In a 1976 lecture to the Society of Surgical Oncology, the late Jerome Urban lamented the loss of a rational approach to the treatment of breast cancer, which he thought had been replaced “by an emotional appeal to the patient’s vanity. A great cry has been raised in the public media to save the breast, despite the long-term consequences.” In this issue, Fisher and colleagues and Veronesi and colleagues describe the long-term outcomes of two pivotal randomized trials comparing breast-conserving surgery and mastectomy. These studies document how far our understanding of breast cancer has evolved since Urban’s lecture. Breast cancer has a long natural history, and conclusions drawn from short-term follow-up studies may give an inaccurate picture of the ultimate outcome. The failure to observe a survival advantage of mastectomy after 20 years should convince even the most determined sceptics that mastectomy is not superior to breast conservation for the treatment of breast cancer.

More intensive screening and treatment for prostate cancer is not associated with lower prostate cancer specific mortality. Lu-Yao and colleagues compared the Seattle-Puget Sound area in the United States, where screening and aggressive treatment were adopted early, with Connecticut, where adoption was slower. In 1987–90 men aged 65–79 in Seattle were five times as likely to undergo prostate specific antigen testing and twice as likely to undergo biopsy, and rates of radical prostatectomy and radiotherapy were also substantially higher. Nevertheless, through 11 years of follow up, prostate cancer mortality was similar in the two areas.

Although the experts continue to argue about the evidence on screening, the public has come to different conclusions. The irresistible logic of finding the cancer early, the drive to avoid regretting later the decision not to have the test, the right to obtain information about oneself by testing, and a perceived right to parity with women’s access to screening may all be more important arguments.

These lay arguments for prostate specific antigen testing have their own logic and validity. What they mostly do not recognise are the costs of screening. Screening is the business of changing identities; it is the business of producing patients. Becoming a patient is not a trivial matter. It has profound health, social, psychological, and economic consequences. Screening therefore raises important ethical problems. As Cochrane and Holland pointed out three decades ago: “If a patient asks a medical practitioner for help, the doctor does the best possible. The doctor is not responsible for defects in medical knowledge. If, however, the practitioner initiates screening procedures the doctor is in a very different situation. The doctor should, in our view, have conclusive evidence that screening can alter the natural history of disease in a significant proportion of those screened.”

Those involved in the provision of acute medical care are suffering from work overload, change overload and information overload. If we were enzymes (and at one level that is all we are), we would be saturated with substrate and at, or approaching, our Vmax. We all know that our acute services cannot continue in their present form and that something has got to change, but we are less certain about what should change and how. Most physicians see the long-term solution as evolutionary, involving more doctors, more nurses and more acute beds, but are uncertain about how to maintain the service until these become available. Others believe that ‘we need completely new thinking to solve the problem – not just refinements of the present system’.

Some managers would like to turn the present system upside down, with all emergencies being admitted to small, local hospitals which are bristling with technology and networked to larger district general hospitals. Practising physicians who are, by nature, cautious (but not, as is sometimes claimed, reactionary) are largely unconvinced by arguments for quantum leaps into the unknown. They are also suspicious that such changes might be introduced without prior evaluation. The Royal College of Physicians has published various reports which relate to the practice of acute medicine and has now produced three more, one on the practice of acute medicine in hospitals which lack other acute services such as acute surgery, critical care and on-site diagnostic services, and another on the interface between accident and emergency services and acute medical services. The third, is on the interface between acute general medicine and critical care. All three reports are in the category of evolutionary rather than quantum-leap change, so do they contribute to the current debate or are they just a further addition to the information overload?

Arguments over the scope of a proposed worldwide ban on cloning are buying time for mavericks who want to create the first human clones, experts have warned New Scientist.

This week the UN General Assembly, meeting in New York, will be setting out the broad areas to be covered by a proposed treaty banning human cloning. The treaty will be formally drafted next year, and if all goes to plan it could be in place within months.

Almost everyone agrees that cloning for reproductive purposes – producing cloned babies, in other words – should be outlawed. But opinion is sharply divided over therapeutic cloning, where an embryo is used solely for the purpose of extracting cells to treat a matching patient. Led by the US and the Vatican, a group of countries – including many that are predominantly Roman Catholic, and some Islamic states – is pressing for the ban to cover this kind of cloning too.

But whatever is agreed, time is running short. Mavericks such as the Italian fertility expert Severino Antinori make no secret of their determination to create human clones. There were rumours earlier this year that one of his patients is already carrying one. And Clonaid, a company formed in California by the Raelian cult, has also hinted that a clone may already be on the way.

If the first human clone were born just after such a treaty came into effect, it is not clear whether the perpetrator would be punished retrospectively.