, an Aleppo blogger who supported the uprising but has been critical of the armed rebellion on his @edwardedark Twitter feed, reported that another huge blast had shaken the city.

a massive blast shockwave shakes Aleppo city just now. no idea what it is yet #Syria

— edward dark (@edwardedark) 26 Feb 13

Ms. Sly reported on Twitter Wednesday night that two more missiles were fired at rural Aleppo. “They landed in fields,” she observed. “That’s how accurate they are. Seems a bit pointless.”

Late Wednesday, Mr. Solvang pointed to video posted on YouTube by opposition activists, showing what they said were distant images of a missile being launched from Damascus in the direction of Aleppo.

Video said to show a missile being fired by Syrian government forces outside the capital, Damascus, on Wednesday night.

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AP Source: 49ers to send Smith to KC

SAN FRANCISCO (AP) — Alex Smith quietly stayed behind the scenes after losing his job and watched from the sideline as San Francisco returned to the Super Bowl for the first time in 18 years. Yet the No. 1 overall draft pick from 2005 did make one thing known: The veteran quarterback still considers himself a starter.

And he hoped to get that chance again. Now, he appears to have it.

The Kansas City Chiefs have agreed to acquire Smith from the 49ers in the first major acquisition since Andy Reid took over as the team's new coach in early January, a person with knowledge of the trade told The Associated Press on Wednesday.

The person spoke on condition of anonymity because the deal cannot become official until March 12, when the NFL's new business year begins. Another person familiar with the swap said the 49ers will get a second-round pick in April's draft, No. 34 overall, and a conditional pick in the 2014 draft.

After spending his first eight up-and-down years with the 49ers, Smith will get a welcome new start. The Chiefs will get the proven play-caller they hope can help turn things around under a new coach much the way Smith did under Jim Harbaugh in San Francisco.

"You never know when your opportunity's going to come," Smith said late in the season. "The good ones are ready when they do come."

The Chiefs have gone this route before, acquiring Joe Montana from the 49ers nearly 20 years ago, in April 1993, after he won four Super Bowls but gave way to Steve Young — San Francisco's quarterback of the future.

Not so different from Smith's situation last season behind second-year QB Colin Kaepernick.

Moving Smith was hardly unexpected. He realized it once Kaepernick emerged as a capable starter over the season's final two months, and Smith all but said goodbye with his first pro team when he played briefly in the regular-season finale against Arizona to cheers of "Let's Go, Alex!" and "Alex! Alex!" from the Candlestick Park crowd.

With Smith now headed for Kansas City, Matt Cassel is likely headed out of town. And Reid will enter his first draft as Chiefs coach in April no longer needing to search for a quarterback.

The Chiefs' problems at quarterback are the single biggest reason they went 2-14 last season and secured the No. 1 pick in the draft for the first time in franchise history.

It's been a long-running problem for a franchise that has tried Steve Bono and Elvis Grbac (two more one-time 49ers), and more recently Damon Huard, Tyler Thigpen and Tyler Palko at quarterback. And then there's Cassel.

He was acquired by recently fired general manager Scott Pioli, and has two years left on a $63 million, six-year deal. He will likely be cut once Smith is acquired.

Cassel was benched last season in favor of Brady Quinn, who also is a free agent after going 1-7 as the starter.

If Smith can bring the steady form that defined his last two years, the Chiefs might be able to establish a much-needed consistency under center. They also found themselves a team-first player who led the 49ers through workouts during the 2011 lockout.

Under the three-year contract he signed last March, Smith is guaranteed $8.5 million in base salary for the 2013 season.

Smith thrived under 49ers coach and former NFL quarterback Harbaugh in one-plus season as the starter. Then, just like that, it all changed after he sustained a concussion.

Last week at the NFL combine, Harbaugh praised Smith and reiterated just how strong San Francisco was with Colin Kaepernick as the starter and someone with Smith's credentials at backup.

Yet everyone knew it was likely the 49ers would do their best to improve Smith's situation considering all he did for the franchise for nearly the past decade.

"Alex is really playing the best football of his career the last two years," Harbaugh said. "We think we got the best quarterback situation in the National Football League, feel strongly about that. Again, that'll be a process that plays out. Alex Smith continuing to be a 49er or if a trade occurs in the next weeks or months. Those are the two possibilities, most likely possibilities."

Smith acknowledged when he lost the job to Kaepernick back in November that he had done nothing wrong but get hurt. Not only had he completed 26 of his previous 28 passes — 18 of 19 for 232 yards and three touchdowns without an interception and a 157.1 passer rating in a Monday Night Football win at Arizona on Oct. 29 — Smith had just earned NFC Offensive Player of the Week honors after that victory in the desert.

He then sustained a concussion in the second quarter of a 24-24 tie against St. Louis on Nov. 11 — saying later he threw a touchdown pass with blurry vision. Smith sat out the next game as Kaepernick dazzled in his debut as an NFL starter, beating the Bears handily at home on Monday Night Football.

After that, Harbaugh vowed to stick with the "hot hand," as he regularly put it, while complicating matters by still referring to Smith as a starter.

Smith's most poignant response to the situation was, "I feel like the only thing I did to lose my job was get a concussion."

Kaepernick led the 49ers to the NFC championship and a 34-31 loss to Baltimore in the Super Bowl in his second season. Now the 49ers are looking for his backup.

The 28-year-old Smith struggled for most of his career in San Francisco, plagued as much by coaching and constant coordinator changes as by his own indecisiveness. But when Harbaugh became coach in January 2011, Smith blossomed under the former QB's guidance. He was among the league leaders in passer rating (104.1) with a 70.2 completion percentage when he got hurt last season.

Fox Sports first reported the deal Wednesday.

___

AP Pro Football Writer Barry Wilner and AP Sports Writer Dave Skretta contributed to this story.

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Global Health: After Measles Success, Rwanda to Get Rubella Vaccine

Rwanda has been so successful at fighting measles that next month it will be the first country to get donor support to move to the next stage — fighting rubella too.

On March 11, it will hold a nationwide three-day vaccination campaign with a combined measles-rubella vaccine, hoping to reach nearly five million children up to age 14. It will then integrate the dual vaccine into its national health service.

Rwanda can do so “because they’ve done such a good job on measles,” said Christine McNab, a spokeswoman for the Measles and Rubella Initiative. M.R.I. helped pay for previous vaccination campaigns in the country and the GAVI Alliance is helping to finance the upcoming one.

Rubella, also called German measles, causes a rash that is very similar to the measles rash, making it hard for health workers to tell the difference.

Rubella is generally mild, even in children, but in pregnant women, it can kill the fetus or cause serious birth defects, including blindness, deafness, mental retardation and chronic heart damage.

Ms. McNab said that Rwanda had proved that it can suppress measles and identify rubella, and it would benefit from the newer, more expensive vaccine.

The dual vaccine costs twice as much — 52 cents a dose at Unicef prices, compared with 24 cents for measles alone. (The MMR vaccine that American children get, which also contains a vaccine against mumps, costs Unicef $1.)

More than 90 percent of Rwandan children now are vaccinated twice against measles, and cases have been near zero since 2007.

The tiny country, which was convulsed by Hutu-Tutsi genocide in 1994, is now leading the way in Africa in delivering medical care to its citizens, Ms. McNab said. Three years ago, it was the first African country to introduce shots against human papilloma virus, or HPV, which causes cervical cancer.

In wealthy countries, measles kills a small number of children — usually those whose parents decline vaccination. But in poor countries, measles is a major killer of malnourished infants. Around the world, the initiative estimates, about 158,000 children die of it each year, or about 430 a day.

Every year, an estimated 112,000 children, mostly in Africa, South Asia and the Pacific islands, are born with handicaps caused by their mothers’ rubella infection.

Thanks in part to the initiative — which until last year was known just as the Measles Initiative — measles deaths among children have declined 71 percent since 2000. The initiative is a partnership of many health agencies, vaccine companies, donors and others, but is led by the American Red Cross, the United Nations Foundation, the Centers for Disease Control and Prevention, Unicef and the World Health Organization.

This article has been revised to reflect the following correction:

Correction: February 27, 2013

An earlier version of this article misstated the source of the vaccine and some financing for the campaign. The vaccine and financing is being provided by the GAVI Alliance, not the Measles and Rubella Initiative.

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DealBook: J.C. Penney’s Poor Showing Is Another Retail Miss for Ackman

With J.C. Penney‘s awful fourth-quarter results, William A. Ackman has found success in retail investments elusive once more.

It’s hard to call J.C. Penney’s latest quarterly report anything but breathtaking. The retailer lost $552 million for the quarter, which at $1.95 a share far exceeded the 17-cent loss that analysts had been expecting. Same-store sales tumbled nearly 32 percent from the same time a year ago.

Shares in the company were down nearly 9 percent in after-hours trading.

So far, J.C. Penney’s chief executive, Ron Johnson — whom Mr. Ackman recruited from Apple — has asked for patience, citing all the changes that he has rolled out at the formerly dowdy department store chain. (Indeed, he spent the first several minutes of an investor Webcast on Wednesday enumerating the many innovations at the store.)

One wonders whether Mr. Ackman, whose Pershing Square Capital Management owns a 17.8 percent stake in J.C. Penney, can wait that long.

It isn’t the first time that he has taken a bath betting on a retailer. Mr. Ackman’s most recent failure in the industry was a bet on the Borders Group, taking a 17 percent stake in the troubled bookseller by late 2007.

Despite efforts by the hedge fund manager to help prop up the company, including offering to finance a merger with the much larger Barnes & Noble, Borders filed for bankruptcy in late 2010. Mr. Ackman has acknowledged losing at least $125 million on the investment.

Perhaps his most notable troubled investment was in Target, a wager in which Mr. Ackman actually created a special fund dedicated to the discount retailer. He also embarked on a lengthy and expensive campaign to gain seats on the company’s board, to forcefully advocate for a complicated restructuring he said would generate better returns for shareholders.

That didn’t quite work out either. Mr. Ackman lost the proxy fight. He sold Pershing’s stake by early 2011, having lost about 90 percent of his firm’s $2 billion investment.

Last month, it appeared that Mr. Ackman was willing to give Mr. Johnson room to prove naysayers wrong. “We put Ron in charge, and we’re letting him run the company,” the hedge fund manager told CNBC in an interview.

But he added that he’ll run out of patience — in three year’s time.

“If three years from now, Ron Johnson is still struggling to turn around J.C. Penney,” Mr. Ackman said to CNBC, “he’s probably the wrong guy.”

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Rocket From Gaza Hits Israel, Breaking Cease-Fire

Tsafrir Abayov/Associated Press

Israeli explosives experts gathered near a rocket believed to have been fired from the Gaza Strip, landing near Ashkelon, on Tuesday.

JERUSALEM — A Grad rocket fired from the Gaza Strip struck in southern Israel early Tuesday, threatening to further escalate tensions that have been mounting since Saturday, when a 30-year-old Palestinian prisoner died in an Israeli jail.

The rocket, which came down on a road outside the city of Ashkelon and caused no injuries, was the first from Gaza to hit Israel in the three months since a cease-fire agreement ended eight days of cross-border violence. Israel has violated the cease-fire several times by firing on fishermen and farmers approaching newly relaxed security perimeters, but the agreement has otherwise held.

A subgroup of the Al Aksa Martyrs Brigade, the military wing of the Palestinians’ Fatah faction, said it fired the rocket in response to what it called the “assassination” of Arafat Jaradat, the prisoner who died on Saturday. Palestinian leaders have blamed Mr. Jaradat’s death on what they described as “severe torture” during interrogation, though Israeli officials say the bruising and broken ribs cited as evidence of torture could have been caused by resuscitation efforts.

Mushir al-Masri, a lawmaker from the militant Hamas faction that rules the Gaza Strip, said in an interview that Israel was “fully responsible for the consequences of the wave of the Palestinian public fury.”

After the rocket attack, Israel shut its border crossings with Gaza to goods and people, allowing only “medical, humanitarian and exceptional cases,” according to a statement from the military. President Shimon Peres, who was visiting southern Israel on a previously scheduled tour, said, “Quiet will be met with quiet; missiles will be met with a response.”

Giora Eiland, a senior research fellow at Israel’s Institute for National Security Studies, said renewed rocket fire could change the current delicate balance between Israel and the Palestinians, because international opinion is largely critical of Israel’s actions in the West Bank but is sympathetic when Israel comes under attack from Gaza.

“I believe that it is under control, it can be contained, and with some gestures from both sides and clear messages from Washington — which I understand are coming every few hours — it will be able to prevent an escalation and not to deteriorate ourselves to a third intifada,” Mr. Eiland said, using the Arabic word for uprising. “There is a very delicate line between two conflicting interests: to do something in order to preserve the Jihadiic identity, to preserve the spirit of resistance, to serve so many domestic interests, but not to do something that would bring some unproportional response.”

Fares Akram contributed reporting from Gaza City.

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Experts: Pistorius violated basic firearms rules

JOHANNESBURG (AP) — Even if Oscar Pistorius is acquitted of murder, firearms and legal experts in South Africa believe that, by his own account, the star athlete violated basic gun-handling regulations and exposed himself to a homicide charge by shooting into a closed door without knowing who was behind it.

Particularly jarring for firearms instructors and legal experts is that Pistorius testified that he shot at a closed toilet door, fearing but not knowing for certain that a nighttime intruder was on the other side. Instead of an intruder, Pistorius' girlfriend Reeva Steenkamp was in the toilet cubicle. Struck by three of four shots that Pistorius fired from a 9 mm pistol, she died within minutes. Prosecutors charged Pistorius with premeditated murder, saying the shooting followed an argument between the two. Pistorius said it was an accident.

South Africa has stringent laws regulating the use of lethal force for self-protection. In order to get a permit to own a firearm, applicants must not only know those rules but must demonstrate proficiency with the weapon and knowledge of its safe handling, making it far tougher to legally own a gun in South Africa than many other countries where a mere background check suffices.

Pistorius took such a competency test for his 9 mm pistol and passed it, according to the South African Police Service's National Firearms Center. Pistorius' license for the 9 mm pistol was issued in September 2010. The Olympic athlete and Paralympic medalist should have known that firing blindly, instead of at a clearly identified target, violates basic gun-handling rules, firearms and legal experts said.

"You can't shoot through a closed door," said Andre Pretorius, president of the Professional Firearm Trainers Council, a regulatory body for South African firearms instructors. "People who own guns and have been through the training, they know that shooting through a door is not going to go through South African law as an accident."

"There is no situation in South Africa that allows a person to shoot at a threat that is not identified," Pretorius added. "Firing multiple shots, it makes it that much worse. ...It could have been a minor — a 15-year-old kid, a 12-year-old kid — breaking in to get food."

The Pistorius family, through Arnold Pistorius, uncle of the runner, has said it is confident that the evidence will prove that Steenkamp's death in the predawn hours of Feb. 14 was "a terrible and tragic accident."

In an affidavit to the magistrate who last Friday freed him on bail, Pistorius said he believed an intruder or intruders had gotten into his US$560,000 (€430,000) two-story house, in a guarded and gated community with walls topped by electrified fencing east of the capital, Pretoria, and were inside the toilet cubicle in his bathroom. Believing he and Steenkamp "would be in grave danger" if they came out, "I fired shots at the toilet door" with the pistol that he slept with under his bed, he testified.

Criminal law experts said that even if the prosecution fails to prove premeditated murder, firing several shots through a closed door could bring a conviction for the lesser but still serious charge of culpable homicide, a South African equivalent of manslaughter covering unintentional deaths through negligence.

Johannesburg attorney Martin Hood, who specializes in firearm law, said South African legislation allows gun owners to use lethal force only if they believe they are facing an immediate, serious and direct attack or threat of attack that could either be deadly or cause grievous injury.

According to Pistorius' own sworn statement read in court, he "did not meet those criteria," said Hood, who is also the spokesman for the South African Gun Owners' Association.

"If he fired through a closed door, there was no threat to him. It's as simple as that," he added. "He can't prove an attack on his life ... In my opinion, at the very least, he is guilty of culpable homicide."

The Associated Press emailed a request for comment to Vuma, a South African reputation management firm hired by the Pistorius family to handle media questions about the shooting.

The firm replied: "Due to the legal sensitivities around the matter, we cannot at this stage answer any of your questions as it might have legal implications for a case that still has to be tried in a court of law." Vuma said on Monday it referred the AP's questions to Pistorius' legal team, which by Tuesday had not replied.

Culpable homicide covers unintentional deaths ranging from accidents with no negligence, like a motorist whose brakes fail, killing another road user, "to where it verges on murder or where it almost becomes intentional," said Hood. Sentences — ranging from fines to prison — are left to courts to determine and are not set by fixed guidelines.

The tough standards for legally acquiring a gun were instituted in part because of a wave of weapons purchases after the end of racist white rule in 1994, said Rick De Caris, a former legal director in the South African police. Under South Africa's white-minority apartheid regime, gun owners often learned how to handle firearms during military service. Many of the new gun owners had little or no firearms training, which brought tragic results, De Caris said.

"People were literally shooting themselves when cleaning a firearm," said De Caris, who helped draft the Firearms Control Act of 2000.

Prospective gun owners must now take written exams that include questions on the law, have to show they can safely handle and shoot a gun and are required to hit a target the size of a glossy magazine in 10 of 10 shots from seven meters (23 feet), said Pretorius of the Professional Firearm Trainers Council.

In his affidavit, Pistorius said he wasn't wearing his prosthetic limbs "and felt extremely vulnerable" after hearing noise from the toilet.

"I grabbed my 9 mm pistol from underneath my bed. On my way to the bathroom, I screamed words to the effect for him/them to get out of my house and for Reeva to phone the police. It was pitch-dark in the bedroom and I thought Reeva was in bed," he testified.

Legal experts said they are puzzled why Pistorius apparently didn't first fire a warning shot to show the supposed intruder he was armed. Also unanswered is why, after he heard noise in his bathroom that includes the toilet cubicle, Pistorius still went toward the bathroom — toward the perceived danger — rather than retreat back into his bedroom.

"He should have tried to get out of the situation," said Hood, the attorney.

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Advanced Breast Cancer May Be Rising Among Young Women, Study Finds

The incidence of advanced breast cancer among younger women, ages 25 to 39, may have increased slightly over the last three decades, according to a study released Tuesday.

But more research is needed to verify the finding, which was based on an analysis of statistics, the study’s authors said. They do not know what may have caused the apparent increase.

Some outside experts questioned whether the increase was real, and expressed concerns that the report would frighten women needlessly.

The study, published in The Journal of the American Medical Association, found that advanced cases climbed to 2.9 per 100,000 younger women in 2009, from 1.53 per 100,000 women in 1976 — an increase of 1.37 cases per 100,000 women in 34 years. The totals were about 250 such cases per year in the mid-1970s, and more than 800 per year in 2009.

Though small, the increase was statistically significant, and the researchers said it was worrisome because it involved cancer that had already spread to organs like the liver or lungs by the time it was diagnosed, which greatly diminishes the odds of survival.

For now, the only advice the researchers can offer to young women is to see a doctor quickly if they notice lumps, pain or other changes in the breast, and not to assume that they cannot have breast cancer because they are young and healthy, or have no family history of the disease.

“Breast cancer can and does occur in younger women,” said Dr. Rebecca H. Johnson, the first author of the study and medical director of the adolescent and young adult oncology program at Seattle Children’s Hospital.

But Dr. Johnson noted that there is no evidence that screening helps younger women who have an average risk for the disease and no symptoms. “We’re certainly not advocating that young women get mammography at an earlier age than is generally specified,” she said.

Expert groups differ about when screening should begin; some say at age 40, others 50.

Breast cancer is not common in younger women; only 1.8 percent of all cases are diagnosed in women from 20 to 34, and 10 percent in women from 35 to 44. However, when it does occur, the disease tends to be more deadly in younger women than in older ones. Researchers are not sure why.

The researchers analyzed data from SEER, a program run by the National Cancer Institute to collect cancer statistics on 28 percent of the population of the United States. The study also used data from the past when SEER was smaller.

The study is based on information from 936,497 women who had breast cancer from 1976 to 2009. Of those, 53,502 were 25 to 39 years old, including 3,438 who had advanced breast cancer, also called metastatic or distant disease.

Younger women were the only ones in whom metastatic disease seemed to have increased, the researchers found.

Dr. Archie Bleyer, a clinical research professor in radiation medicine at the Knight Cancer Institute at the Oregon Health and Science University in Portland who helped write the study, said scientists needed to verify the increase in advanced breast cancer in young women in the United States and find out whether it is occurring in other developed Western countries. “This is the first report of this kind,” he said, adding that researchers had already asked colleagues in Canada to analyze data there.

“We need this to be sure ourselves about this potentially concerning, almost alarming trend,” Dr. Bleyer said. “Then and only then are we really worried about what is the cause, because we’ve got to be sure it’s real.”

Dr. Johnson said her own experience led her to look into the statistics on the disease in young women. She had breast cancer when she was 27; she is now 44. Over the years, friends and colleagues often referred young women with the disease to her for advice.

“It just struck me how many of those people there were,” she said.

Dr. Donald A. Berry, an expert on breast cancer data and a professor of biostatistics at the University of Texas’ M. D. Anderson Cancer Center in Houston, said he was dubious about the finding, even though it was statistically significant, because the size of the apparent increase was so small — 1.37 cases per 100,000 women, over the course of 30 years.

More screening and more precise tests to identify the stage of cancer at the time of diagnosis might account for the increase, he said.

“Not many women aged 25 to 39 get screened, but some do, but it only takes a few to account for a notable increase from one in 100,000,” Dr. Berry said.

Dr. Silvia C. Formenti, a breast cancer expert and the chairwoman of radiation oncology at New York University Langone Medical Center, questioned the study in part because although it found an increased incidence of advanced disease, it did not find the accompanying increase in deaths that would be expected.

A spokeswoman for an advocacy group for young women with breast cancer, Young Survival Coalition, said the organization also wondered whether improved diagnostic and staging tests might explain all or part of the increase.

“We’re looking at this data with caution,” said the spokeswoman, Michelle Esser. “We don’t want to invite panic or alarm.”

She said it was important to note that the findings applied only to women who had metastatic disease at the time of diagnosis, and did not imply that women who already had early-stage cancer faced an increased risk of advanced disease.

Dr. J. Leonard Lichtenfeld
, deputy chief medical officer of the American Cancer Society, said he and an epidemiologist for the society thought the increase was real.

“We want to make sure this is not oversold or that people suddenly get very frightened that we have a huge problem,” Dr. Lichtenfeld said. “We don’t. But we are concerned that over time, we might have a more serious problem than we have today.”

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Economic Scene: Medicare Needs Fixing, but Not Right Now

What’s the rush? For all the white-knuckled wrangling over spending cuts set to start on Friday, the fundamental partisan argument over how to fix the government’s finances is not about the immediate future. It is about the much longer term: how will the nation pay for the care of older Americans as the vast baby boom generation retires? Will the government keep Medicare spending in check by asking older Americans to shoulder more costs? Should we raise taxes instead?

It might not be a good idea to try to resolve these questions quite so urgently. Partisan bickering under the threat of automatic budget cuts is unlikely to produce a calm, thoughtful deal.

“We don’t have to solve this tomorrow; not even next year,” said Jonathan Gruber, an economist at the Massachusetts Institute of Technology who worked on the design of President Obama’s health care reform.

More significantly perhaps, some economists point out that the problem may already be on the way toward largely fixing itself. The budget-busting rise in health care costs, it seems, is finally losing speed. While it would be foolhardy to assume that this alone will stabilize government’s finances, the slowdown offers hope that the challenge may not be as daunting as the frenzied declarations from Washington make it seem.

The growth of the nation’s spending slowed sharply over the last four years. This year, it is expected to increase only 3.8 percent, according to the Centers for Medicare and Medicaid Services, the slowest pace in four decades and slower than the rate of nominal economic growth.

Medicare spending is growing faster — stretched by baby boomers stepping out of the work force and into retirement. But its pace has slowed markedly, too. Earlier this month, the Congressional Budget Office said that by 2020 Medicare spending would be $126 billion less than it predicted three years ago. Spending over the coming decade, it added, would be $143 billion less than it forecast just last August.

While economists acknowledge that the recession accounts for part of the decline, depressing incomes and consumption, something else also seems to be going on: insurers, doctors, hospitals and other providers are experimenting with new, cheaper and more efficient ways to deliver care.

Prodded by President Obama’s Affordable Care Act, which offers providers a share of savings reaped by Medicare from any efficiency gains, many doctors are dropping the costly practice of charging a fee for each service regardless of its contribution to patients’ health. Doctors are joining hundreds of so-called Accountable Care Organizations, which are paid to maintain patients in good health and are thus encouraged to seek the most effective treatments at the lowest possible cost.

This has kindled hope among some scholars that Medicare could achieve the needed savings just by cleaning out the health care system’s waste.

Elliott Fisher, who directs Dartmouth’s Atlas of Health Care, which tracks disparities in medical practices and outcomes across the country, pointed out that Medicare spending per person varies widely regardless of quality — from $7,734 a year in Minneapolis to $11,646 in Chicago — even after correcting for the different age, sex and race profiles of their populations.

He noted that if hospital stays by Medicare enrollees across the country fell to the length prevailing in Oregon and Washington, hospital use — one of the biggest drivers of costs — would fall by almost a third.

“Twenty to 30 percent of Medicare spending is pure waste,” Dr. Fisher argues. “The challenge of getting those savings is nontrivial. But those kinds of savings are not out of the question.”

We could be disappointed, of course. Similar breakthroughs before have quickly fizzled. Just think back to that brief spell in the mid-1990s when health maintenance organizations seemed to have beat health care inflation — until patients rebelled against being denied services and doctors dropped out of their networks rather than accept lower fees.

The Centers for Medicare and Medicaid Services already expects spending to rebound in coming years. Without tougher cost control devices, be it vouchers to limit government spending or direct government rationing, counting on savings of the scale needed to overcome the expected increase in Medicare rolls may be hoping for pie in the sky.

“It makes no sense,” said Eugene Steuerle, an economist at the Urban Institute, to expect the government will reap vast Medicare savings without having an impact on the quality of care.

The Affordable Care Act already contemplates fairly big cuts to Medicare. In its latest long-term projections published last year, the Congressional Budget Office estimated that under current law, growth in spending per beneficiary over the coming decade would be about half a percentage point slower than the rate of economic growth per person.

To understand how ambitious this is, consider that Medicare spending per beneficiary since 1985 has exceeded the growth of gross domestic product per person by about 1.5 percentage points per year. Slowing down that spending would require deep cuts in doctor reimbursements that, though written into law, Congress has never allowed to happen — repeatedly voting to cancel or postpone them.

Under a more realistic situation, the Budget Office projected that the growth of Medicare spending per capita over the next 10 years would be in fact 0.6 percentage points higher than under current law and accelerate further after that.

Yet despite the ambition of these targets, they would not be enough to stabilize future Medicare spending as a share of the economy. A report by three health care policy experts, Michael Chernew and Richard Frank of Harvard Medical School, together with Stephen Parente of the University of Minnesota, concluded that to do that would require limiting the growth of spending per beneficiary at 1.25 percentage points less than the growth of our gross domestic product per person.

“The Affordable Care Act places Medicare spending on a trajectory that is historically low,” Mr. Chernew said, noting his opinion was not an official statement as vice chairman of Medicare’s Payment Advisory Commission, which advises Congress on Medicare. “Could we do better? Of course. Will we? That requires a little more skepticism.”

Yet even if it is unrealistic to expect that newfound efficiencies will stabilize Medicare’s finances, the slowdown in health care spending suggests that politicians in Washington calm down. It offers, at the very least, more breathing room to carefully consider reforms to the system to raise revenue or trim benefits in the least damaging way.

There are many ideas out there — from changing Medicare’s premiums, deductibles and coinsurance to introducing a tax on carbon emissions to raise revenue. Some of them are not as good as others. Until recently, President Obama favored increasing the eligibility age for Medicare. Then research by the Kaiser Family Foundation concluded that raising the age would increase insurance premiums and cost businesses, beneficiaries and states more than the federal government would save. The nation would lose money in the deal.

“As we do this, there are smarter and dumber ways to do it,” Mr. Gruber said. “It would be a problem if we were to do things in a panic mode that set us backward.”

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Skepticism Surrounds Resumption of Nuclear Talks With Iran

ALMATY, Kazakhstan — Talks between Iran and six world powers over its nuclear program resume here on Tuesday after a break of eight months, but there is a general atmosphere of gloom about their prospects for success, even if narrowly defined.

Since talks in Moscow last June, Iran has continued to increase its stockpile of uranium enriched to 20 percent purity, has begun to install a new generation of centrifuges and has not yet completed an agreement on inspection of suspect military sites with the International Atomic Energy Agency, a deal originally advertised as all but done last May.

With presidential elections in Iran scheduled for June, senior Western diplomats involved with these talks expressed skepticism that Tehran’s chief negotiator, Saeed Jalili, would be willing to make compromises that could be portrayed as weakness at home.

Mr. Jalili is the personal representative of Iran’s supreme leader, Ayatollah Ali Khamenei, considered the dominant voice on the nuclear issue. Ayatollah Khamenei has recently expressed continued mistrust of the United States and its intentions, saying that he would not allow the kind of bilateral talks between Washington and Tehran that most analysts think would be crucial to any resolution.

At the same time, Iran has taken some of its stockpile of 20 percent enriched uranium and converted it into reactor fuel, which cannot easily be turned back. The conversion means that Iran now has less of the uranium needed to make a bomb, reducing the sense of urgency among the six powers, and Israel, that its nuclear program needs to be slowed.

But the total Iranian stockpile of 20 percent enriched uranium has nonetheless grown since November to 167 kilograms from 135 kilograms, according to the most recent I.A.E.A. report — closer to, if still significantly below, the 240 kilograms or 250 kilograms many experts consider necessary, once enriched further, to produce a nuclear weapon.

Iran denies that its nuclear program has any military aim. The six world powers, the so-called P5-plus-1 group, which are the five permanent members of the United Nations Security Council — Britain, China, France, Russia and the United States — and Germany, want Iran to obey Security Council resolutions ordering it to suspend enrichment and open itself up fully to I.A.E.A. inspectors, to ensure that there is no effort to build a nuclear weapon.

To press Iran to comply, the Security Council, the United States and the European Union have created an increasingly painful set of economic sanctions on Iran, as part of a dual-track strategy — negotiations and sanctions. Iran has for its part insisted that as a precondition for serious negotiations, the world should lift all the sanctions and recognize Iran’s “right to enrich,” which Iran asserts it has as a signatory to the Nuclear Nonproliferation Treaty.

The negotiations have been tedious, with Iran appearing to be playing for time, diplomats say. The six powers had asked for a resumption of these talks as early as December, but Iran rejected dates and sites before finally suggesting and agreeing upon Almaty. The choice pleased Western diplomats for its symbolic value, since Kazakhstan, when it became independent of the Soviet Union, freely relinquished the nuclear weapons it had inherited from Moscow. American officials are holding up Kazakhstan, one of the world’s largest producers of uranium and a maker of nuclear fuel, as an example to Iran of the benefits of peaceful nuclear energy and compliance with the I.A.E.A.

President Nursultan Nazarbayev of Kazakhstan appealed to Tehran in a New York Times Op-Ed article in March 2012 to abandon what he suggested was its pursuit of nuclear power status. “Kazakhstan’s experience shows that nations can reap huge benefits from turning their backs on nuclear weapons,” he wrote.

While expectations are low, the six hope to leave here with some momentum and signs of Iranian willingness to engage in what all have agreed should be a reciprocal and step-by-step process of lifting sanctions in return for Iranian actions to comply.

“Iran needs to understand that there is an urgent need to make concrete and tangible progress” in these talks, said Michael Mann, the spokesman for Catherine Ashton, the European Union’s foreign policy chief and chairwoman of the P5-plus-1 group.

Mr. Mann said that the six powers have together “prepared a good and updated offer for the talks which we believe is balanced and a fair basis for constructive talks” and that is “also responsive to Iranian ideas.”

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AP source: Tom Brady gets 3-year extension

Tom Brady will be a Patriot until he is 40 years old.

Brady agreed to a three-year contract extension with New England on Monday, a person familiar with the contract told The Associated Press. The extension is worth about $27 million and will free up nearly $15 million in salary cap room for the team, which has several younger players it needs to re-sign or negotiate new deals with.

The person spoke on condition of anonymity because the extension has not been announced.

Sports Illustrated first reported the extension.

The 35-year-old two-time league MVP was signed through 2014, and has said he wants to play at least five more years.

A three-time Super Bowl champion, Brady will make far less in those three seasons than the going rate for star quarterbacks. Brady currently has a four-year, $72 million deal with $48 million guaranteed.

Drew Brees and Peyton Manning are the NFL's highest-paid quarterbacks, at an average of $20 million and $18 million a year, respectively.

Brady has made it clear he wants to finish his career with the Patriots, whom he led to Super Bowl wins for the 2001, 2003 and 2004 seasons, and losses in the big game after the 2007 and 2011 seasons. By taking less money in the extension and redoing his current contract, he's hopeful New England can surround him with the parts to win more titles.

Among the Patriots' free agents are top receiver Wes Welker and his backup, Julian Edelman; right tackle Sebastian Vollmer; cornerback Aqib Talib; and running back Danny Woodhead.

Brady has been the most successful quarterback of his era, of course, as well as one of the NFL's best leaders. His skill at running the no-huddle offense is unsurpassed, and he's easily adapted to the different offensive schemes New England has concentrated on through his 13 pro seasons.

The Patriots have gone from run-oriented in Brady's early days to a deep passing team with Randy Moss to an offense dominated by throws to tight ends, running backs and slot receivers.

Brady holds the NFL record for touchdown passes in a season with 50 in 2007, when the Patriots went 18-0 before losing the Super Bowl to the Giants. He has thrown for at least 28 touchdowns seven times and led the league three times.

Last season, Brady had 34 TD passes and eight interceptions as the Patriots went 12-4, leading the league with 557 points, 76 more than runner-up Denver.

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