Study finds mammograms lead to unneeded treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Online:

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

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

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

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Hamas-Israel cease-fire takes hold but mistrust runs deep

CAIRO/GAZA (Reuters) - A ceasefire between Israel and Gaza's Hamas rulers took hold on Thursday after eight days of conflict, although deep mistrust on both sides cast doubt on how long the Egyptian-sponsored deal can last.

Even after the ceasefire came into force late on Wednesday, a dozen rockets from the Gaza Strip landed in Israel, all in open areas, a police spokesman said. In Gaza, witnesses reported an explosion shortly after the truce took effect at 9 p.m (1900 GMT), but there were no casualties and the cause was unclear.

The deal prevented, at least for the moment, an Israeli ground invasion of the Palestinian enclave following bombing and rocket fire which killed five Israelis and 162 Gazans, including 37 children.

But trust was in short supply. The exiled leader of Hamas, Khaled Meshaal, said his Islamist movement would respect the truce if Israel did, but would respond to any violations. "If Israel complies, we are compliant. If it does not comply, our hands are on the trigger," he told a news conference in Cairo.

Israeli Prime Minister Benjamin Netanyahu said he had agreed to "exhaust this opportunity for an extended truce", but told his people a tougher approach might be required in the future.

Both sides quickly began offering differing interpretations of the ceasefire, brokered by Egypt's new Islamist government and backed by the United States, highlighting the many actual or potential areas of discord.

If it holds, the truce will give 1.7 million Gazans respite from days of ferocious air strikes and halt rocket salvoes from militants that unnerved a million people in southern Israel and reached Tel Aviv and Jerusalem for the first time.

"Allahu akbar, (God is greatest), dear people of Gaza you won," blared mosque loudspeakers in Gaza as the truce took effect. "You have broken the arrogance of the Jews."

Fifteen minutes later, wild celebratory gunfire echoed across the darkened streets, which gradually filled with crowds waving Palestinian flags. Ululating women leaned out of windows and fireworks lit up the sky.

Meshaal thanked Egypt for mediating and praised Iran for providing Gazans with financing and arms. "We have come out of this battle with our heads up high," he said, adding that Israel had been defeated and failed in its "adventure".

Some Israelis staged protests against the deal, notably in the southern town of Kiryat Malachi, where three people were killed by a Gaza rocket during the conflict, army radio said.

Netanyahu said he was willing to give the truce a chance but held open the possibility of reopening the conflict. "I know there are citizens expecting a more severe military action, and perhaps we shall need to do so," he said.

The Israeli leader, who faces a parliamentary election in January, delivered a similar message earlier in a telephone call with U.S. President Barack Obama, his office said.

"AN OPEN PRISON"

According to a text of the agreement seen by Reuters, both sides should halt all hostilities, with Israel desisting from incursions and targeting of individuals, while all Palestinian factions should cease rocket fire and cross-border attacks.

The deal also provides for easing Israeli restrictions on Gaza's residents, who live in what British Prime Minister David Cameron has called an "open prison".

The text said procedures for implementing this would be "dealt with after 24 hours from the start of the ceasefire".

Israeli sources said Israel would not lift a blockade of the enclave it enforced after Hamas, which rejects the Jewish state's right to exist, won a Palestinian election in 2006.

However, Meshaal said the deal covered the opening of all of the territory's border crossings. "The document stipulates the opening of the crossings, all the crossings, and not just Rafah," he said. Israel controls all of Gaza's crossings apart from the Rafah post with Egypt.

Hamas lost its top military commander to an Israeli strike in the conflict and suffered serious hits to its infrastructure and weaponry, but has emerged with its reputation both in the Arab world and at home stronger.

Israel can take comfort from the fact it dealt painful blows to its enemy, which will take many months to recover, and showed that it can defend itself from a barrage of missiles.

"No one is under the illusion that this is going to be an everlasting ceasefire. It is clear to everyone it will only be temporary," said Michael Herzog, a former chief of staff at the Israeli ministry of defence.

"But there is a chance that it could hold for a significant period of time, if all goes well," he told Reuters.

Egypt, an important U.S. ally now under Islamist leadership, took centre stage in diplomacy to halt the bloodshed. Cairo has walked a fine line between its sympathies for Hamas, an offshoot of the Muslim Brotherhood to which President Mohamed Mursi belongs, and its need to preserve its 1979 peace treaty with Israel and its ties with Washington, its main aid donor.

Announcing the agreement in Cairo, Egyptian Foreign Minister Mohamed Kamel Amr said mediation had "resulted in understandings to cease fire, restore calm and halt the bloodshed".

U.S. Secretary of State Hillary Clinton, standing beside Amr, thanked Mursi for peace efforts that showed "responsibility, leadership" in the region.

The Gaza conflict erupted in a Middle East already shaken by last year's Arab uprisings that toppled several veteran U.S.-backed leaders, including Egypt's Hosni Mubarak, and by a civil war in Syria, where President Bashar al-Assad is fighting for survival.

In his call with Netanyahu, Obama in turn repeated U.S. commitment to Israel's security and promised to seek funds for a joint missile defence program, the White House said.

BUS BOMBING

The ceasefire was forged despite a bus bomb explosion that wounded 15 Israelis in Tel Aviv earlier in the day and despite more Israeli air strikes that killed 10 Gazans. It was the first serious bombing in Israel's commercial capital since 2006.

Israel, the United States and the European Union all classify Hamas as a terrorist organization. It seized the Gaza Strip from the Western-backed Palestinian President Mahmoud Abbas in 2007 in a brief but bloody war with his Fatah movement.

"This is a critical moment for the region," Clinton said. "Egypt's new government is assuming the responsibility and leadership that has long made this country a cornerstone for regional stability and peace."

In Amman, U.N. chief Ban Ki-moon urged both sides to stick to their ceasefire pledges. "There may be challenges implementing this agreement," he said, urging "maximum restraint".

(Additional reporting by Noah Browning in Gaza, Ori Lewis, Allyn Fisher-Ilan and Crispian Balmer in Jerusalem, Yasmine Saleh, Shaimaa Fayed and Tom Perry in Cairo, Suleiman al-Khalidi in Amman and Margaret Chadbourn in Washington; Writing by Alistair Lyon and David Stamp; Editing by Louise Ireland)

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Deaths of 5 runaways prompt soul search in China

BEIJING (AP) — On the day China unveiled its new leadership in Beijing with promises of a better life for all, five runaway boys seeking shelter and warmth died in a garbage bin in the south.

The boys were all brothers or cousins aged 9 to 13. Surnamed Tao, they were the sons of three brothers — two of whom are migrant workers with jobs far from home — and most of them lived largely unsupervised in the care of their blind grandmother.

They had been missing for more than a week when, police say, they lit a fire to stay warm on a cold, damp night Nov. 15 in the city of Bijie and died from carbon monoxide poisoning.

As details of the tragedy emerged this week, it touched off the country's latest soul-searching about social responsibility. It renewed concern over the "left-behind" rural children who are often left with grandparents while parents seek work in thriving coastal cities, and the failure of the country's social services to adequately care for them.

"Though you departed from us in a garbage bin, you are not garbage," children's book author Zheng Yuanjie wrote in his microblog, adding that the fault lies with "adults who failed their responsibilities."

Questions have been raised about how the children — found about 25 kilometers from their home village of Caqiangyan — could have gone missing for 10 days without more of an effort launched to find them. Six local officials, including two school principals, were sacked on Tuesday.

"We have failed in our management work," said Tang Guangxing, a spokesman for Bijie city, where the boys' bodies were found Friday. "Our work was not attentive enough."

State media outlets, giving the deaths broad coverage, have joined in the hand-wringing.

"This is a shame that cannot be washed away by a civilized society," the Beijing Youth Daily wrote in an editorial this week.

The official Xinhua News Agency said the boys had poor grades at school and had essentially dropped out of their classes. Xinhua faulted China's education system for putting too much stress on academic excellence at the expense of caring for less successful students.

"Please do not forget the mission of compulsory education. Please spread love and responsibility like sunshine," Xinhua wrote in an editorial. "This is also a tragedy of 'left-behind children,' which is a sign of the time and requires introspection from family, society and government."

Many critics in China have fretted over decaying public morality as the country's economy rapidly grows and its people enjoy unprecedented wealth. A similar outcry erupted last year when a toddler in Guangzhou was run over by two vehicles and then ignored by at least 18 passers-by.

The latest incident has focused concern on the plight of families in impoverished rural areas. An estimated 58 million children countrywide lack sufficient supervision or stay in the care of grandparents when their parents seek work in China's booming cities.

Some details of the boys' home life remain unclear. Their relatives lack telephones and could not be contacted, though some were quoted by Chinese media outlets who sent journalists to the extremely poor, mountainous region of mud huts where farmers earn about 3,000 yuan ($475) a year.

The boys — Zhongjin, Zhonghong, Zhonglin, Chong and Bo — were found in a 1.5-meter-by-1.3-meter (5 foot-by-4 foot) garbage container in Bijie after a night of drizzling rain when temperatures were about 4 Celsius (40 Fahrenheit).

Two of the fathers, ironically, are garbage collectors in the boom city of Shenzhen near Hong Kong, according to a Xinhua report. One of the mothers lives in Shenzhen and another reportedly left the family. The third brother and his wife are farmers in the Bijie area, though they apparently often left the boys to fend for themselves, Xinhua said.

Former journalist and Bijie resident Li Yuanlong posted online that the children had been spotted living in a temporary shelter with plastic cloth, bricks and plywood at a nearby demolition site.

Li, who broke the story on the deaths in an online posting, told The Associated Press on Wednesday that local officials in Bijie were not pleased with the coverage and that police there told him to leave the city for four or five days.

Some observers have faulted the family for not keeping closer watch over their children.

"How could grandparents take care of your child when you are away?" asked Beijing parking attendant Liang Hongjin, a migrant worker from Henan province.

However, much of the criticism has been directed at the government and educational system.

The family reported the boys missing Nov. 5. Beijing lawyer Li Fangping said the failure of local officials to launch a proper search was "horrific."

The boys died hours after Xi Jinping gave his first speech as China's new leader in Beijing's Great Hall of the People. Xi underlined the Communist Party's mission to improve the country's education, employment, social security, housing and health care.

"Our people have an ardent love for life," Xi said in the speech. "They want their children to have sound growth, have good jobs and lead a more enjoyable life."

The boys' death reflects a systematic failure of children services, Beijing Normal University social welfare expert Wang Zhenyao said on state-run China Central Television. The system lacks shelters, social workers and volunteers, and there is poor communication with those in need, he said.

"That's a blank in China," he said.

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Elmo left behind on 'Sesame Street' as actor exits

NEW YORK (AP) — Even on "Sesame Street," where everything is famously A-OK, problems can arise for its residents.

And that includes the Muppets. Cookie Monster grapples with an eating disorder. Oscar the Grouch gets cranky. Mr. Snuffleupagus gets the blues.

But Elmo seemed immune to any of that. Since enjoying his breakout success more than two decades ago, the 3 1/2-year-old red monster has radiated good cheer, love and trilling giggles. No wonder everyone — adults as well as children — adore him.

The key to Elmo is "his innocence, his positiveness and his sweetness," according to Kevin Clash, the man who created him and once told The Associated Press, "I would love to be totally like Elmo."

Now Clash has been scandalously separated from Elmo and from "Sesame Street," the TV series where he reigned behind the scenes for 28 years.

Clash spoke of "personal matters" as the cause of his resignation Tuesday after an unthinkable nine-day stretch that began with an unnamed man in his 20s claiming he had sex with Clash at age 16. That allegation was quickly recanted. But then came another accusation of sexual abuse, and a lawsuit.

That second accuser, a 24-year-old college student named Cecil Singleton, said the actor had engaged in sexual behavior with him when he was 15. He is suing Clash for $5 million.

"I am deeply sorry to be leaving," said Clash in his parting statement, "and am looking forward to resolving these personal matters privately."

But privacy may no longer be possible for Clash, the 52-year-old divorced father of a grown daughter who acknowledged last week that he is gay. Singleton's lawyer, Jeff Herman, said he has been contacted by two other potential victims of Clash and expects additional legal action.

At a news conference Tuesday, Singleton said he and Clash met on a gay chat line and then, for a two-week period, they engaged in sexual contact, though not intercourse. Sex with a person under 17 is a felony in New York if the perpetrator is 21 or older.

Singleton said he didn't know Clash's profession until years later, when he Googled the man's name.

"I was shocked when I found out what he did for a living," said Singleton.

Now that career has ended for Clash, who, in his dream job as a puppeteer for "Sesame Street," was assigned a little-used puppet now known as Elmo, then turned him into a star. In the process, Clash won 23 daytime Emmy awards and one prime-time Emmy. He published his 2006 autobiography, "My Life as a Furry Red Monster," and was the subject of the 2011 documentary "Being Elmo: A Puppeteer's Journey."

Elmo overshadowed Big Bird and other "Sesame" Muppets in popularity and screen time, while marginalizing the cast of live actors. Since 1998, he has had his own show-within-a-show on "Sesame Street" in addition to appearances elsewhere in the hour.

He is also a major moneymaker for Sesame Workshop, the New York-based company that produces the show, and for licensees. At his merchandising height in 1996, he inspired the Tickle Me Elmo doll, which became a cultural phenomenon and that Christmas season's hottest toy.

This year's Elmo dolls, "LOL Elmo," which giggles, and "Let's Rock! Elmo," which sings and comes with a microphone and drum set, haven't made any of this year's hot toy lists. Even so, Elmo toys probably account for one-half to two-thirds of the $75 million in annual sales the "Sesame Street" toy line generates for toy maker Hasbro, estimates BMO Capital Markets analyst Gerrick Johnson.

Johnson said he wasn't sure how this week's news might affect sales of Elmo toys this holiday.

"How many people are going to want to explain to their kid why they're not getting an Elmo?" he asked.

On Tuesday, Hasbro issued a statement saying "We are confident that Elmo will remain an integral part of Sesame Street and that Sesame Street toys will continue to delight children for years to come."

Despite his resignation, Clash will remain an integral part of "Sesame Street" for the foreseeable future. Taping of season No. 44 will wrap by mid-December and will begin airing next September, according to someone close to the show who spoke on condition of anonymity because the person was not authorized to publicly discuss details of its production. That means new episodes with Clash performing as Elmo will presumably continue well into 2014.

As for who might take over as Elmo, other "Sesame Street" puppeteers were already being trained to serve as Clash's stand-in, Sesame Workshop said. It's part of an understudy policy being adopted for all the major Muppet characters.

But no one knows how Elmo will fare going forward. Will the jokes spurred by Clash's downfall leave a lasting mark on Elmo's image? Will there be parents who see him tainted by association with the man who brought him to life?

In the wake of a personal tragedy that may still be unfolding, Elmo's innocence, positiveness and sweetness will be put to the test.

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AP Television Writer David Bauder and AP Retail Writer Mae Anderson contributed to this report.

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

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

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

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

Still, momentum may be building.

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

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

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

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

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

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

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

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

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

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

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

The doctors group made clear that:

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

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

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

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

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

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

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

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

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

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

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Online:

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

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Gaza shakes, Israelis killed as Clinton seeks truce

GAZA/JERUSALEM (Reuters) - Israeli air strikes shook the Gaza Strip and Palestinian rockets struck across the border as U.S. Secretary of State Hillary Clinton held talks in Jerusalem in the early hours of Wednesday, seeking a truce that can hold back Israel's ground troops.

Egypt's new Islamist government is mediating talks and had floated hopes for a ceasefire by late Tuesday between Israel and Hamas, the Islamist movement controlling Gaza. However, by the time Clinton met Israeli Prime Minister Benjamin Netanyahu, it was clear there would be more argument, and more violence, first.

Hamas leaders in Cairo accused the Jewish state of failing to respond to proposals and said an announcement on holding fire would not come before daylight on Wednesday. Israel Radio quoted an Israeli official saying a truce was held up due to "a last-minute delay in the understandings between Hamas and Israel."

An initial halt to attacks may, however, not see the sides stand their forces down from battle stations immediately. Clinton, who flies to Cairo to see Egyptian President Mohamed Mursi later on Wednesday, spoke of a deal "in the days ahead."

Like most Western powers, Washington shuns Hamas as an obstacle to peace and has blamed it for the Gaza conflagration. A U.N. Security Council statement condemning the conflict was blocked on Tuesday by the United States, which complained that it "failed to address the root cause," the Palestinian rockets.

As Clinton arrived in Israel after nightfall, Israel was stepping up its bombardment from air and sea. At one point munitions slammed into Gaza at a rate of one every 10 minutes.

Gazan rocket fire waned overnight but resumed before dawn on Wednesday with six launches, Israel said. No one was hurt.

After seven days of hostilities that have killed over 130 Palestinians and five Israelis, both sides are looking for more than a return to the sporadic calm that has prevailed across the blockaded enclave since Israel ended a much more devastating air and ground offensive four years ago.

ELECTION

Netanyahu, who faces an election in two months that he is, for now, favored to win, told Clinton he wanted a "long-term" solution. Failing that, Netanyahu made clear, he stood ready to step up the military campaign to silence Hamas' rockets.

Hamas for its part is exploring the opportunities that last year's Arab Spring has given it to enjoy favor from the new Islamist governments of states once ruled by U.S. proteges, and from Sunni Gulf powers keen to woo it away from Shi'ite Iran. It has used longer-range missiles, some sent by Tehran, and hopes to eclipse Western-backed Palestinian President Mahmoud Abbas.

Hamas has spoken of an easing of Israel's blockade on the 40-km (25-mile) slice of Mediterranean coast that is home to 1.7 million people. It may count on some sympathy from Mursi, though Egypt's first freely elected leader, whose Muslim Brotherhood inspired Hamas' founders, has been careful to stick by the 1979 peace deal with Israel struck by Cairo's former military rulers.

Clinton, who broke off from an Asian tour with President Barack Obama and assured Netanyahu of "rock-solid" U.S. support for Israel's security, spoke of seeking a "durable outcome" and of Egypt's "responsibility" for promoting peace.

She repeated international calls for the kind of lasting, negotiated, comprehensive Israeli-Palestinian settlement that has eluded the two peoples for decades - something neither of the two warring parties seems seriously to be anticipating.

"In the days ahead, the United States will work with our partners here in Israel and across the region toward an outcome that bolsters security for the people of Israel, improves conditions for the people of Gaza and moves toward a comprehensive peace for all people of the region," Clinton said.

"It is essential to de-escalate the situation in Gaza. The rocket attacks from terrorist organizations inside Gaza on Israeli cities and towns must end and a broader calm restored," she said.

"SELF-DEFENCE"

Netanyahu, who has appeared in no immediate rush to repeat the invasion of winter 2008-09 in which over 1,400 Palestinians died, said: "If there is a possibility of achieving a long-term solution to this problem with diplomatic means, we prefer that.

"But if not, I'm sure you understand that Israel will have to take whatever action is necessary to defend its people."

As Israeli aircraft have carried out hundreds of strikes on rocket stores, launchpads and suspected Hamas command posts since assassinating the head of its military wing a week ago. Tens of thousands of Israeli soldiers have been preparing tanks and infantry units for a possible invasion.

During the night, explosions again rocked the city of Gaza and other parts of the Strip, while rockets from the enclave, some essentially home-made, others Iranian-designed and smuggled through tunnels from Egypt, landed in southern Israel.

One reached as far as Rishon Lezion, near Tel Aviv, on Tuesday, the latest to jar Israel's metropolis, long untroubled by Palestinian attacks. Another rocket fell close to Jerusalem, the holy city claimed by both sides in the conflict.

Medical officials in Gaza said 31 Palestinians were killed on Tuesday. An Israeli soldier and a civilian died when rockets exploded near the Gaza frontier, police and the army said.

Gaza medical officials say 138 people have died in Israeli strikes, mostly civilians, including 34 children. In all, five Israelis have died, including three civilians killed last week.

AMMUNITION STORES

Obama, whose relations with the hawkish Netanyahu have long been strained, has said he wants a diplomatic solution, rather than a possible Israeli ground operation in the densely populated territory, home to 1.7 million Palestinians.

Israel's military said it targeted overnight more than 100 sites in Gaza, including rocket launchers, tunnels and the Ministry of Internal Security, used by Hamas as a command center. Israeli police said more than 150 rockets had been fired from Gaza by Tuesday evening.

"No country would tolerate rocket attacks against its cities and against its civilians," Netanyahu said with U.N. Secretary-General Ban Ki-moon, who arrived in Jerusalem from talks in Cairo, at his side. "Israel cannot tolerate such attacks."

Critics have accused Israel of using disproportionate force that has killed civilians. Israel accuses Hamas of putting Gaza's people in harm's way by siting rockets among them.

Media groups have criticized attacks on Gaza media facilities. On Tuesday, three local journalists died in air strikes on their vehicles.

A building housing AFP's bureau was bombed. The French news agency said its staff were unhurt. Israel's military said it had been targeting a Hamas intelligence centre in the tower.

Hamas executed six Palestinians accused of spying for Israel, who a security source quoted by Hamas Aqsa radio said had been "caught red-handed" with "filming equipment to take footage of positions." The radio said they had been shot.

Militants on a motorcycle dragged the body of one of the men through the streets.

A delegation of nine Arab ministers, led by the Egyptian foreign minister, visited Gaza in a further signal of heightened Arab solidarity with the Palestinians.

(Additional reporting by Cairo bureau; Writing by Alastair Macdonald; Editing by Lisa Shumaker)

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Obama sends Clinton to Mideast amid Gaza crisis

PHNOM PENH, Cambodia (AP) — President Barack Obama dispatched Secretary of State Hillary Rodham Clinton to the Middle East on Tuesday as the U.S. urgently seeks to contain the bloody conflict between Israel and Hamas.

Clinton hastily departed for the region from Cambodia, where she had joined Obama for summit meetings with Asian leaders. The White House said she would make three stops, meeting with Israeli Prime Minister Benjamin Netanyahu in Jerusalem, Palestinian officials in Ramallah, in the West Bank, and Egyptian leaders in Cairo.

Clinton's trip marks the Obama administration's most forceful engagement in the weeklong conflict that has killed more than 100 Palestinians and three Israelis, with hundreds more wounded. While the U.S. has backed Israel's right to defend itself against rocket fire from Gaza, the Obama administration has warned its ally against pursuing a ground assault that would further escalate the violence and could dramatically increase casualties on both sides.

Still, Obama's deputy national security adviser Ben Rhodes said the U.S. believes "Israel will make its own decisions about the military operations and decisions that it undertakes."

"At the same time, we believe that Israel, like the United States, like other countries, would prefer to see their interests met diplomatically and peacefully," Rhodes said. "It's in nobody's interest to see an escalation of the military conflict."

Obama and Clinton have consulted about the widening crisis throughout their three-day tour of Southeast Asia, their final joint trip before Clinton leaves her post as the top U.S. diplomat. They spoke again about the situation Tuesday morning, aides said, and made the decision for her to travel to the region.

Still, it was unclear what impact Clinton's presence would have on the spiraling violence or whether she was heading to the Mideast with any specific overtures from the U.S.

Rhodes said "there are a number of ideas that are in play," but offered no further details. And he insisted the ramped up U.S. involvement was "a matter of what's in everybody's best interests", not a matter of "leverage."

Obama and Clinton each have held multiple telephone calls with their counterparts in Israel and Egypt, which is at the center of negotiations to quell the violence. Because the U.S. considers Hamas a terrorist organization and prohibits contact between its members and American officials, it is relying on Egypt, as well as Turkey and Qatar, to deliver its message to the Hamas leadership in Gaza.

Israel and Hamas say they are open to diplomatic mediation efforts being led by Egypt, but they are far apart in their demands.

Hamas wants Israel to halt all attacks on Gaza and lift tight restrictions on trade and movement in and out of the territory that have been in place since Hamas seized Gaza by force in 2007. Israel demands an end to rocket fire from Gaza and a halt to weapons smuggling into Gaza through tunnels under the border with Egypt.

The widening conflict has threatened to overshadow Obama's three-country tour of Southeast Asia, his first overseas trip after winning re-election. The president, after a marathon day that took him from Thailand to Myanmar to Cambodia, worked the phones with Mideast leaders into the early hours of Tuesday morning, aides said.

The White House said Obama would stay in contact with the key players in the conflict while Clinton was on the ground. The president is scheduled to depart Cambodia later Tuesday, arriving back in Washington before dawn Wednesday.

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Follow Julie Pace at http://twitter.com/jpaceDC

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Fight over 'Modern Family' star returns to court

LOS ANGELES (AP) — A judge is scheduled to wade into the messy family dynamics of teen actress Ariel Winter and determine whether the "Modern Family" star should stay away from her mother, who has been described in court filings as physically and emotionally abusive.

At a hearing Tuesday, Superior Court Judge Michael Levanas will consider whether the 14-year-old should continue living with her sister, who has temporary guardianship of the actress.

The judge will have more information to consider than he did on Oct. 3, when he temporarily stripped Chrisoula Workman of custody of her daughter. Workman has denied all accusations of abuse and filed more than two dozen declarations from friends, acquaintances, stylists and others who say they've never witnessed any abuse.

Winter's father, Glenn Workman, also filed an objection to the guardianship late Monday, stating he wants a better relationship with his daughter and would be willing to care for her.

Winter has been in the care of her adult sister, Shanelle Gray, who was removed from Chrisoula Workman's care in the 1990s amid accusations of abuse. Chrisoula Workman contends Gray was a rebellious teen who left home and that she is contending with a similar situation with Winter, who has been acting since age 7 and currently stars as Alex Dunphy on the hit ABC series "Modern Family."

People on the show's set are concerned about Winter's wellbeing and have been sneaking her food, according to in-court statements by Gray's attorney, Michael Kretzmer.

Gray's filing states Chrisoula Workman has repeatedly slapped Winter and engaged in emotional abuse, including name-calling.

"The allegations made by Ariel are false," said Chrisoula Workman's attorney Anita Gumm. "We really feel she's just a rebellious teen and wants her independence. It's our hope that the court terminates the guardianship. Both parents want Ariel home. Shanelle is not suitable to be a guardian."

Glenn Workman's filing Monday does not address the abuse allegations, but states he believes his daughter should be returned to live with Chrisoula Workman, or that he be allowed to raise her.

"I want to provide for her a calm loving home environment that is a retreat from the glitz and glamour of Hollywood; a place where she can think and relax without any distractions," Glenn Workman wrote. "This whole situation has turned into a circus and places Ariel in a position she should not have to be in."

Kretzmer declined to comment on Glenn Workman's filing.

He has previously told The Associated Press that it is unfortunate that the case became public, but that Winter was removed from her mother's custody for good reasons. "The court granted a temporary guardianship, and I think any rational person will realize that the court simply doesn't see the sky falling but has some basis for granting a temporary guardianship," he said last week.

During a contentious court hearing Workman lashed out at Gray, called Kretzmer a moron and accused Winter of screaming her and hitting her.

"I think what we've got is a situation that's not healthy, at least for a temporary ... basis," Levanas said in early October. He ordered child welfare workers to conduct an investigation and appointed an attorney to represent Winter's interests.

Workman's attorney has also scheduled a deposition of Gray for early December, and a review of Winter's finances will be conducted. Currently, Gray has no access to Winter's money, some of which should be in a special account meant to protect the earnings of child actors.

Gumm and Workman have cited Gray's finances as a reason why she should not be granted guardianship of her sister. But Kretzmer denied last week that money was an issue in the case.

"There's no truth whatsoever to Shanelle obtaining this guardianship for purposes of advancing her career or for some other personal gain," Kretzmer said. "Shanelle is successful and has done very well in her own rights. This is a tragedy for her, too."

Winter has been acting since age 7, appearing in several TV series, including "ER" and "Phineas and Ferb," and movies such as "Kiss Kiss Bang Bang," ''Ice Age: The Meltdown" and "ParaNorman."

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Anthony McCartney can be reached at http://twitter.com/mccartneyAP

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New push for most in US to get at least 1 HIV test

WASHINGTON (AP) — There's a new push to make testing for the AIDS virus as common as cholesterol checks.

Americans ages 15 to 64 should get an HIV test at least once — not just people considered at high risk for the virus, an independent panel that sets screening guidelines proposed Monday.

The draft guidelines from the U.S. Preventive Services Task Force are the latest recommendations that aim to make HIV screening simply a routine part of a check-up, something a doctor can order with as little fuss as a cholesterol test or a mammogram. Since 2006, the Centers for Disease Control and Prevention also has pushed for widespread, routine HIV screening.

Yet not nearly enough people have heeded that call: Of the more than 1.1 million Americans living with HIV, nearly 1 in 5 — almost 240,000 people — don't know it. Not only is their own health at risk without treatment, they could unwittingly be spreading the virus to others.

The updated guidelines will bring this long-simmering issue before doctors and their patients again — emphasizing that public health experts agree on how important it is to test even people who don't think they're at risk, because they could be.

"It allows you to say, 'This is a recommended test that we believe everybody should have. We're not singling you out in any way,'" said task force member Dr. Douglas Owens of Stanford University and the Veterans Affairs Palo Alto Health Care System.

And if finalized, the task force guidelines could extend the number of people eligible for an HIV screening without a copay in their doctor's office, as part of free preventive care under the Obama administration's health care law. Under the task force's previous guidelines, only people at increased risk for HIV — which includes gay and bisexual men and injecting drug users — were eligible for that no-copay screening.

There are a number of ways to get tested. If you're having blood drawn for other exams, the doctor can merely add HIV to the list, no extra pokes or swabs needed. Today's rapid tests can cost less than $20 and require just rubbing a swab over the gums, with results ready in as little as 20 minutes. Last summer, the government approved a do-it-yourself at-home version that's selling for about $40.

Free testing is available through various community programs around the country, including a CDC pilot program in drugstores in 24 cities and rural sites.

Monday's proposal also recommends:

—Testing people older and younger than 15-64 if they are at increased risk of HIV infection,

—People at very high risk for HIV infection should be tested at least annually.

—It's not clear how often to retest people at somewhat increased risk, but perhaps every three to five years.

—Women should be tested during each pregnancy, something the task force has long recommended.

The draft guidelines are open for public comment through Dec. 17.

Most of the 50,000 new HIV infections in the U.S. every year are among gay and bisexual men, followed by heterosexual black women.

"We are not doing as well in America with HIV testing as we would like," Dr. Jonathan Mermin, CDC's HIV prevention chief, said Monday.

The CDC recommends at least one routine test for everyone ages 13 to 64, starting two years younger than the task force recommended. That small difference aside, CDC data suggests fewer than half of adults under 65 have been tested.

"It can sometimes be awkward to ask your doctor for an HIV test," Mermin said — the reason that making it routine during any health care encounter could help.

But even though nearly three-fourths of gay and bisexual men with undiagnosed HIV had visited some sort of health provider in the previous year, 48 percent weren't tested for HIV, a recent CDC survey found. Emergency rooms are considered a good spot to catch the undiagnosed, after their illnesses and injuries have been treated, but Mermin said only about 2 percent of ER patients known to be at increased risk were tested while there.

Mermin calls that "a tragedy. It's a missed opportunity."

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Clinton heads to Mideast amid Gaza crisis

GAZA CITY, Gaza Strip (AP) — Efforts to end a week-old convulsion of Israeli-Palestinian violence drew in the world's top diplomats on Tuesday, with President Barack Obama dispatching his secretary of state to the region on an emergency mission and the U.N. chief appealing from Cairo for an immediate cease-fire.

Israel and Gaza's militant Hamas rulers have staked tough, hard-to-bridge positions, and the gaps keep alive the threat of an Israeli ground invasion. On Tuesday, grieving Gazans were burying militants and civilians killed in ongoing Israeli airstrikes, and barrages of rockets from Gaza sent terrified Israelis scurrying to take cover.

From Egypt, U.N. chief Ban Ki-moon said he came to the region because of the "alarming situation."

"This must stop, immediate steps are needed to avoid further escalation, including a ground operation," Ban said. "Both sides must hold fire immediately ... Further escalation of the situation could put the entire region at risk."

A deputy White House national security adviser said U.S. Secretary of State Hillary Rodham Clinton would depart for the Mideast on Tuesday from Cambodia, where she had accompanied Obama on a visit to Southeast Asia. The official said Clinton would begin her Mideast diplomacy by meeting with Israeli Prime Minister Benjamin Netanyahu in Jerusalem, then she would meet with senior officials of the Palestinian government in the West Bank before heading to Cairo to meet with Egyptian leaders.

The U.S. considers Hamas, which has killed hundreds of Israelis in suicide and other attacks, to be a terror group and does not meet with its officials. The Obama administration blames Hamas for the latest eruption of violence and says Israel has the right to defend itself. At the same time, it has warned against a ground invasion, saying it could send casualties spiraling.

The conflict erupted last week, when a resurgence in rocket fire from Gaza provoked Israel to strike back, killing Hamas' military chief in an air attack and carrying out hundreds of assaults on militants' underground rocket launchers and weapons stores.

The onslaught abruptly turned deadlier over the weekend as aircraft were ordered to go after Hamas military commanders and buildings suspected of housing their commands and weapons caches. In the narrow alleys and warrens of crowded Gaza, where militants often operate from residential areas, civilian casualties mounted.

By Tuesday, civilians accounted for 54 of the 113 Palestinians killed since the operation began. Some 840 people have been wounded, including 225 children, Gaza health officials said.

Early Tuesday, Israeli aircraft targeted another Hamas symbol of power, battering the headquarters of the bank senior Hamas officials set up to sidestep international sanctions on the militant group's rule. After Hamas violently overran Gaza in June 2007, foreign lenders stopped doing business with the militant-led Gaza government, afraid of running afoul of international terror financing laws.

The inside of the bank, which was set up by leading Hamas members and describes itself as a private enterprise, was destroyed. Abuilding supply business in the basement was damaged.

Owner Suleiman Tawil, 31, grimly surveyed the damage to his store and six company cars. "I'm not involved in politics," he said. "I'm a businessman. But the more the Israelis pressure us, the more we will support Hamas."

Fuad Hijazi and two of his toddler sons were killed Monday evening when missiles struck their one-story shack in northern Gaza, leaving a crater about two to three meters (seven to 10 feet) deep in the densely populated neighborhood. Residents said the father was not a militant.

On Tuesday morning, the boys' bodies lay next to each other on a rack in the local morgue, wrapped tightly in white burial shrouds. Their father lay in a rack below.

"We want to tell the world which is supporting the state of Israel, what this state is doing," said neighbor Rushdie Nasser. "They are supporting a state that kills children ... We want to send a message to the U.N. and the West: Enough of supporting the Zionists, who are killing children."

Three Israeli civilians have also been killed and dozens wounded since the fighting began last week, the numbers possibly kept down by a rocket-defense system that Israel developed with U.S. funding. More than 1,000 rockets have been fired at Israel this week, the military said, including three that struck schools that had been emptied because of the fighting.

As part of global efforts to end the Gaza fighting, U.N. chief arrived in Cairo on Monday and was to meet with Israeli President Shimon Peres in Jerusalem on Tuesday. In Cairo, Ban said he would also travel to the West Bank to meet with Palestinian President Mahmoud Abbas. With tens of thousands of Israeli soldiers dispatched to the Gaza border, awaiting a possible order to invade, his mission was all the more urgent.

Germany's foreign minister was also headed to the region for talks with Israeli and Palestinian leaders. Turkey's foreign minister and a delegation of Arab League foreign ministers were to visit Gaza on Tuesday.

Egypt, the traditional mediator between Israel and the Arab world, has been at the center of recent diplomatic efforts involving the U.S., Turkey, Qatar and other nations.

On Monday, Egyptian intelligence officials met separately in Cairo with an Israeli envoy and with Khaled Mashaal, the top Hamas leader in exile, to try to bridge the considerable differences.

Israel demands an end to rocket fire from Gaza and a halt to weapons smuggling into Gaza through tunnels under the border with Egypt. It also wants international guarantees that Hamas will not rearm or use Egypt's Sinai region, which abuts both Gaza and southern Israel, to attack Israelis.

Hamas wants Israel to halt all attacks on Gaza and lift tight restrictions on trade and movement in and out of the territory that have been in place since Hamas seized Gaza by force in 2007. Israel has rejected such demands in the past.

Mashaal told reporters Monday that Hamas would only agree to a cease-fire if its demands are met. "We don't accept Israeli conditions because it is the aggressor," he said. "We want a cease-fire along with meeting our demands."

Israeli Foreign Ministry spokesman Yigal Palmor said Israel prefers to end this round of violence through diplomacy but insists the outcome would guarantee Israel long-term quiet along its border with Gaza.

"The declared purpose of this operation was to make rockets stop, once and for all, or at least for a very long time," he said Tuesday, without specifying a timeframe. "All instruments have their limitations. But if the diplomatic path proves itself unuseful, then the only path that will be left is the military. But we hope to explore the diplomatic path to its full extent."

Successive Israeli governments, meanwhile, have struggled to come up with an effective policy toward Hamas, which is deeply rooted in Gaza, a densely populated territory of 1.6 million.

Neither Israel's economic blockade of the territory nor bruising military strikes have cowed Gaza's Islamists, weakened their grip on the Palestinian strip their ability to fire rockets at the Jewish state.

An Israeli ground invasion would risk Israeli troop losses, and it could send the number of Palestinian civilian casualties ballooning — a toll Israel could be reluctant to risk just four years after its last invasion drew allegations of war crimes.

Still, with Israeli elections just two months away, polls show Israeli public sentiment has lined up staunchly behind the offensive Netanyahu's government has launched.

Israel and Gaza's militants have a long history of fighting, but the dynamics have changed radically since they last warred four years ago. Though their hardware is no match for the Israeli military, militants have upgraded their capabilities with weapons smuggled in from Iran and Libya, Israeli officials claim.

Only a few years ago, tens of thousands of Israelis were within rocket range. Today those numbers have swollen to 3.5 million, as the militants' improved weapons allowed the unprecedented targeting of Tel Aviv and Jerusalem this week.

Hamas, a branch of the region-wide Muslim Brotherhood, is also negotiating from a stronger position than four years ago, when Israel launched a three-week war on the militants in Gaza. At that time, Hamas was internationally isolated; now, the Muslim Brotherhood is in power in Egypt and Tunisia, and Hamas is also getting political support from Qatar and Turkey.

At home, too, the military offensive has shored up Hamas at a time when it was riven by internal divisions over its direction and the new Egyptian government's refusal to lift the blockade it imposed along with Israel after Hamas seized the territory in 2007.

This newfound backing contrasts radically with the loss of stature the Western-backed Palestinian President Mahmoud Abbas has endured as Palestinians lose faith in his ability to bring them a state through negotiations with Israel.

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Teibel reported from Jerusalem. AP writer Ibrahim Barzak contributed from Gaza City.

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