Here is a news article: Image caption The attacks targeted luxury hotels and a railway station

 Police in the Indian capital, Delhi, say they have arrested a key figure allegedly involved in the planning of the deadly Mumbai attacks of 2008.

 Abu Jindal, also known as Syed Zabiuddin, has been remanded to police custody, a senior police official told the BBC.

 He is being described as the "handler" of the 10 gunmen who carried out the deadly assault on targets in Mumbai.

 The attacks claimed 165 lives. Nine gunmen were also killed.

 The sole surviving gunman from the attacks, Mohammad Ajmal Amir Qasab, was convicted of murder and waging war on India in May 2010 and given a death sentence.

 The 60-hour siege of Mumbai began on 26 November 2008, targeting luxury hotels, the main railway station and a Jewish cultural centre.

 Relations between India and Pakistan hit rock bottom after India blamed the Pakistan-based militant group Lashkar-e-Taiba for the attacks.

 After initial denials, Pakistan acknowledged that the assault had been partially planned on its territory and that Qasab was a Pakistani citizen. ||||| NEW DELHI: After tracking him for more than three years, security agencies have arrested Sayed Zabiuddin alias Abu Hamza , alleged Lashker-e-Taiba ultra and the Hindi tutor of 10 terrorists who carried out the audacious attack in Mumbai in 2008.The 30-year-old Ansari alias Abu Jindal, who hails from Georai area of Beed district in Maharashtra, was arrested on June 21 when he arrived in India from a Gulf country, official sources said on Monday.India had also secured an Interpol Red Corner notice against him in which he was accused of crimes involving the use of weapons, explosives and terrorism.With his arrest, the mysterious voice recorded during the conversation between 10 Lashker terrorists and their handlers in Pakistan has been identified, the sources said.According to the officials associated with the probe, Ansari had told Lashker terrorists carrying out attack in Nariman House to convey to the media that the "attack was a trailer and the entire movie was yet to come".The voice was that of Ansari and after this his activities were traced before he was finally nabbed in a Gulf country, according to officials.In the intercepted tapes, Ansari was also heard using typical Hindi words like "prashasan" (government) and was directing the terrorists to conceal their Pakistani identity and identify themselves from Deccan Mujahideen hailing from Toli Chowk in Hyderabad.His presence was also stated by Ajmal Kasab , the lone terrorist arrested during the Mumbai attack, in his deposition before a special court. He told the court that one person by the name of Abu Jindal had tutored 10 terrorists on how to speak Hindi.Missing since 2005, Ansari, who had undergone training at Indian Technical Institute in Beed, had a sudden rise in the ranks of Lashker-e-Taiba after he was indoctrinate by banned SIMI post Gujarat riots in 2002.The Central security agencies had quizzed many arrested terrorists to study the case of Ansari during which it came to light that he had been operating out of terror camps in Karachi and Pakistan-occupied Kashmir and was a key figure in the terror group's plan to carry out the strikes in the country's hinterland. ||||| New Delhi: The Delhi Police have arrested Abu Jundal, one of the key conspirators and handlers in the 26/11 Mumbai terror attacks. He is the first Lashkar-e-Taiba (LeT) operative to be arrested after Ajmal Kasab. The operative is believed to have guided and controlled the terrorists at the Nariman House from a Karachi control room throughout the night of November 27, 2008.

 Here are the instructions he gave to the Mumbai attackers at the Nariman House:

 - As long as you have hostages, the police can't do anything.

 - If there is any problem, if the pressure builds up, shoot them.

 - Do a good job… support your partner.

 - Keep your morale high and say your prayers.

 In a major breakthrough for security agencies involved in the 26/11 probe, Jundal is believed to have been deported from Saudi Arabia and arrested by the Delhi Police after he reached the national capital, with the entire slick undercover operation being kept under wraps, including Jundal's production and remand in a court last week.

 According to officials, Jundal was one of the five handlers present in the control room in Karachi. He was directing terrorists carrying out the Mumbai attacks at every step.

 Jundal was also responsible for weapon training the terrorists and familiarising them with the Hindi language.

 He was involved in a blast in Ahmedabad in 2006 and the Aurangabad arms haul the same year. He was named in the 26/11 chargesheet and was considered one of the most wanted.

 Kasab's testimony to Mumbai police names Jundal for seeing off the 10 attackers at Pakistan shore. Abu Hamza, Abu Qaafa and Lakhvi were the others.

 After the Aurangabad arms haul, Abu Jundal fled to Pakistan. There he became closely involved with the activities of the LeT and eventually started working towards plotting the 26/11 attacks. The Mumbai crime branch which is probing the attack will now be taking a voice sample to further confirm that he indeed was one of the handlers.

 Quite contrary to high profile busts, the Delhi Police stayed mum in this case. Sources said this was an operation managed at a diplomatic level and involved many central agencies.

 Abu Jundal was an important LeT operative handling the groups operations in India. His arrest will be crucial not only for taking investigations into the Mumbai attacks forward but also for our agencies to find out the current structure, reach and plans of Pakistan-based terror groups. What they will also focus on is to find out what he was doing in Saudi Arabia for the last several months |||||
A summary of this is?

– Indian police say they've arrested one of the masterminds behind 2008's dramatic Mumbai terrorist attack. Delhi police tell the BBC that Abu Jindal, aka Sayed Zabiuddin, was the "handler" of the 10 gunmen, and that his voice can be heard on recordings of conversations between the gunmen and their leaders in Pakistan. Sources tell the Times of India that he was nabbed last week while entering India from a "Gulf country"; an IBNLive report says he was deported from Saudi Arabia. "As long as you have hostages, the police can't do anything," Jindal allegedly advised the gunmen. But "if there is any problem, if the pressure builds up, shoot them." Jindal was originally from India, but allegedly was among five Lashkar-e-Taiba operatives who directed the attack from Karachi, Pakistan. He was also the one who allegedly gave the terrorists their weapons training, and taught them Hindi.


ROSA KHUTOR, Russia, February 15 (R-Sport) – Doctors have performed a successful 6 1/2-hour operation on a Russian freestyle skier who suffered a broken back in a training crash in the mountains above Sochi, the Russian Freestyle Federation spokesman told R-Sport on Saturday.

 Skicross racer Maria Komissarova sustained the injury while training Saturday morning at the PSX Olympic skicross venue at Rosa Khutor Extreme Park, the federation said.

 She was rushed to Krasnaya Polyanskaya Hospital No. 8, where the 23-year-old was immediately operated on. The diagnosis was a fractured and dislocated spine, officials said.

 "The operation lasted 6 1/2 hours, and it was successful," Mikhail Vezhba, the federation's spokesman told R-Sport. "We'll know more about the details later."

 A source close to the situation earlier told R-Sport that Komissarova's condition was too grave to transfer her to Moscow.

 Russian President Vladimir Putin's spokesman said Putin had "decided to visit" Komissarova, who he said was already conscious.

 Komissarova's best career result came with second place at a World Cup event in 2012, but she was not expected to be a medal contender in the women's ski cross competition Friday. The federation has not commented on the nature of the injury other than to say it is "serious" and that Komissarova is ruled out of competition.

 So far in the February 7-23 Sochi Olympics, serious injuries have been rare. A track worker broke both legs when hit by a non-competition bobsled Thursday, and a Russian ski jumper broke two ribs in a training crash Wednesday.

 On Tuesday, Canadian slopestyle skier Yuki Tsubota suffered a broken jaw when her own knee struck her in the face during a crash in the final of her competition.

 Updated with Putin’s plan to visit Komissarova. ||||| Russian freestyle skier Maria Komissarova during a night training session for the 2014 Sochi Winter Olympics at the extreme park in Rosa Khutor, Russia, on Feb. 2. Reuters

 SOCHI, Russia—A Russian skier broke her back and dislocated a vertebra during a practice session on the Olympic freestyle course here Saturday, landing her in a 6.5-hour emergency surgery that has stabilized her condition.

 Maria Komissarova, a 23-year-old from St. Petersburg, was training for a Feb. 21 competition in ski cross, a freestyle event added to the Games in 2010 in which skiers race down a mountain while negotiating artificial obstacles including big-air jumps and rollers.

 Komissarova failed to clear an obstacle during the practice session Saturday morning and crashed, breaking her T12 vertebra, according to the Freestyle Federation of Russia, which said her prognosis wouldn't become clear for three to four days.

 Mikhail Verzhba, a spokesman for the association, described the injury as a fracture with a dislocation. Komissarova remains in serious but stable condition.

 Verzhba confirmed through a translator that Russian President Vladimir Putin visited Komissarova in the hospital Saturday night. The translator said Komissarova was conscious and spoke with the president.

 Doctors immediately rushed to assist Komissarova on the course of the Rosa Khutor Extreme Park after the incident and quickly decided she would need to undergo surgery immediately at the newly built hospital in Sochi's Krasnaya Polyana district. Komissarova couldn't be transferred to a hospital in Moscow or abroad because of the emergency nature of the surgery, Verzhba said.

 The skier remained conscious after the injury and before entering surgery, where doctors reconstructed her vertebra and inserted a metal implant. She will remain in Sochi until doctors can move her to a special hospital in Moscow or abroad for further operation, the Federation said in a news release.

 "It's a very dangerous discipline," Verzhba said. He said it is unclear why exactly Komissarova crashed. Such accidents are common in ski cross and other freestyle sports, he said. Competitors in ski cross take serious air off of massive jumps while speeding down the course, making it a particularly dangerous pursuit.

 As is standard, the ski-cross course was inspected Saturday, an official training day, where all athletes and coaches were present. There were no major complaints about the course, according to Tom Kelly, a spokesman for the U.S. Ski and Snowboard Association, whose coach, John Teller was there.

 Komissarova has avoided the most negative outcome, which would be damage to her spinal cord, her coach, Vladimir Baryshnikov, told the Russian sports newspaper Sovetsky Sport.

 Before the surgery had concluded on Saturday, Verzhba said he didn't know the extent to which Komissarova's spine had been damaged during the accident and was waiting to hear from doctors. He says other people with similar injuries have recovered fully.

 "We are hoping for a recovery back to health," he said, though he warned the final prognosis remains unclear. Komissarova won't compete in the Sochi Games.

 The Russian skier finished second in the ski cross World Cup in Grindelwald, Switzerland, in 2012. It was the same competition where Canadian ski-cross competitor Nik Zoricic died after flying off the side of a jump on the course and smashing into the safety net. Canadian freestyle skier Sarah Burke, who excelled at halfpipe skiing and successfully pushed for its inclusion in the Olympics for the first time this year, died in a training accident in the U.S. the same year.

 Extreme sports including freestyle skiing and snowboarding are among the newest and most dangerous Winter Olympic disciplines. "These are the sports that have had more injuries in recent years," said Bill Mallon, an Olympic historian and orthopedic surgeon based in the U.S.

 Mallon said a dislocation at the T12 vertebra, such as the one suffered by Komissarova, could cause some paralysis, but he said the prognosis depends on the extent of damage to the spinal cord. He said it is unclear whether any nerve damage would be permanent.

 Komissarova currently is receiving medical care at City Hospital No. 8, a facility near the Olympic venues in Sochi's Krasnaya Polyana mountain district. Organizers overhauled and completely rebuilt the hospital ahead of the Games, installing an array of foreign medical equipment to prepare for any serious Olympics-related injuries.

 Russia's Freestyle Federation said it received many calls from "friends and completely unknown people offering all sorts of help."

 "That included offers to organize a charter for the athlete's delivery to any point in the world and money to pay for treatment," the Federation said in a statement. "We thank everyone for their participation and sympathy."

 Write to Paul Sonne at paul.sonne@wsj.com ||||| Story highlights Maria Komissarova is on a ventilator, Russian TV reports

 Komissarova broke her back during training

 The decision was made to operate immediately

 She was training for the ski-cross competition

 Russian freestyle skier Maria Komissarova has undergone more than six hours of surgery after breaking her back during a training run at the Winter Games in Sochi, the Russian Freestyle Federation spokesman said Saturday.

 Komissarova, 23, fractured a vertebra and dislocated her spine when she crashed at the PSX Olympic skicross venue at Rosa Kuhtor, federation spokesman Mikhail Vezhba told the state-run RIA Novosti news agency.

 "The operation lasted 6½ hours, and it was successful," Vezhba said. "We'll know more about the details later."

 A source close to the situation earlier told the Russian news agency that Komissarova's condition was too serious to transfer her to Moscow.

 The skier was reportedly in "unbearable" pain when she was rushed to the hospital, the news agency reported.

 Komissarova placed second in a World Cup event in 2012 but was not considered a medal contender in Sochi. She injured her leg last year, requiring surgery and keeping her off the slopes for almost six months.

 Russian President Vladimir Putin visited with Komissarova in the hospital, news channel Russia-24 reported.

 Footage showed Putin meeting with the skier, who was on a ventilator, in the hospital. He patted her head as he spoke. |||||
What is a one-paragraph summary of the above article?

– After she broke her back, Olympic skier Maria Komissarova of Russia had "successful" surgery, a rep for the Russian Freestyle Federation tells RIA Novosti. Now, she is in stable condition, the Wall Street Journal reports. The good news is that the accident didn't damage her spinal cord, her coach says. Surgeons rebuilt one of Komissarova's vertebrae; she also received a metal implant, the Journal reports, noting that she was conscious following the accident. Now she's due for a hospital visit from Vladimir Putin, CNN reports. As for this year's Games, we won't be seeing her on the slopes.


News article:

Still, it wasn’t dissuasive enough, so I rang up an MD friend from college. If anyone was going to talk me out of this, it was going to be a physician I’d drank too much with before. He wasn’t alarmed though. “As doctors get financially squeezed, you’ll see more and more side businesses. It’s like your old classmate who’s giving cosmetic G-spot injections. Does it hurt anybody? Probably not. Is it necessary? Probably not.” (Note: I had no idea my old classmate was doing this, or that anybody else was either.)

 As for the price, he said it wasn’t a bad deal -- for an ER visit, the doctor’s bill alone would be higher, plus, nobody goes to the ER for a hangover unless it’s in a police car or an ambulance. The treatment’s cheaper in other cities, but house calls always run steeper -- and regardless, this is New York: if the sauce costs more here than in Chicago, why wouldn’t the salvation? ||||| REAL PEOPLE EXPERIENCING REAL RESULTS FROM IV HANGOVER CURES

 We have used IV therapy to treat tens of thousands of tourists for hangovers in Las Vegas. Dr. Burke and his team are experts at IV hangover cures IV Vitamin therapy, and IV hydration. We have basic IV packages for mild, nuisance hangovers, and premium hangover cure packages for severe hangovers.

 We can treat you at our Las Vegas IV Hangover Clinic near Trump Tower, or we can come to you and treat your hangover in your hotel room. Our clinic is also a short Uber from the Las Vegas Strip.

 We strongly encourage you to pre-book your appointment, as treatment slots for IV therapy can be limited on the weekends. Our typical intravenous hydration or hangover treatments take 35 to 40 minutes. Use our convenient online booking system to reserve your spot today! ||||| Nick Andreottola and his house guests woke up one morning in a Hamptons rental home feeling worse for wear -- bleary-eyed, heads aching, stomachs twisting. They were beyond hungover.

 That's where the I.V. Doctor came in. For a few hundred dollars each, a nurse showed up with half a dozen I.V. bags and brought them back to life.

 The I.V. Doctor, a service started in December by New York urologist Dr. Elliot Nadelson and his surgical resident son Adam, totes intravenous hydration and other medicine to help quell hangovers to ailing New Yorkers in luxe Hamptons beach homes, and apartments and offices throughout the city.

 Dr. Adam Nadelson said the service has about 60 nurses in the city and 12 more in the Hamptons, who set clients up with about 200 ml of fluid, and any combination of anti-nausea, anti-heartburn and anti-inflammatory or headache medicine. The full cocktail of all the drugs, which Nadelson said is their most popular request, costs $249.

 Related: Can enough money buy you eternal youth?

 While Nadelson said his clients range from European princesses to Olympic track stars, the majority of those who use his service are in finance. It helps when they're working long hours, entertaining clients late into the night and having to perform at a high level early the next morning.

 "They're burning the candle at both ends and this helps them get back on their feet quickly," he said.

 That's why Jon, a 31-year-old sales trader at a bank in New York who did not want his last name published, started calling the I.V. Doctor back in January. He was going to an event with clients for the Super Bowl and knew it was going to be a "big night," so he booked an appointment at his office the next morning at 8 a.m.

 In a small, discrete conference room at his office, a nurse hooked him up to the I.V. bag while he checked emails for the next 40-or-so minutes, and she left in time for him to start his day.

 "Look, it's not a miracle cure. There's nothing that really 100% gets rid of a hangover," he said. "But if you go in feeling like a 2, you come out a half-hour later feeling like a 7. That's a game changer."

 Since then, Jon said he's had about a dozen appointments and recommended it to all of his friends. He now books an appointment in advance if he knows he's going out at night, so it's all set up for him at the office the next morning before a hangover can really set in.

 Related: For sale: Dream beach homes

 Adam Nadelson said the company is about more than just curing the over-served. They visit patients who have food poisoning or the flu, and athletes after big games or races.

 But it's also about bringing in a new revenue stream.

 "It's much harder to be a successful doctor today," he said, though his father still has three offices in New York. "You're starting to see family practitioners doing Botox on the side for money. This business has no overhead and is really catching on."

 The Nadelsons aren't the first to climb up the hangover money tree. Hangover Heaven opened two years ago in Las Vegas, with a clinic open 24 hours a day, seven days a week. The services run from $129 to $239 in the clinic, but those who want a nurse to come to their hotel room will pay an extra $200 during business hours and $300 between 5 p.m. and 9 a.m.

 Related: No 99%ers allowed

 The Nadelsons aren't settling for just one city. They're expanding to Chicago this summer and are making a big social media play for potential clients in the Hamptons.

 Andreottola and his Hamptons guests were satisfied.

 "We're the work-hard, play-hard type and everyone said they felt replenished," he said. "Even some of the server girls we hired for a barbeque got it done and they all said they felt better." |||||
What is a shorter version of the above article?

– If there's one thing everyone who's ever had a hangover can probably admit to, it's that they'll try just about anything to minimize the anguish. Now, thanks to The "IV Doctor," a service started in December by New York urologist Dr. Elliot Nadelson and his surgical resident son Adam, one's degree of suffering may be at least marginally reduced—for a price. Ailing partiers in NYC and the Hamptons (and, soon, Chicago) with the right kind of pocket change can for $249 have a nurse come to their homes or offices and administer 200ml of fluid by IV, plus a cocktail of drugs to combat nausea (Zofran), heartburn (Pepcid), and headache/inflammation (Toradol). That particular package, called "Revive," is the most popular, and recommended for those on their "deathbed." "Look, it's not a miracle cure ... but if you go in feeling like a 2, you come out a half-hour later feeling like a 7, that's a game changer," one repeat customer tells CNN Money. A reporter who tried the service for Thrillist—his prep included four martinis and an "indeterminate portion" of a whisky bottle—notes the advantages of the IV: a higher absorption rate, less peeing, and a quicker impact. He says he ended up "achieving a state of heightened alrightness ... a victory." Nadelson says his team has treated European princesses and Olympic track stars, but that his biggest client base works in finance, "burning the candle at both ends." This service isn't the first of its kind. Hangover Heaven opened two years ago in Las Vegas with a 24-hour clinic and nurses who will make hotel-room visits, and Miami and Atlanta are home to REVIV and Hydration Station, respectively. (Hungover? Don't blame it on this mixture.)


These crawls are part of an effort to archive pages as they are created and archive the pages that they refer to. That way, as the pages that are referenced are changed or taken from the web, a link to the version that was live when the page was written will be preserved.Then the Internet Archive hopes that references to these archived pages will be put in place of a link that would be otherwise be broken, or a companion link to allow people to see what was originally intended by a page's authors.The goal is to fix all broken links on the web . Crawls of supported "No More 404" sites. ||||| I. Child Sex Abuse in India

 India is home to 430 million children, roughly one in five of all children (individuals under age 18) in the world. From the moment they are born, the challenges many of them face are staggering. [4]

 At least 1.7 million children die before the age of five every year in India.[5] Malnutrition means that almost half of those that survive are stunted, and 43 percent are underweight.[6] The right to education is enshrined in the Indian constitution,[7] but, though the situation is improving, there were still 8.1 million out-of-school children in mid-2009.[8] The government estimates that 40 percent of India's children are vulnerable to threats such as trafficking, homelessness, forced labor, drug abuse, and crime, and are in need of protection.[9]More than half of the country's married women were wed before the legal age of 18.[10] Currently, only about 60 percent of births in India are even registered.[11]

 In 2007 the government published its first ever survey to address what the then minister of women and child development, Renuka Chowdhury, described as the “conspiracy of silence” surrounding child sexual abuse. [12] The report uncovered some alarming statistics, though, as explained below, the report methodology was limited and the numbers should be taken more as an indication of the seriousness of the problem than a reflection of the actual incidence of abuse.[13] Of the children interviewed, more than half (53 percent) said that they had been subjected to one or more forms of sexual abuse. Over 20 percent of those interviewed said they were subjected to severe forms of abuse, defined in the report as “sexual assault, making the child fondle private parts, making the child exhibit private body parts and being photographed in the nude.” Of those who said they were sexually abused, 57 percent were boys.[14]

 The survey also found that very few cases are ever reported. The vast majority of victims (72 percent) said that they did not report the matter to anyone and only 3 percent of them or their families told the police. In most cases the perpetrator was known to the child. For example, 31 percent of sexual assaults were committed by the victim's uncle or neighbor . Among those interviewed, children living on the street, in institutions, or already working were more likely to be the victims of sexual assault than those living with their parents and attending school, but even wealthy families were affected.

 The government survey was based on interviews with 12,500 children in 13 different states and was one of the largest ever conducted in the world. However, many child protection experts have criticized the way it was carried out and even its authors admit that most of the respondents were from especially vulnerable backgrounds . For example, when researchers visited schools, they interviewed pupils who their teachers had already identified as being at risk from abuse.[15]Thus, drawing broader conclusions about the percentages of all Indian children affected, given that no random sample of children was done, would be misleading. However, the survey does show that the problem is very significant and that the government is aware of it .

 Other studies have shown the seriousness of the problem. In 1998 the Indian NGO Recovery and Healing from Incest (RAHI) conducted India's first study of child sexual abuse. It surveyed 600 English-speaking middle and upper-class women, 76 percent of whom said they had been abused in childhood or adolescence, 40 percent by at least one family member, most commonly an uncle or cousin. [16]

 More recently, in 2005, the international organization Save the Children and an Indian NGO, Tulir - Centre for Healing and Prevention of Child Sex Abuse, surveyed 2,211 school-going children, from different backgrounds, in Chennai. [17] At least 48 percent of the boys and 39 percent of the girls interviewed said they had faced sexual abuse of one form or another, mainly from people they knew, while 15 percent of the children complained of severe forms of abuse, defined in this study as “oral sex, sexual intercourse, making the child touch the offender's private parts, or making the children take off their clothes and looking at them or taking their pictures.”

 Official crime records are also indicative of how serious a problem this is. In response to the widely reported rape and murder of a 23-year old student in New Delhi in December 2012, the UN resident coordinator in India and the UNICEF representative issued a joint statement calling for better protection of women and girls against sexual violence. “It is alarming that too many of these cases are children. One in three rape victims is a child. More than 7,200 children, including infants are raped every year. Given the stigma attached to rapes, especially when it comes to children, this most likely is only the tip of the iceberg,” said Louis-Georges Arsenault, UNICEF representative to India.[18]

 Together with nongovernmental organizations, India’s media has played a leading role in increasing awareness of child sexual abuse in the country. As well as highlighting the enormous scale of the problem, journalists have also exposed failings in the system to protect children, putting considerable pressure on the government to act. Public outrage after high-profile cases has forced the government to address the problem.

 In May 2012, in a major step forward, the India's parliament enacted its first law outlawing child sexual abuse. The demand for this law became more urgent after the widely reported case involving Ruchika Girhotra, who was sexually abused in 1990 by a senior police officer when she was 14. Even though there was an eyewitness to the abuse, the alleged perpetrator, SPS Rathore, escaped prosecution for years. Instead he received numerous promotions and eventually retired as Haryana state’s senior-most officer.

 Meanwhile, the Girhotra family said they became the victims of a campaign of harassment. Ruchika was expelled from school, and her brother was arrested several times for theft. Three years after she was abused, Ruchika committed suicide.[19]

 Finally, 19 years later, in December 2009, Rathore was convicted but sentenced to prison for just six months for “molesting” Ruchika, the only existing law under which he could face charges. After widespread outrage, the Central Bureau of Investigation appealed for a tougher punishment, and a court in Haryana increased the term to 18 months. Rathore is presently out on bail while the appeal of his conviction is pending.[20]

 The National Commission for the Protection of Child Rights (NCPCR) was established in 2007 and is an autonomous watchdog or ombudsman, whose mandate is to ensure that “all Laws, Policies, Programmes, and Administrative Mechanisms are in consonance with the Child Rights perspective as enshrined in the Constitution of India and also the UN Convention on the Rights of the Child.”[21] It has been responsible for some important interventions, such as a campaign against corporal punishment in schools. Despite concerns that it is short staffed, the commission has also been charged with monitoring the implementation of the Protection of Children from Sexual Offences Act, as well as India’s ambitious Right to Education Act of 2009, which compels state governments to provide free education in neighborhood schools to all 6 to 14-year-olds and contains important provisions on child protection.[22]

 The NCPCR was set up after the discovery in December 2006 of one of the grisliest crimes in Indian history, when at least 19 children and young women were apparently raped and then killed. The murders came to light when workmen came across body parts while unblocking a sewer in front of a home in Noida, a wealthy suburb outside New Delhi. For months the parents of missing young women and children in the nearby slum of Nithari had complained to the police that their girls and boys had disappeared and named the man responsible.[23] However, the police refused to help them. The NCPCR was established to intervene in cases such as this, where the police failed to accept complaints or properly investigate a crime.

 However, the Indian government has yet to create an effective social services network to protect children and prevent crimes against them. This shortfall became news in 2012 when Falak, a two-year-old girl, was brought to the hospital with serious injuries, including cuts to her head and bite marks on her cheeks and leg. She died two months later. [24]

 Falak had been left in the care of a 14-year-old, who herself had had a violent upbringing. Her father used to beat her, as did a warden in a children’s residential care facility where she lived for three years. [25] After being coerced into sex work, she was left taking care of Falak, an illegally adopted baby. She told investigators that she had slapped and bitten the infant to stop her from crying. [26] At no time had the state social service system stepped in to assist the 14-year-old despite her history of domestic violence, abuse in a residential care facility, and sexual abuse.

 According to Raj Mangal Prasad, chairman of the Child Welfare Committee of South Delhi, which was responsible for looking after both girls once their plight became known, “the story is a grim reminder of failure of the government ... There are lakhs [hundreds of thousands] of Falaks in our country who are waiting for immediate help.” [27] |||||

Write a summary.

– December's deadly gang-rape in New Delhi put a spotlight on the country's ugly problem of sexual assault. But India faces another terrible sexual abuse failing—this one involving its children. Human Rights Watch today released an 82-page report on the rampant sexual abuse of Indian children, reports al-Jazeera. Though the report relies on in-depth case studies of 100 abuse victims rather than a "quantitative analysis," it does highlight a 2007 survey of 12,500 at-risk children that found a stunning 53.2% of those questioned had faced one or more forms of sexual abuse; 72% of those victims say they told no one. "Shockingly the very institutions that should protect vulnerable children can place them at risk of horrific child sexual abuse," said HRW's South Asia director. India's poorly trained and poorly paid police often refuse to register complaints; children who do report abuse and are seen by a doctor often undergo traumatic exams. Last year India finally passed its first law banning child sex abuse, but that's not enough, says HRW. "The criminal justice system, from the time police receive a complaint until trials are completed, needs urgent reform." See the full report here.


Summarize this article:

SAN JOSE — After vowing for the past year to recall the Santa Clara County judge who gave a lenient sentence to former Stanford athlete Brock Turner for sexually assaulting an unconscious, intoxicated woman, organizers Monday made their pledge official.

 About 35 people gathered as the campaign filed a notice of intent to recall Superior Court Judge Aaron Persky with the county registrar of voters, some holding signs with slogans such as “Soon to be unemployed. Aaron Persky” and “Recall Aaron Persky. Enough is enough.”

 The campaign also submitted a scathing 198-word statement branding the judge as an apologist for rapists and batterers.

 Related Articles Brock Turner assault case: Recall target Judge Persky lands major endorsement

 Recall leader outraises judge targeted over Brock Turner sentence

 Judicial commission backs Judge Persky in Brock Turner sentence If the statement is approved by the county registrar of voters, it will appear — along with a response by Persky — on petitions that proponents plan to begin circulating in August.

 Recall proponents must collect 58,634 valid voter signatures within a 160-day period ending in January to qualify the measure for the June 2018 countywide ballot. The campaign, spearheaded by Stanford law professor Michele Dauber, has already hired a firm to help collect signatures. Dauber is a friend of the victim’s family and a longtime activist against campus sexual assault.

 The judge, who has not commented on the uproar over the Turner sentence, could not immediately be reached Monday.

 But a key supporter, District Attorney Jeff Rosen, noted Monday that the case has already had a significant impact, including his successful effort to get a state law passed requiring a prison term for sexual assault of an unconscious or intoxicated person. Rosen said he has also tried to raise national awareness by organizing a campus sexual assault symposium and crafting a ground-breaking protocol on how colleges and law enforcement handle such assaults.

 “Judge Persky’s sentence in that case was wrong, in my opinion, but he had the right to give it,” Rosen said in a written statement. “My focus as we move forward is less about an individual judge than it is to the victims of campus sexual assault.”

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 According to the statement signed by 50 elected officials, Stanford professors and leaders of women’s rights groups, including San Jose Vice Mayor Magdelena Carrasco, “Santa Clara County residents deserve a judge who will protect victims — not rapists,” the statement says. It also claims that Persky, “a former Stanford athlete, has a long history of awarding lenient sentences to athletes and upper-class defendants for sex crimes and violence against women.”

 Persky was transferred to civil court at his own request last summer. But recall proponents note he still could potentially preside over civil lawsuits alleging sexual assault.

 Other signatories included Jillian McNerney, co-founder of Electing Women Silicon Valley; San Jose City Councilman and former police officer Raul Peralez; Palo Alto Councilman Cory Wolbach; and Viera Whye, artistic director of San Jose’s Tabia African American Theater Ensemble.

 The judge now has seven days to submit his up to 198-word response.

 Monday night, a committee fighting the recall released a statement in support of Persky.

 “Recalling a longtime respected judge and former prosecutor over a single decision in which he followed the Santa Clara County Probation Department’s recommendation sets a dangerous precedent that should concern us all,” read the statement from Retain Judge Persky. “Every judge has made an unpopular decision; judicial recalls are an extreme step that should be reserved for actual misconduct.

 “Recall proponents’ claims of Judge Persky’s bias are completely unfounded and unfortunately reflect these unsettling times when judges are more and more frequently coming under political attack.”

 Turner was convicted in June of sexually assaulting an intoxicated, unconscious young woman in 2015 outside a campus fraternity party, after two cyclists caught him in the act.

 Prosecutors asked Persky to sentence Turner to six years in state prison. But Persky, who followed a probation department recommendation in handing down Turner’s sentence last June, opted for jail, plus three years of probation, noting under California law Turner also will have to register as sex offender for the rest of his life. Turner served three months in jail and has moved back to his hometown in Ohio.

 Katherine Spillar, co-founder of the Feminist Majority and executive editor of Ms. magazine, told the crowd at the registrar of voters’ office that county residents not only have the right to recall Persky, “They have a duty” to send a message to the “entire justice system” across the country, she said.

 “Silicon Valley is where women are going to say enough is enough,” Spillar said.

 Civil rights leader and former Santa Clara County Superior Judge LaDoris Cordell disagrees with the sentence, but opposes the recall.

 “Without discretion, we are left with cookie cutter justice that imposes mandatory sentences without any regard to defendants’ circumstances,” she said. “We’ve been there before, and the results are far more damaging than the occasional ill-advised sentence.”

 If the recall qualifies, voters also will have a chance on the same ballot to immediately pick his replacement, just as they did when they ousted Gov. Gray Davis in 2003 and chose Arnold Schwarzenegger to replace him out of 134 other candidates.

 Any lawyer in California may run for judge; there is no requirement in judicial races that candidates must live in the county.

 If the recall qualifies and Persky loses, whoever gets the most votes would serve out the rest of Persky’s six-year term, ending in 2022. The winner needs only a plurality of the votes, not a majority.

 So far, only one candidate is weighing whether to run for Persky’s seat has surfaced: assistant district attorney Cindy Hendrickson, an executive in Rosen’s administration. Hendrickson supports the recall.

 Dauber said Monday that proponents have raised $450,000. By the end of 2016, Persky had raised $64,618, according to his latest campaign finance report. The next statement is not due until midsummer.

 Two judges have been recalled in California, in San Francisco in 1913 and Los Angeles in 1932. The first judge had reduced bail for felony assault of a teenage girl.

 Dauber predicted the campaign’s biggest challenge would be managing what she said has already been a huge outpouring of support and offers by volunteers to collect signatures.

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 Sign up for the free PM Report newsletter.

 Persky’s backers include dozens of law school professors in California, including UC Irvine’s Erwin Chemerinsky and Santa Clara University’s Gerald Uelmen.

 The professors, including 11 who teach at Stanford, are opposed to the proposed recall on the grounds that the sentence was lawful and dovetailed with a probation officer’s recommendation.

 Persky’s ouster, they wrote, would cause great harm, because judges may well feel pressured into making decisions based on public opinion. Other groups, including the California Judges Association, have issued similar statements expressing concern about judicial independence.

 County officials are still conducting research but have said it would cost slightly more than $1.1 million to put the recall on the June 5, 2018, ballot, far less than the $6.8 million cost of holding a special countywide election in November.

 However, recall proponents believe it would cost half that, and are still negotiating with the county on the issue. ||||| Activists in Northern California launched a campaign to recall a judge for what they say is a pattern of lenient sentences for sex crime convictions, including the punishment in the well-publicized Brock Turner case.

 The group said Monday that it filed a notice of intent at the Santa Clara County Registrar of Voters to begin collecting signatures to remove Judge Aaron Persky.

 Organizers hope to get the recall on the June 2018 ballot.

 “Santa Clara residents deserve a judge who will protect victims, not rapists,” said Stanford law professor Michele Dauber, who is leading the campaign. She and other activists made remarks to reporters on Monday.

 Persky sentenced the Stanford University swimmer to six months in jail after he was found guilty of three felony sex crimes for sexually assaulting an unconscious woman in 2015.

 The judge cited his young age and his lack of criminal record as reasons for the lenient sentence. Turner, now in his early 20s, was released after three months but must register as a sex offender for life.

 Widespread outrage over the sentence

 The incident and the judge’s sentence spawned national outrage. The woman Turner sexually assaulted read a letter to him in court about how the incident affected her mental health.

 Persky faced widespread criticism for the sentence, and more than 1.3 million people signed a Change.org petition calling for his removal from the bench.

 California legislators passed a bill mandating prison sentences for people who sexually assault unconscious or intoxicated victims.

 “The campaign believes that Judge Aaron Persky has a long pattern of bias in cases involving sex crimes, and violence against women in favor of white or privileged defendants, particularly college athletes,” the group said in a news release.

 “The judge’s bias came to light after he sentenced Brock Turner,” the Recall Persky Campaign said. “Thanks to Judge Persky, Turner was released after only three months in county jail.”

 Several dozen community leaders are part of the campaign, including politicians, academics and women’s rights activists.

 Commission weighed in

 In December, the Commission on Judicial Performance, an independent state body, reviewed thousands of complaints about Persky from people who said he abused his judicial authority.

 But the panel said “there is not clear and convincing evidence of bias, abuse of authority” or other reasons “to conclude that Judge Persky engaged in judicial misconduct warranting discipline.

 “Accordingly, the participating commission members voted unanimously to close, without discipline, its preliminary investigation of the complaints against the judge regarding his sentencing decision in the Turner case,” the commission said.

 Amid the furor, Persky recused himself from a child pornography case and stepped down from criminal to civil court.

 A source familiar with the judge’s thinking said Persky wanted to step aside in part because he didn’t want cases before him to receive unfair and unwarranted national attention. |||||

– "Santa Clara residents deserve a judge who will protect victims, not rapists," said Stanford law professor Michele Dauber as the campaign to recall the judge in the Brock Turner case officially began. Dauber and other activists filed a notice of intent Monday to recall Santa Clara Superior Court Judge Aaron Persky, WGNO reports. The judge has a "long pattern of bias in cases involving sex crimes and violence against women in favor of white or privileged defendants, particularly college athletes," which came to light after he sentenced Turner to just six months in jail for the sexual assault of an unconscious woman in 2015, the Recall Persky campaign said in a statement. Prosecutors had asked for six years. If campaigners can gather 58,634 voter signatures, the measure to recall Persky will appear on the countywide ballot in June of next year. Recall supporters say it will send a message to the whole country. Persky has already shifted from criminal to civil court, and supporters including District Attorney Jeff Rosen note that the Turner case has led to changes in the law, the San Jose Mercury News reports. "Judge Persky’s sentence in that case was wrong, in my opinion, but he had the right to give it,” Rosen said in a statement. "My focus as we move forward is less about an individual judge than it is to the victims of campus sexual assault." (A state commission cleared Persky of misconduct last year.)


Article:
*** UPDATE *** 4:45 PM ET: In a press conference after the vote, Sens. Joe Lieberman and Susan Collins announced that they will introduce a stand-alone bill to repeal "Don't Ask Don't Tell" and that Senate Majority Leader Reid has promised to support it. Reid told Lieberman that he will bring the legislation up for a vote before the end of the lame duck session, the Connecticut lawmaker said.

 "We're not going to give up," Lieberman said. "We're going to keep fighting until the last possible minute in the session."

 Collins said that she was "very disappointed" that Reid "walked away from negotiations" and brought the bill up for a vote before an agreement on the process of the debate had been reached and the 60 votes needed to move forward were assured.

 If the Senate approves the standalone measure, the House would have to approve it as well.

 4:08 pm ET: A key procedural vote on the bill containing a repeal of the military's Don't Ask Don't Tell policy failed Thursday, likely dealing a final blow to advocates who hoped to overturn the 17-year old ban on gays and lesbians serving openly in the military during this session of Congress.

 Democrats needed 60 votes to advance the Defense Authorization bill for debate on the floor. The vote failed, 57-40.

 Ultimately, Majority Leader Harry Reid called for the vote without having reached a procedural agreement with moderate Republican Sen. Susan Collins of Maine, who supports repeal but wanted greater openness for the process of amending and passing the bill. Collins voted aye on the measure, but other Republicans who support repeal but had voiced similar procedural concerns -- Sens. Scott Brown and Lisa Murkowski -- voted no.

 One Democrat, newly-elected Sen. Joe Manchin of West Virginia, broke with his party to vote no.

 The result means that repeal of the ban, enacted in 1993, is unlikely to be changed by Congress anytime soon. The policy is also currently being considered in court proceedings.

 Supporters of repeal, including Adm. Mike Mullen and Defense Secretary Robert Gates, have warned that a failure of congressional action could mean a hasty and disorderly implementation of a change if the courts overturn the policy first.

 Opponents of repeal say that a change in policy during wartime could disrupt the effectiveness and safety of troops in combat. A recent survey showed that troops serving in combat and members of the Marine Corps were more likely than other servicemembers to voice concerns about the consequences of repeal.

 In remarks shortly before the vote, Reid blamed Republicans – but not Collins – for blocking the massive defense measure from coming to the floor.

 "It's quite clear that they're trying to run out the clock," Reid said of GOP opponents before calling for the vote.

 Reid went out of his way to praise Collins for trying to reach an arrangement that would have paved the way for Democrats to win the 60 votes they need to advance the measure containing the DADT language. "She's tried," Reid said.

 Collins said on the Senate floor that she was "perplexed and frustrated" that the bill would fall victim to "politics."

 "I just do not understand why we can't proceed on a path... that will allow us to get the 60 votes to proceed," she said.

 NBC's Ken Strickland contributed ||||| Drew Angerer/The New York Times , Republican of Maine, and Senator Joseph I. Lieberman , independent of Connecticut, center, announced shortly after the vote their intention to introduce a new bill to repeal “ don’t ask, don’t tell .” Senator Mark Udall , Democrat of Colorado, joined them at the podium. , Republican of Maine, and Senator, independent of Connecticut, center, announced shortly after the vote their intention to introduce a new bill to repeal “.” Senator, Democrat of Colorado, joined them at the podium.

 A Republican senator and an independent senator said today that they will jointly introduce a stand-alone bill to repeal the military’s “don’t ask, don’t tell” policy after a larger defense bill containing the repeal failed to advance in the Senate.

 Senate Republicans blocked the attempt to move ahead with the bill that would have repealed the ban on gay troops serving openly in the military. The vote was 57-40, almost entirely along party lines, and three short of the 60 needed.

 The vote was a setback to President Obama and the Democratic leadership, who have made repealing the Clinton-era policy a key priority. And it short-circuited the efforts of a handful of Republicans who said they supported a repeal but wanted more time to negotiate the process of debating and voting on the measure.

 The lawmaker leading that effort, Senator Susan Collins of Maine, voted in favor of the motion but was not joined by any of her colleagues. Ms. Collins and Senator Joseph I. Lieberman of Connecticut, an independent, announced shortly after the vote their intention to introduce a new bill.

 “I am convinced that there are 60 or even 61 or 62 votes to repeal ‘don’t ask, don’t tell’,” Ms. Collins told reporters. “I’m extremely disappointed that the Senate majority leader walked away from negotiations in which we were engaged and which were going well.”

 A spokesman for Senator Harry Reid, the majority leader, said Mr. Reid will co-sponsor the stand-alone legislation. “We do intend to take a free-standing bill to the floor,” said Jim Manley, a spokesman for Mr. Reid.

 But a bill focused solely on repealing the “don’t ask, don’t tell” policy faces steep challenges, including the likelihood that supporters of the policy in the Senate could seek to offer numerous amendments during a debate over the legislation.

 In a statement, President Obama said he was disappointed that “yet another filibuster” by Republicans had blocked the defense bill and the provisions to repeal the “don’t ask, don’t tell” policy.

 “A minority of Senators were willing to block this important legislation largely because they oppose the repeal of ‘Don’t Ask, Don’t Tell,’” Mr. Obama said. “While today’s vote was disappointing, it must not be the end of our efforts. I urge the Senate to revisit these important issues during the lame duck session.”

 Mr. Reid had called for the procedural vote on the overall defense bill despite having failed to reach agreement with the Republicans on how to proceed. In a statement after the vote, Ms. Collins said those negotiations were “going well” and she accused Mr. Reid of walking away from the discussions.

 Republicans had earlier indicated that without an agreement about the number of amendments and the timing of the debate, they would vote against moving forward to vote on the legislation.

 Advocates of repealing the policy criticized the vote, saying the effort to allow gays to serve openly in the military had fallen victim to political squabbles in the Congress. One newly elected Democrat, Senator Joe Manchin of West Virginia, also voted against the measure.

 “Today leaders of both parties let down the U.S. military and the American people,” said Joe Solmonese, president of Human Rights Campaign. “Instead of doing what is right, ‘the world’s greatest deliberative body’ devolved into shameful schoolyard spats that put petty partisan politics above the needs of our women and men in uniform.”

 Mr. Solmonese vowed that “this fight is too important to give up despite this setback and we will continue fighting in this lame duck session. It’s not over.”

 A veterans group also expressed anger at the vote, which delays approval of the massive military spending bill to which the repeal was attached. The Congress has not failed to pass a military spending bill for decades.

 “By voting to filibuster the Defense Authorization Act, today, a minority of Senators have betrayed our troops,” said Ashwin Madia, interim chairman of VoteVets.org. “Leaving aside ‘Don’t Ask, Don’t Tell,’ this bill is crucial to our military readiness, and funding our troops in harm’s way.”

 Prior to the vote, Mr. Reid conceded that that the failure to reach an agreement could doom the effort to repeal the policy, which has been a key priority for President Obama and gay activists.

 “Despite the critical importance for our troops, for our nation, and for justice that we get this bill done, we have not been able to reach an agreement,” Mr. Reid said this afternoon. “And I regret to say that it is our troops who will pay the price for our inability to overcome partisan political posturing.”

 Mr. Reid’s decision to move forward in an attempt to force a vote caught senators off guard, including Ms. Collins, who had been negotiating with Mr. Reid about the terms of the debate.

 In an impassioned, impromptu speech, Ms. Collins complained that she wanted to vote in favor of the overall bill, including the repeal provision, but could not do so without an agreement on the process first. |||||Summary:

– Repeal of Don't Ask, Don't Tell will get another chance. Republican Susan Collins and Independent Joe Lieberman say they plan to introduce a stand-alone measure in the lame-duck session, and Harry Reid says he's on board, reports MSNBC. It's no gimme by any stretch—opponents could try to talk it to death with amendments, for one thing, notes the Times—but "we're not going to give up," says Lieberman. Assuming it comes up after the tax issue is settled, it could theoretically pick up three decisive pro-repeal votes from Scott Brown, Lisa Murkowski, and Dick Lugar, writes Greg Sargent at his Plum Line blog. The measure that failed today (by three votes) was part of a larger defense bill, and Harry Reid knew it was going to fail when he brought it up for vote, writes Sargent. So why did he do it? He figured it was doomed anyway—that even if he had agreed to Collins' demands for four days of debate, others wouldn't abide by that deal. "You can talk about four days until the cows come home," an aide tells Sargent. "That has very little meaning for Coburn and DeMint and others who have become very skilled at grinding this place to a halt."


With a smile on his face, George Zimmerman spent Saturday afternoon posing for photos, sharing hugs and shaking hands with gun enthusiasts at a firearms expo in Lake Mary.

 "It's so odd to me," said Zimmerman, about the celebrity treatment he receives in public. "[But] it is appreciated."

 In his first interview with the Orlando Sentinel, Zimmerman described life after his acquittal last year in the shooting death of 17-year-old Trayvon Martin. The former Neighborhood Watch volunteer shot the unarmed black teen in Sanford on Feb. 26, 2012.

 Now life for the 30-year-old is completely different.

 He's always moving.

 He's in debt.

 And he's constantly receiving death threats.

 "I just try to be smart where I go," said Zimmerman, who described the gun show at Gander Mountain Academy as a "friendly" event that didn't warrant extra protection.

 Zimmerman said he carries a semi-automatic handgun for added safety.

 "It's part of life," said Zimmerman, whose Twitter feed is a constant barrage of death threats. "It's unfortunately necessary right now."

 The polarizing case that made Zimmerman a household name captured the world's attention for more than a year, prompting protests after Trayvon was fatally shot and Zimmerman was not immediately charged — then sparking more protests when Zimmerman was acquitted.

 Zimmerman attended Saturday's expo after being invited by his friends at The Arms Room gun shop near Orlando. Donning a black Arms Room T-shirt, khaki shorts and a baseball cap, Zimmerman more or less blended in with the rest of the crowd until someone would approach him asking for a photo.

 Not everyone in attendance Saturday was fazed by Zimmerman's appearance.

 "I don't think he has a reason to be hidden from the public," said Katie Strupp, national events coordinator for the U.S. Concealed Carry Association, one of the event's sponsors.

 Others were not as supportive. One woman who declined to be identified jumped and grabbed her chest when she found out Zimmerman was there.

 Aside from harsh criticism or palpable hatred, Zimmerman said people often wish him well and tell him, "God bless you." He said they often comment that he's not what they expected him to be.

 He said he's been described by strangers as soft-spoken and even kind. He also frequently receives invitations to parties and barbecues from strangers and will go if he's in town.

 But Zimmerman still often finds himself embroiled in controversy. About a week ago, a driver called Lake Mary police accusing Zimmerman of threatening to shoot him during a road-rage incident. The driver didn't press charges, so Zimmerman was not arrested.

 The odd celebrity and media attention aside, Zimmerman describes himself as a regular, free citizen and tries to live a normal life. He said people have told him to use aliases, but he said "I'm not able to lie."

 Zimmerman said he is constantly on the move, spending no more than a month in one state. He often flies to California, Texas and Virginia for speaking engagements and meetings with lawyers.

 He recently launched a website to give himself a platform to speak freely. One of his posts discusses a series of portraits he has painted honoring the four Americans killed in Benghazi, Libya.

 Zimmerman said he plans to give the original paintings to the families of the four people killed but will sell replicas and donate all the funds to various wounded veterans' organizations.

 Zimmerman painted the portraits so the names of the victims killed wouldn't go unknown. He shared that sentiment on his site's first post Sept. 17: "I cannot fathom an America where the name of Tyrone Woods is not as well known as mine. It makes a difference, a tremendous one."

 The post was signed "Your Friend, George M. Zimmerman."

 cdineen@orlandosentinel.com or 407-420-5414 ||||| Starting in 1996, Alexa Internet has been donating their crawl data to the Internet Archive. Flowing in every day, these data are added to the Wayback Machine after an embargo period. |||||
What is a one-paragraph summary of the above article?

– George Zimmerman is constantly on the move and in the news. It's been nearly three years since he shot unarmed black teen Trayvon Martin to death in Sanford, Fla., and his speaking engagements and meetings with attorneys afford him no more than a month in any given state. The Orlando Sentinel recently caught up with him at a gun show and reports that the 30-year-old is in debt, constantly under attack on Twitter, and carries a semi-automatic handgun for extra protection but that he refuses to use an alias because, he says, "I'm not able to lie." Zimmerman continues to pop in and out of the news. Late last year he made headlines when bids on eBay for his "first hand painted artwork" hit nearly $100,000, reports the Miami Herald. A few months prior, his estranged wife—who'd just filed for divorce—called 911 saying he'd threatened her with a gun, but she never followed up with charges. Not long after that, he was arrested on domestic violence charges, which his girlfriend ultimately dropped. (Earlier this month, a driver in Florida called police saying Zimmerman had threatened to shoot him dead when overcome by road rage.)


Here is a news article: Original Contribution

 JAMA. doi: 10.1001/jama.2011.90

 Axillary Dissection vs No Axillary Dissection in Women With Invasive Breast Cancer and Sentinel Node Metastasis

 A Randomized Clinical Trial

 Next Section Abstract Context Sentinel lymph node dissection (SLND) accurately identifies nodal metastasis of early breast cancer, but it is not clear whether further nodal dissection affects survival. Objective To determine the effects of complete axillary lymph node dissection (ALND) on survival of patients with sentinel lymph node (SLN) metastasis of breast cancer. Design, Setting, and Patients The American College of Surgeons Oncology Group Z0011 trial, a phase 3 noninferiority trial conducted at 115 sites and enrolling patients from May 1999 to December 2004. Patients were women with clinical T1-T2 invasive breast cancer, no palpable adenopathy, and 1 to 2 SLNs containing metastases identified by frozen section, touch preparation, or hematoxylin-eosin staining on permanent section. Targeted enrollment was 1900 women with final analysis after 500 deaths, but the trial closed early because mortality rate was lower than expected. Interventions All patients underwent lumpectomy and tangential whole-breast irradiation. Those with SLN metastases identified by SLND were randomized to undergo ALND or no further axillary treatment. Those randomized to ALND underwent dissection of 10 or more nodes. Systemic therapy was at the discretion of the treating physician. Main Outcome Measures Overall survival was the primary end point, with a noninferiority margin of a 1-sided hazard ratio of less than 1.3 indicating that SLND alone is noninferior to ALND. Disease-free survival was a secondary end point. Results Clinical and tumor characteristics were similar between 445 patients randomized to ALND and 446 randomized to SLND alone. However, the median number of nodes removed was 17 with ALND and 2 with SLND alone. At a median follow-up of 6.3 years (last follow-up, March 4, 2010), 5-year overall survival was 91.8% (95% confidence interval [CI], 89.1%-94.5%) with ALND and 92.5% (95% CI, 90.0%-95.1%) with SLND alone; 5-year disease-free survival was 82.2% (95% CI, 78.3%-86.3%) with ALND and 83.9% (95% CI, 80.2%-87.9%) with SLND alone. The hazard ratio for treatment-related overall survival was 0.79 (90% CI, 0.56-1.11) without adjustment and 0.87 (90% CI, 0.62-1.23) after adjusting for age and adjuvant therapy. Conclusion Among patients with limited SLN metastatic breast cancer treated with breast conservation and systemic therapy, the use of SLND alone compared with ALND did not result in inferior survival. Trial Registration clinicaltrials.gov Identifier: NCT00003855

 Axillary lymph node dissection (ALND) has been part of breast cancer surgery since the description of the radical mastectomy.1 ALND reliably identifies nodal metastases and maintains regional control,2,3 but the contribution of local therapy to breast cancer survival is controversial.4,5 The Early Breast Cancer Trialists' Collaborative Group synthesized findings from 78 randomized controlled trials, concluding that local control of breast cancer was associated with improved disease-specific survival.6

 ALND, as a means for achieving local disease control, carries an indisputable and often unacceptable risk of complications such as seroma, infection, and lymphedema.7,8,9 Sentinel lymph node dissection (SLND) was therefore developed to accurately stage tumor-draining axillary nodes with less morbidity than ALND.10 SLND alone is the accepted management for patients whose sentinel lymph nodes (SLNs) are histologically free of tumor, while ALND remains the standard of care for patients whose SLNs contain metastases.11

 Cancer biology is much better understood now than it was when ALND was introduced. Biological factors may affect the predilection of some malignant cells to selectively invade lymph nodes rather than visceral organs, just as certain tumor types metastasize to certain organs and not others.12 Recognition of the complexity of tumor biology has changed cancer treatment, with more liberal use of systemic therapy to treat occult cancer cells wherever they may be in the body. Consequently, the decision to administer systemic therapy is influenced by a variety of patient- and tumor-related factors, with lymph node tumor status influencing13,14 but not necessarily dictating the use of chemotherapy.15,16,17,18 Other factors, such as early cancer detection by screening mammography, have led to earlier intervention in breast cancer, reducing the incidence of nodal metastases and even the number of tumor-involved lymph nodes.19

 These evolving concepts have called into question the need for ALND.20,21 A variety of algorithms have been developed to help clinicians decide which patients would benefit from ALND.22,23,24 Review of Surveillance, Epidemiology, and End Results data has shown that the use of ALND for SLN metastases has decreased in recent years.25 No study has conclusively demonstrated a survival benefit or detriment for omitting ALND when metastatic breast cancer is identified by SLND. In the late 1990s, the American College of Surgeons Oncology Group designed and began the multicenter Z0011 trial. The primary aim of this study was to determine the effects of ALND on overall survival in patients with SLN metastases treated in the contemporary era with lumpectomy, adjuvant systemic therapy, and tangential-field radiation therapy.

 Previous Section Next Section METHODS Patient Characteristics This multicenter, randomized phase 3 trial was registered with the National Cancer Institute and approved by the institutional review boards of participating centers. All patients provided written informed consent. Adult women with histologically confirmed invasive breast carcinoma clinically 5 cm or less, no palpable adenopathy, and an SLN containing metastatic breast cancer documented by frozen section, touch preparation, or hematoxylin-eosin staining on permanent section were eligible for participation. Patients with metastases identified initially or solely with immunohistochemical staining were ineligible. Treatment with lumpectomy to negative margins (no tumor at ink) was required. Women were ineligible if they had 3 or more positive SLNs, matted nodes, or gross extranodal disease, or if they had received neoadjuvant hormonal therapy or chemotherapy. Study Design and Treatment Before randomization, all women underwent SLND and were stratified according to age (≤50 and >50 years), estrogen-receptor status, and tumor size (≤1 cm, >1 cm and ≤2 cm, or >2 cm). Eligible women were randomly assigned to ALND or no further axillary-specific intervention—specifically, no third-field nodal irradiation. ALND was defined as an anatomical level I and II dissection including at least 10 nodes. All women were to receive whole-breast opposing tangential-field radiation therapy. The use of adjuvant systemic therapy was determined by the treating physician and was not specified in the protocol. Patients most commonly entered the study post-SLND following identification of metastases on final pathology report. However, of the 891 registered patients, 287 were registered pre-SLND and assigned to treatment after intraoperative documentation of SLN metastases. Patients in this group subsequently found to have 3 or more tumor-involved lymph nodes were included in the analysis. Patients were assessed for disease recurrence according to standard clinical practice. History and physical examination were performed every 6 months for the first 36 months and yearly thereafter. Annual mammography was required; other testing was based on symptoms and investigator preference. Study End Points The primary end point was overall survival, defined as the time from randomization until death from any cause. A short-term primary end point was occurrence of surgical morbidities. The study plan was to report surgical morbidities following the completion of accrual and prior to overall survival reporting after receiving permission from the data and safety monitoring committee. These morbidities have been reported.10 A secondary end point was disease-free survival, defined as the time from randomization to death or first documented recurrence of breast cancer. Breast cancer recurrence was categorized as locoregional disease (tumor in the breast or ipsilateral supraclavicular, subclavicular, internal mammary, or axillary nodes) or distant metastases. Disease-free survival and its components (locoregional disease and distant metastases) are reported instead of the protocol-specified secondary end point (eg, distant disease–free survival) to facilitate comparison with other studies. Statistical Analysis The primary end point was overall survival as a measure of noninferiority of no further axillary specified interventions (SLND-alone group) compared with the ALND group. Based on the literature at the time of study design, we hypothesized that overall survival was 80% at 5 years for optimally treated women with positive nodes.26,27,28 Clinical noninferiority was defined as the SLND-alone group having a 5-year survival of not less than 75% of that observed in the ALND group. Noninferiority of the SLND-alone treatment was also considered if the hazard ratio (HR) for mortality was less than 1.3 when compared with ALND. An estimated 500 deaths were needed for the study to have 90% power to confirm noninferiority of SLND alone compared with ALND, with the use of a 2-sided 90% confidence interval (CI) for the HR from a Cox regression model.29 Specifically, if the 90% CI for the HR was below 1.3, this would indicate that patients undergoing SLND alone do not have an unacceptably worse overall survival than patients undergoing SLND plus ALND. The use of a 2-sided 90% CI corresponds to a 1-sided significance level of .05.30 The enrollment of 1900 patients in 4 years with a minimum follow-up period of 5 years was initially planned. Four formal interim analyses and 1 final analysis were planned for overall survival, and the O’Brien-Flemming α-spending strategy was used to generate stopping boundaries for each planned analysis. The overall study significance was maintained at .05. However, none of the planned interim analyses were performed before the study was closed based on the recommendation of the data and safety monitoring committee. Because of this, a single terminal hypothesis test with an α of .05 is applied to the data, which makes it consistent with the planned overall significance level of .05 in the original study plan. Ineligible patients were retained in all analyses (ie, both the intent-to-treat analyses and the treatment-received analyses). Kaplan-Meier survival curves for overall survival were compared by log-rank test. The unadjusted HR (and 90% CI) was calculated using a Cox regression analysis, and noninferiority P values are reported. As a secondary analysis, known prognostic factors including adjuvant treatment were included in the Cox regression model to generate an adjusted HR for overall survival (with a 90% CI and noninferiority P values). Disease-free survival was analyzed using Kaplan-Meier curves and univariable and multivariable Cox regression analyses with 95% CIs. The fact that there were only 94 deaths limited the number of variables that could be used in a multivariable model without affecting model stability. We created a base model that included the treatment group (SLND alone vs ALND), age (≤50 vs >50 years), and whether the patient received adjuvant therapy (yes vs no) and added prognostic variables to this model individually. Only variables obtained on 90% or more of the patients were included in the multivariable analysis. Locoregional recurrence rates were compared with the Fisher exact test. Each analysis, other than analysis for the primary end point of overall survival, was performed with 2-sided P values, 5% significance, and a 95% CI; all analyses were performed using SAS release 9.1 (SAS Institute Inc, Cary, North Carolina).

 Previous Section Next Section RESULTS Patient Characteristics The first patient was enrolled in May 1999, and accrual closed in December 2004 based on a recommendation of the independent data and safety monitoring committee because of concerns regarding the extremely low mortality rate. Even if the trial had accrued the targeted 1900 patients, it would have taken more than 20 years of follow-up to observe 500 deaths at the realized event rate. At the time of the decision to terminate the study there had been no formal analysis comparing the survival experience between the 2 groups; the decision was based solely on the observed mortality rate for pooled data from the 2 groups. The date of last follow-up for this analysis was March 4, 2010. Patients were enrolled from 115 institutions, which included affiliates of the Cancer Trials Support Unit and the North Central Cancer Treatment Group. Of 891 patients, 445 were randomly assigned to the ALND group and 446 to the SLND-alone group (Figure 1). Thirty-five patients were excluded after withdrawing consent prior to surgery. The 103 ineligible patients were included in the analyses reported here. Because this was a noninferiority trial, a more conservative analysis was performed on the treatment-received sample (n = 813 patients); 32 patients in the ALND group did not have ALND, and 11 patients in the SLND-alone group had ALND. No qualitative differences were observed between treatment-received sample and intent-to-treat sample analyses, so only intent-to-treat results are reported. Disease characteristics at baseline were well balanced between the 2 groups (Table 1). View larger version: Download as PowerPoint Slide Figure 1. Study Flow ALND indicates axillary lymph node dissection; SLND, sentinel lymph node dissection. View this table: Download as PowerPoint Slide Table 1. Baseline Patient and Tumor Characteristics by Study Group Treatment Results There was an expected difference between ALND and SLND-alone treatment groups in total number of removed lymph nodes and total number of tumor-involved nodes; the median total number of nodes removed was 17 (interquartile range [IQR], 13-22) in the ALND group and 2 (IQR, 1-4) in the SLND-alone group.31 The median total number of nodes with histologically demonstrated tumor involvement (including SLNs) in the ALND group and SLND-alone group was equal (1 [IQR, 1-2] for both groups). Hematoxylin-eosin–stained tumor deposits no larger than 2 mm were defined as micrometastases and were identified in SLNs of 137 of 365 patients (37.5%) in the ALND group compared with 164 of 366 (44.8%) in the SLND-alone group (P = .05). In the ALND group, 97 of 355 patients (27.3%) had additional metastasis in lymph nodes removed by ALND, including 10% of patients with SLN micrometastasis who had macroscopically involved non-SLNs removed. Total nodal involvement is summarized in Table 1; 21.0% of patients undergoing ALND had 3 or more involved nodes compared with 3.7% undergoing SLND alone. Four or more involved nodes were seen in 13.7% of patients receiving ALND and 1.0% of those receiving SLND alone. Adjuvant systemic therapy was delivered to 403 women (96.0%) in the ALND group and 423 women (97.0%) in the SLND-alone group.31 No differences in the proportion of women receiving endocrine therapy, chemotherapy, or both were observed. The type of chemotherapy administered was similar in the 2 groups; anthracycline- and taxane-based combination regimens were the most common. The majority of the women (n = 605) received whole-breast radiation therapy: 263 of 296 (88.9%) in the ALND group and 277 of 309 (89.6%) in the SLND-alone group. Overall Survival At a median follow-up of 6.3 years (IQR, 5.2-7.7), there were 94 deaths (SLND-alone group, 42; ALND group, 52). The use of SLND alone compared with ALND did not appear to result in statistically inferior survival (Figure 2) (P = .008 for noninferiority). The unadjusted HR comparing overall survival between the SLND-alone group and the ALND group was 0.79 (90% CI, 0.56-1.10), which did not cross the specified boundary of 1.3 (Figure 3). The 5-year overall survival rates were 92.5% (95% CI, 90.0%-95.1%) in the SLND-alone group and 91.8% (95% CI, 89.1%-94.5%) in the ALND group. This was substantially greater than the 80% anticipated at protocol design. The HR for overall survival adjusting for adjuvant therapy (chemotherapy, endocrine therapy, and/or radiation therapy) and age for the SLND-alone group compared with the ALND group was 0.87 (90% CI, 0.62-1.23). The adjusted HRs comparing the SLND-alone group with the ALND group in the other multivariable models ranged from 0.86 to 0.92 (Table 2), all similar to the unadjusted rate of 0.79. An exploratory analysis revealed that treatment with ALND vs SLND alone produced no statistically significant difference in outcome among patients grouped by receptor status of the primary tumor (ER+/PR+ or ER−/PR−). View larger version: Download as PowerPoint Slide Figure 2. Survival of the ALND Group Compared With SLND-Alone Group ALND indicates axillary lymph node dissection; SLND, sentinel lymph node dissection. View larger version: Download as PowerPoint Slide Figure 3. Hazard Ratios Comparing Overall Survival Between the ALND and SLND-Alone Groups Blue dashed line at hazard ratio = 1.3 indicates noninferiority margin; blue-tinted region to the left of hazard ratio = 1.3 indicates values for which SLND alone would be considered noninferior to SLND plus ALND. ALND indicates axillary lymph node dissection; CI, confidence interval; SLND, sentinel lymph node dissection. View this table: Download as PowerPoint Slide Table 2. Adjusted Hazard Ratios for Overall Survival Comparing SLND-Alone vs ALND Groups Disease-Free Survival Disease-free survival (Figure 2) did not differ significantly between treatment groups. The 5-year disease-free survival was 83.9% (95% CI, 80.2%-87.9%) for the SLND-alone group and 82.2% (95% CI, 78.3%-86.3%) for the ALND group (P = .14). The unadjusted HR comparing the SLND-alone group with the ALND group was 0.82 (95% CI, 0.58-1.17), and the HR adjusted for adjuvant treatment and age was 0.88 (95% CI, 0.62-1.25) (Table 3). The adjusted HRs comparing the SLND-alone group with the ALND group in the other multivariable models ranged from 0.84 to 0.89 (Table 3), all similar to the unadjusted rate of 0.82. Locoregional recurrence and its correlates have been previously reported.31 The 5-year rates of local recurrence were 1.6% (95% CI, 0.7%-3.3%) in the SLND-alone group and 3.1% (95% CI, 1.7%-5.2%) in the ALND group (P = .11). Locoregional recurrence–free survival at 5 years was 96.7% (95% CI, 94.7%-98.6%) in the SLND-alone group and 95.7% (95% CI, 93.6%-97.9%) in the ALND group (P = .28). View this table: Download as PowerPoint Slide Table 3. Adjusted Hazard Ratios for Disease-Free Survival Comparing SLND-Alone vs ALND Groups Surgical Morbidities Paresthesias, shoulder pain, weakness, lymphedema, and axillary web syndrome are recognized morbidities of ALND.7,8,9 As previously reported,10 the rate of wound infections, axillary seromas, and paresthesias among patients in the Z0011 trial was higher for the ALND group than for the SLND-alone group (70% vs 25%, P < .001). Lymphedema in the ALND group was significantly more common by subjective report (P < .001) and also tended to be higher by objective assessment of arm circumference. These findings are in accordance with other randomized comparisons of SLND with vs without ALND.32,33

 Previous Section Next Section COMMENT In the American College of Surgeons Oncology Group Z0011 randomized trial, ALND did not significantly affect overall or disease-free survival of patients with clinical T1-T2 breast cancer and a positive SLN who were treated with lumpectomy, adjuvant systemic therapy, and tangential-field whole-breast radiation therapy. These survival findings are consistent with those of the National Surgical Adjuvant Breast and Bowel Project B04 trial, in which women with clinically negative nodes were randomized to treatment by radical mastectomy, total mastectomy plus nodal irradiation, or total mastectomy with delayed ALND if nodal recurrence was observed.4 Initially and at each interim analysis for up to 25 years of follow-up, no statistically significant survival differences were observed between any of the groups. For patients treated in the modern era, the relevance of the B04 study, which included patients with larger tumors undergoing mastectomy without adjuvant systemic therapy, is uncertain, because an axillary recurrence after SLND in patients with a lower risk of death from distant disease might negatively affect survival. The findings from Z0011 document the high rate of locoregional control achieved with modern multimodality therapy, even without ALND. In contrast to B04, in which about 40% of patients in the radical mastectomy group were node-positive and the same number in the total mastectomy group were assumed to be node-positive and 5-year overall survival was only about 60%, 100% of patients in Z0011 had nodal involvement; yet the 5-year overall survival was more than 90%. Furthermore, a 19% rate of axillary first failure was observed in B04,4 whereas the axillary nodal recurrence rate was only 0.9% in the SLND-alone group in Z0011.31 The excellent local and distant outcomes in this study highlight the effects of multiple changes in breast cancer management during the interval between the 2 studies. These changes, which include improved imaging, more detailed pathological evaluation, improved planning of surgical and radiation approaches, and more effective systemic therapy, emphasize the need for ongoing reevaluation of “standard” local therapy. The well-documented morbidity from ALND has led other investigators to explore alternative methods of axillary treatment in patients with clinically negative nodes, including radiation, systemic therapy, and axillary observation. These have consistently demonstrated low axillary failure rates, with no significant differences in survival.34,35 The International Breast Cancer Study Group trial of ALND vs observation is noteworthy because more than half of the patients did not receive breast or axillary radiotherapy. In women 60 years and older receiving adjuvant tamoxifen but no axillary treatment, the rate of axillary recurrence was only 3%, and overall survival was 73% at a median follow-up of 6.6 years.36 The low rates of locoregional recurrence at 5 years and the nearly identical overall and disease-free survival between treatment groups in Z0011 would suggest that differences in survival between study groups are unlikely to emerge with longer follow-up, because ALND would only affect survival by virtue of improved locoregional control. In the Early Breast Cancer Trialists' Collaborative Group overview, statistically significant survival differences between treatments at 15 years were seen only when differences in locoregional recurrence between treatments were greater than 10% at 5 years.6 Axillary recurrence is usually an early event, occurring at a median of 14.8 months in B04; in that trial, only 7 of 68 axillary recurrences occurred more than 5 years after study entry.4 Greco et al37 reported that median time to axillary recurrence was 30.6 months for 401 patients who underwent breast-conserving procedures and radiation therapy with no axillary surgery. Recent reports of long-term follow-up in randomized trials confirm these findings.38,39 Because the total locoregional recurrence rate in the Z0011 SLND-alone group at 5 years is only 2.5% compared with 3.6% in the ALND group, it is unlikely that further follow-up would result in enough additional recurrences to generate a clinically meaningful survival difference between groups. The absolute difference in 5-year overall survival between the treatment groups in Z0011 is 0.7%, numerically favoring the SLND-alone group. The HR for overall survival comparing the SLND-alone group with the ALND group was 0.79 (90% CI, 0.56-1.10). The worst HR (1.10) is less than 1.3, which was hypothesized as the inferiority margin threshold. In essence, this means that the 5-year overall survival for the SLND-alone group might be as low as 90.3% if the true 5-year overall survival for the ALND group was 91.8% and the HR as high as 1.10. Most importantly, there is no suggestion that rates of locoregional recurrence, the mechanism by which variations in local therapy result in survival differences, differ between groups to the extent needed to produce survival differences or are likely to do so in the future. Taken together, this suggests that contemporary women may sustain the morbidity of ALND without any meaningful improvement in survival rates. Limitations of the study, such as failure to achieve target accrual and possible randomization imbalance favoring the SLND-alone group, must be considered. However, even in high-risk women (ER−/PR−) in Z0011, preliminary analysis suggests no effect of elimination of ALND on survival. Despite limitations of the Z0011 trial, its findings could have important implications for clinical practice. Examination of the regional nodes with SLND can identify hematoxylin-eosin–detected metastases that would indicate a higher risk for systemic disease and the need for systemic therapy to reduce that risk. Results from Z0011 indicate that women with a positive SLN and clinical T1-T2 tumors undergoing lumpectomy with radiation therapy followed by systemic therapy do not benefit from the addition of ALND in terms of local control, disease-free survival, or overall survival. The only additional information gained from ALND is the number of nodes containing metastases. This prognostic information is unlikely to change systemic therapy decisions and is obtained at the cost of a significant increase in morbidity.10 The only rationale for ALND in these patients would be if the finding of additional nodal metastases would result in changes in systemic therapy. Because current guidelines do not support differences in adjuvant systemic therapy based on the number of positive lymph nodes, except in some uncommon select subgroups,40 ALND does not appear to be warranted in this patient population. The Z0011 trial did not include patients undergoing mastectomy, those undergoing lumpectomy without radiotherapy, those treated with partial-breast irradiation, those receiving neoadjuvant therapy, and those receiving whole-breast irradiation in the prone position, in which the low axilla is not treated. In those patients, ALND remains standard practice when SLND identifies a positive SLN. However, ALND may no longer be justified for women who have clinical T1-T2 breast cancer and hematoxylin-eosin–detected metastasis in the SLN and who are treated with breast-conserving surgery, whole-breast irradiation, and adjuvant systemic therapy. Implementation of this practice change would improve clinical outcomes in thousands of women each year by reducing the complications associated with ALND and improving quality of life with no diminution in survival.

 Previous Section Next Section Author Information Author Affiliations: John Wayne Cancer Institute at Saint John’s Health Center, Santa Monica, California (Dr Giuliano); M. D. Anderson Cancer Center, Houston, Texas (Dr Hunt); Mayo Clinic Rochester, Rochester, Minnesota (Dr Ballman); Dallas Surgical Group, Dallas, Texas (Dr Beitsch); Nashville Breast Center, Nashville, Tennessee (Dr Whitworth); Morton Plant Hospital, Clearwater, Florida (Dr Blumencranz); University of Texas Southwestern Medical Center, Dallas (Dr Leitch); McLaren Regional Medical Center, Michigan State University, Flint (Dr Saha); American College of Surgeons Oncology Group, Durham, North Carolina (Ms McCall); and Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Morrow). Corresponding Author: Armando E. Giuliano, MD, John Wayne Cancer Institute at Saint John’s Health Center, 2200 Santa Monica Blvd, Santa Monica, CA 90404 (giulianoa{at}jwci.org).

 Author Contributions: Dr Giuliano had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Giuliano. Acquisition of data: Giuliano, Beitsch, Whitworth, Blumencranz, Leitch, Saha, Morrow. Analysis and interpretation of data: Giuliano, Hunt, Ballman, Whitworth, Leitch, McCall, Morrow. Drafting of the manuscript: Giuliano, Ballman, Beitsch, Whitworth, Morrow. Critical revision of the manuscript for important intellectual content: Giuliano, Hunt, Ballman, Beitsch, Whitworth, Blumencranz, Leitch, Saha, McCall, Morrow. Statistical analysis: Ballman, McCall. Administrative, technical, or material support: Giuliano, Hunt, Whitworth, Leitch, Saha. Study supervision: Giuliano, Whitworth. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Funding/Support: This study was supported by National Cancer Institute grant U10 CA 76001 to the American College of Surgeons Oncology Group (ACOSOG). Role of the Sponsor: The National Cancer Institute had no role in the design and conduct of the study; the collection, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript. Additional Contributions: We thank the ACOSOG staff, in particular the leadership of Heidi Nelson, MD (Mayo Clinic, Rochester, Minnesota), David Ota, MD (Duke University, Durham, North Carolina), and Samuel A. Wells Jr, MD (National Cancer Institute, Bethesda, Maryland). All 3 of these individuals contributed to study design, manuscript review, or both; none received compensation for their contributions. We also thank all of the investigators and their site research teams. Lastly, we wish to thank the brave patients with breast cancer who participated in this study and their caregivers. ||||| A new study finds that many women with early breast cancer do not need a painful procedure that has long been routine: removal of cancerous lymph nodes from the armpit.

 The discovery turns standard medical practice on its head. Surgeons have been removing lymph nodes from under the arms of breast cancer patients for 100 years, believing it would prolong women’s lives by keeping the cancer from spreading or coming back.

 Now, researchers report that for women who meet certain criteria — about 20 percent of patients, or 40,000 women a year in the United States — taking out cancerous nodes has no advantage. It does not change the treatment plan, improve survival or make the cancer less likely to recur. And it can cause complications like infection and lymphedema, a chronic swelling in the arm that ranges from mild to disabling.

 Removing the cancerous lymph nodes proved unnecessary because the women in the study had chemotherapy and radiation, which probably wiped out any disease in the nodes, the researchers said. Those treatments are now standard for women with breast cancer in the lymph nodes, based on the realization that once the disease reaches the nodes, it has the potential to spread to vital organs and cannot be eliminated by surgery alone.

 Experts say that the new findings, combined with similar ones from earlier studies, should change medical practice for many patients. Some centers have already acted on the new information. Memorial Sloan-Kettering Cancer Center in Manhattan changed its practice in September, because doctors knew the study results before they were published. But more widespread change may take time, experts say, because the belief in removing nodes is so deeply ingrained.

 “This is such a radical change in thought that it’s been hard for many people to get their heads around it,” said Dr. Monica Morrow, chief of the breast service at Sloan-Kettering and an author of the study, which is being published Wednesday in The Journal of the American Medical Association. The National Cancer Institute paid for the study.

 Doctors and patients alike find it easy to accept more cancer treatment on the basis of a study, Dr. Morrow said, but get scared when the data favor less treatment.

 The new findings are part of a trend to move away from radical surgery for breast cancer. Rates of mastectomy, removal of the whole breast, began declining in the 1980s after studies found that for many patients, survival rates after lumpectomy and radiation were just as good as those after mastectomy.

 The trend reflects an evolving understanding of breast cancer. In decades past, there was a belief that surgery could “get it all” — eradicate the cancer before it could spread to organs and bones. But research has found that breast cancer can begin to spread early, even when tumors are small, leaving microscopic traces of the disease after surgery.

 The modern approach is to cut out obvious tumors — because lumps big enough to detect may be too dense for drugs and radiation to destroy — and to use radiation and chemotherapy to wipe out microscopic disease in other places.

 But doctors have continued to think that even microscopic disease in the lymph nodes should be cut out to improve the odds of survival. And until recently, they counted cancerous lymph nodes to gauge the severity of the disease and choose chemotherapy. But now the number is not so often used to determine drug treatment, doctors say. What matters more is whether the disease has reached any nodes at all. If any are positive, the disease could become deadly. Chemotherapy is recommended, and the drugs are the same, no matter how many nodes are involved.

 The new results do not apply to all patients, only to women whose disease and treatment meet the criteria in the study.

 The tumors were early, at clinical stage T1 or T2, meaning less than two inches across. Biopsies of one or two armpit nodes had found cancer, but the nodes were not enlarged enough to be felt during an exam, and the cancer had not spread anywhere else. The women had lumpectomies, and most also had radiation to the entire breast, and chemotherapy or hormone-blocking drugs, or both.

 The study, at 115 medical centers, included 891 patients. Their median age was in the mid-50s, and they were followed for a median of 6.3 years.

 After the initial node biopsy, the women were assigned at random to have 10 or more additional nodes removed, or to leave the nodes alone. In 27 percent of the women who had additional nodes removed, those nodes were cancerous. But over time, the two groups had no difference in survival: more than 90 percent survived at least five years. Recurrence rates in the armpit were also similar, less than 1 percent. If breast cancer is going to recur under the arm, it tends to do so early, so the follow-up period was long enough, the researchers said.

 One potential weakness in the study is that there was not complete follow-up information on 166 women, about equal numbers from each group. The researchers said that did not affect the results. A statistician who was not part of the study said the missing information should have been discussed further, but probably did not have an important impact.

 It is not known whether the findings also apply to women who do not have radiation and chemotherapy, or to those who have only part of the breast irradiated. Nor is it known whether the findings could be applied to other types of cancer.

 The results mean that women like those in the study will still have to have at least one lymph node removed, to look for cancer and decide whether they will need more treatment. But taking out just one or a few nodes should be enough.

 Dr. Armando E. Giuliano, the lead author of the study and the chief of surgical oncology at the John Wayne Cancer Institute at St. John’s Health Center in Santa Monica, Calif., said: “It shouldn’t come as a big surprise, but it will. It’s hard for us as surgeons and medical oncologists and radiation oncologists to accept that you don’t have to remove the nodes in the armpit.”

 Dr. Grant W. Carlson, a professor of surgery at the Winship Cancer Institute at Emory University, and the author of an editorial accompanying the study, said that by routinely taking out many nodes, “I have a feeling we’ve been doing a lot of harm.” |||||
A summary of this is?

– A new study has the potential to make breast cancer treatment easier for a sizable number of women, the New York Times reports. The study says the removal of lymph nodes from the armpit—a common, painful procedure that carries side effects of its own—isn't necessary for about 20% of patients in early stages of the disease. "The discovery turns standard medical practice on its head," declares the Times. “This is such a radical change in thought that it’s been hard for many people to get their heads around it,” says a doctor at Sloan-Kettering and an author of the study. The hospital has already changed its treatment procedures accordingly. The full study, published in the Journal of American Medicine, is here.