Longer tamoxifen use cuts breast cancer deaths

Breast cancer patients taking the drug tamoxifen can cut their chances of having the disease come back or kill them if they stay on the pills for 10 years instead of five years as doctors recommend now, a major study finds.

The results could change treatment, especially for younger women. The findings are a surprise because earlier research suggested that taking the hormone-blocking drug for longer than five years didn't help and might even be harmful.

In the new study, researchers found that women who took tamoxifen for 10 years lowered their risk of a recurrence by 25 percent and of dying of breast cancer by 29 percent compared to those who took the pills for just five years.

In absolute terms, continuing on tamoxifen kept three additional women out of every 100 from dying of breast cancer within five to 14 years from when their disease was diagnosed. When added to the benefit from the first five years of use, a decade of tamoxifen can cut breast cancer mortality in half during the second decade after diagnosis, researchers estimate.

Some women balk at taking a preventive drug for so long, but for those at high risk of a recurrence, "this will be a convincer that they should continue," said Dr. Peter Ravdin, director of the breast cancer program at the UT Health Science Center in San Antonio.

He reviewed results of the study, which was being presented Wednesday at a breast cancer conference in San Antonio and published by the British medical journal Lancet.

About 50,000 of the roughly 230,000 new cases of breast cancer in the United States each year occur in women before menopause. Most breast cancers are fueled by estrogen, and hormone blockers are known to cut the risk of recurrence in such cases.

Tamoxifen long was the top choice, but newer drugs called aromatase inhibitors — sold as Arimidex, Femara, Aromasin and in generic form — do the job with less risk of causing uterine cancer and other problems.

But the newer drugs don't work well before menopause. Even some women past menopause choose tamoxifen over the newer drugs, which cost more and have different side effects such as joint pain, bone loss and sexual problems.

The new study aimed to see whether over a very long time, longer treatment with tamoxifen could help.

Dr. Christina Davies of the University of Oxford in England and other researchers assigned 6,846 women who already had taken tamoxifen for five years to either stay on it or take dummy pills for another five years.

Researchers saw little difference in the groups five to nine years after diagnosis. But beyond that time, 15 percent of women who had stopped taking tamoxifen after five years had died of breast cancer versus 12 percent of those who took it for 10 years. Cancer had returned in 25 percent of women on the shorter treatment versus 21 percent of those treated longer.

Tamoxifen had some troubling side effects: Longer use nearly doubled the risk of endometrial cancer. But it rarely proved fatal, and there was no increased risk among premenopausal women in the study — the very group tamoxifen helps most.

"Overall the benefits of extended tamoxifen seemed to outweigh the risks substantially," Dr. Trevor Powles of the Cancer Centre London wrote in an editorial published with the study.

The study was sponsored by cancer research organizations in Britain and Europe, the United States Army, and AstraZeneca PLC, which makes Nolvadex, a brand of tamoxifen, which also is sold as a generic for 10 to 50 cents a day. Brand-name versions of the newer hormone blockers, aromatase inhibitors, are $300 or more per month, but generics are available for much less.

The results pose a quandary for breast cancer patients past menopause and those who become menopausal because of their treatment — the vast majority of cases. Previous studies found that starting on one of the newer hormone blockers led to fewer relapses than initial treatment with tamoxifen did.

Another study found that switching to one of the new drugs after five years of tamoxifen cut the risk of breast cancer recurrence nearly in half — more than what was seen in the new study of 10 years of tamoxifen.

"For postmenopausal women, the data still remain much stronger at this point for a switch to an aromatase inhibitor," said that study's leader, Dr. Paul Goss of Massachusetts General Hospital. He has been a paid speaker for a company that makes one of those drugs.

Women in his study have not been followed long enough to see whether switching cuts deaths from breast cancer, as 10 years of tamoxifen did. Results are expected in about a year.

The cancer conference is sponsored by the American Association for Cancer Research, Baylor College of Medicine and the UT Health Science Center.

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

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Wall Street flat, Freeport offsets China comments

LOS ANGELES (Reuters) - Former "Malcolm in the Middle" child star Frankie Muniz said on Tuesday he had suffered a mini-stroke, at the age of 26. "I was in the hospital last Friday. I suffered a 'Mini Stroke', which was not fun at all. Have to start taking care of my body! Getting old!," Muniz said on Twitter. Muniz put his acting career on hold six years ago to race cars for a living, and earlier this year he joined a rock band. According to celebrity website TMZ.com, Muniz was taken ill in Arizona last Friday when friends noticed he was having trouble speaking and understanding. ...

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India Ink: International Olympic Committee Suspends India

The International Olympic Committee (IOC) suspended India’s national Olympic Association on Tuesday because of government interference in its election process, two officials with knowledge of the decision told The Associated Press.

After months of warnings, the IOC executive board imposed the sanction when the Indian Olympic Association failed to comply with the world body’s demands for holding independent elections, the officials said.

In New Delhi, the acting president of the Indian Olympic Association, Vijay Kumar Malhotra, told the A.P. that the association “has not been intimated about any suspension so far.”

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Prince William Returns to Kate's Side But Queen Elizabeth II Won't Visit

By Phil Boucher and Simon Perry

12/04/2012 at 10:00 AM EST

Prince William arrives at King Edward Hospital on Dec. 4

XPosure

Prince William returned to the hospital to visit pregnant wife Kate as she spends her second day being treated for severe morning sickness.

William – in a purple sweater, blue collared shirt and black jeans – walked straight into King Edward VII Hospital after exiting a green Land Rover.

Without a wave or signal to the 100-strong waiting media, the father-to-be, 30, had his head down, briefly running his hand through his hair as he strolled through the doors.

Kate, who is believed to be being cared for by Dr. Marcus Setchell (he delivered royal babies for the Countess of Wessex, William's aunt), was brought to the hospital by William on Monday after her sickness became more acute.

Meanwhile, Palace sources tell PEOPLE that Queen Elizabeth, who was only told Kate was expecting once the couple had decided to head to hospital, will be unlikely to visit.

"She doesn't normally go because it disrupts the running of the hospital," the source said. "And the Duchess just wants to recover and get out."

Kate's office has cancelled all her planned engagements this week. She was due to appear at a charity day at a London bank Wednesday, a gala for the Centrepoint homeless charity and visit the military tournament this weekend.

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Fossil fuel subsidies in focus at climate talks

DOHA, Qatar (AP) — Hassan al-Kubaisi considers it a gift from above that drivers in oil- and gas-rich Qatar only have to pay $1 per gallon at the pump.

"Thank God that our country is an oil producer and the price of gasoline is one of the lowest," al-Kubaisi said, filling up his Toyota Land Cruiser at a gas station in Doha. "God has given us a blessing."

To those looking for a global response to climate change, it's more like a curse.

Qatar — the host of U.N. climate talks that entered their final week Monday — is among dozens of countries that keep gas prices artificially low through subsidies that exceeded $500 billion globally last year. Renewable energy worldwide received six times less support — an imbalance that is just starting to earn attention in the divisive negotiations on curbing the carbon emissions blamed for heating the planet.

"We need to stop funding the problem, and start funding the solution," said Steve Kretzmann, of Oil Change International, an advocacy group for clean energy.

His group presented research Monday showing that in addition to the fuel subsidies in developing countries, rich nations in 2011 gave more than $58 billion in tax breaks and other production subsidies to the fossil fuel industry. The U.S. figure was $13 billion.

The Paris-based Organization for Economic Cooperation and Development has calculated that removing fossil fuel subsidies could reduce carbon emissions by more than 10 percent by 2050.

Yet the argument is just recently gaining traction in climate negotiations, which in two decades have failed to halt the rising temperatures that are melting Arctic ice, raising sea levels and shifting weather patterns with impacts on droughts and floods.

In Doha, the talks have been slowed by wrangling over financial aid to help poor countries cope with global warming and how to divide carbon emissions rights until 2020 when a new planned climate treaty is supposed to enter force. Calls are now intensifying to include fossil fuel subsidies as a key part of the discussion.

"I think it is manifestly clear ... that this is a massive missing piece of the climate change jigsaw puzzle," said Tim Groser, New Zealand's minister for climate change.

He is spearheading an initiative backed by Scandinavian countries and some developing countries to put fuel subsidies on the agenda in various forums, citing the U.N. talks as a "natural home" for the debate.

The G-20 called for their elimination in 2009, and the issue also came up at the U.N. earth summit in Rio de Janeiro earlier this year. Frustrated that not much has happened since, European Union climate commissioner Connie Hedegaard said Monday she planned to raise the issue with environment ministers on the sidelines of the talks in Doha.

Many developing countries are positive toward phasing out fossil fuel subsidies, not just to protect the climate but to balance budgets. Subsidies introduced as a form of welfare benefit decades ago have become an increasing burden to many countries as oil prices soar.

"We are reviewing the subsidy periodically in the context of the total economy for Qatar," the tiny Persian gulf country's energy minister, Mohammed bin Saleh al-Sada, told reporters Monday.

Qatar's National Development Strategy 2011-2016 states it more bluntly, saying fuel subsides are "at odds with the aspirations" and sustainability objectives of the wealthy emirate.

The problem is that getting rid of them comes with a heavy political price.

When Jordan raised fuel prices last month, angry crowds poured into the streets, torching police cars, government offices and private banks in the most sustained protests to hit the country since the start of the Arab unrest. One person was killed and 75 others were injured in the violence.

Nigeria, Indonesia, India and Sudan have also seen violent protests this year as governments tried to bring fuel prices closer to market rates.

Iran has used a phased approach to lift fuel subsidies over the past several years, but its pump prices remain among the cheapest in the world.

"People perceive it as something that the government is taking away from them," said Kretzmann. "The trick is we need to do it in a way that doesn't harm the poor."

The International Energy Agency found in 2010 that fuel subsidies are not an effective measure against poverty because only 8 percent of such subsidies reached the bottom 20 percent of income earners.

The IEA, which only looked at consumption subsidies, this year said they "remain most prevalent in the Middle East and North Africa, where momentum toward their reform appears to have been lost."

In the U.S., environmental groups say fossil fuel subsidies include tax breaks, the foreign tax credit and the credit for production of nonconventional fuels.

Industry groups, like the Independent Petroleum Association of America, are against removing such support, saying that would harm smaller companies, rather than the big oil giants.

In Doha, Mohammed Adow, a climate activist with Christian Aid, called all fuel subsidies "reckless and dangerous," but described removing subsidies on the production side as "low-hanging fruit" for governments if they are serious about dealing with climate change.

"It's going to oil and coal companies that don't need it in the first place," he said.

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Associated Press writers Abdullah Rebhy in Doha, Qatar, and Brian Murphy in Dubai, United Arab Emirates, contributed to this report

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Karl Ritter can be reached at www.twitter.com/karl_ritter

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Wall Street set for flat start on fiscal cliff angst

NEW YORK (Reuters) - Stocks were set to open little changed on Tuesday as the market remains hostage to negotiations in Washington on how to avert a "fiscal cliff" that could push the U.S. economy into recession.

Republicans in Congress proposed steep spending cuts to bring down the budget deficit on Monday but gave no ground on President Barack Obama's call to raise taxes on the wealthiest Americans, and the proposal was quickly dismissed by the White House.

Headlines about the back-and-forth preliminary proposals by Republicans and Democrats have fixated the market. Still, many investors expect the two sides to come up with a deal before the year-end deadline, which could trigger a rally in equities.

"Support (for the market) is based on a belief that Washington will come to some agreement before we go over the fiscal cliff," said Art Hogan, managing director of Lazard Capital Markets in New York.

He said that while politicians are concerned with showing a hard line in public, there is hope "their staffers are looking for middle ground."

Hogan added, "On the first show of flexibility from either side, we'll get a relief rally."

Obama will meet with U.S. governors at the White House on Tuesday to talk about the fiscal cliff, a $600 billion package of tax hikes and federal spending cuts that would begin January 1.

The president is also expected to talk about the fiscal cliff during an interview scheduled for 12:30 p.m. (1730 GMT) on Bloomberg TV.

Coach became the latest company to advance the date of its next dividend payment. Expectations of higher taxes on dividends kicking in in 2013 have pushed many companies to pay special dividends this year or advance their next pay-back to investors.

S&P 500 futures dipped less than a point and were flat in terms of fair value, a formula that evaluates pricing by taking into account interest rates, dividends and time to expiration on the contract. Dow Jones industrial average futures rose 18 points, and Nasdaq 100 futures added 3 points.

The light calendar for data includes the Institute for Supply Management-New York release of its November index of regional business activity at 9:45 a.m. (1445 GMT).

Toll Brothers shares rose 4.2 percent in premarket trading after the largest U.S. luxury homebuilder reported a higher quarterly profit and said new orders rose sharply.

MetroPCS Communications shares dropped 6 percent premarket after Sprint Nextel appeared unlikely to make a counter-offer for the wireless service provider.

Cerberus Capital Management is in talks to join Virtu Financial's bid for U.S. brokerage Knight Capital Group , the Wall Street Journal reported, citing people familiar with the discussions. Knight became a takeover target after a trading glitch left it nearly bankrupt earlier his year.

Shares of Pep Boys-Manny Moe and Jack were down 8.7 percent in premarket trading a day after the release of the auto parts retailer's results.

U.S. stocks fell on Monday as disappointing numbers on U.S. factory activity overshadowed optimism about China's economic growth.

(Reporting by Rodrigo Campos; Editing by Kenneth Barry)

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Amid Euphoria Over U.N. Vote, Palestinians Still Face Familiar Challenges

Majdi Mohammed/Associated Press

Palestinians held pictures of President Mahmoud Abbas  in the West Bank city of Ramallah on Sunday, as they celebrated the recent United Nations vote.

RAMALLAH, West Bank — “Now we have become a state!” Mahmoud Abbas, the president of the Palestinian Authority, announced Sunday to a crowd of thousands in the courtyard of his headquarters in this Palestinian city.

Flags and balloons, a marching band, and a huge poster on the outside wall of the compound proclaiming “You are now in the State of Palestine” added a festive touch as Mr. Abbas returned home triumphant days after the United Nations General Assembly voted to enhance the standing of the Palestinians in the face of heavy Israeli and American opposition.

But an airplane flying high above the compound served as a reminder that the Palestinians have no airport, and they depend on Israeli ports for access to the high seas for shipping. The traffic was as clogged as usual around the Israeli-controlled Qalandia checkpoint, which largely seals off Ramallah from Jerusalem, the eastern part of which has now been widely endorsed as the future Palestinian capital.

At least in the short term, with Israeli elections scheduled for January, things are likely to get tougher for the Palestinians before they get better.

In Jerusalem on Sunday, the Israeli government unanimously rejected the General Assembly’s decision to upgrade the status of Palestine to a nonmember observer state of the United Nations. Prime Minister Benjamin Netanyahu described the Palestinian move as “a gross violation of the agreements that have been signed with the State of Israel.”

In its latest response, Israel said it would not transfer tax revenues it collected on behalf of the Palestinian Authority last month, instead using the money, about $100 million, to pay off about half the debt run up by the authority to the Israel Electric Corporation.

The Palestinian Authority has already been suffering through a financial crisis, often unable to pay the salaries of its employees on time. Palestinian officials said that Arab countries had promised to donate funds and make up for any losses caused by punitive Israeli actions, though it was a shortfall in donor money, largely from Arab nations, that caused the financial crisis in the first place.

Israel’s financial sanctions followed a government decision to build 3,000 previously planned housing units in contested areas of Jerusalem and in parts of the West Bank that Israel intends to keep under any future arrangement with the Palestinians. The Palestinians have long refused to return to the negotiating table unless Israel halts the construction of settlements.

The government has also decided to continue planning and zoning work for the development of a particularly contentious area of East Jerusalem known as E1, a project long condemned by Washington because it would harm the prospects for a contiguous Palestinian state, though privately, Israeli and Palestinian officials said that this last decision could be easily reversed.

Mr. Abbas, for his part, was expected to hold meetings with the members of his leadership to discuss how to begin to translate the Palestinians’ new status into practical steps.

“We are celebrating our dignity,” said Xavier Abu Eid, a Palestinian spokesman. “Our small nation withstood a lot of pressure for something that is our right.”

But the way forward may be fraught with legal obstacles as the Palestinians try to balance their diplomatic victory with the demands of their previous, more concrete achievements.

Israel signed its agreements with the Palestine Liberation Organization, which resulted in the creation of an interim self-rule body, the Palestinian Authority. Asked whether the Palestinian Authority would remain the Palestinian Authority in name, Mr. Abu Eid said: “That requires a decision of the leadership. I think it will not be changed in a day.”

Palestinian officials have insisted that they will not give up the option of seeking to join the International Criminal Court and pursuing claims against Israel, and some Palestinians now expect their leaders to take legal action against the Israelis’ settlement building.

Letters of application for membership in various United Nations bodies and international agencies have been signed “The State of Palestine.”

But the Palestinians may not rush to change the name on the front of their passports to Palestine. Even Mr. Abbas is dependent on Israel’s good graces to be allowed to travel through checkpoints and across borders.

Many Palestinians were hoping that Mr. Abbas would now seek genuine reconciliation with his rivals in Hamas, the Islamic militant group that controls Gaza.

“Unity is the most important step,” said Malik Barghouti, an employee of the authority’s Finance Ministry in Ramallah. “We are one people.”

But if there is no tangible change on the ground, some Palestinians warned, the celebrations could eventually be eclipsed by frustration.

“Most people here think we now have lots of rights,” said Mahmoud Mansour, 22, a student of electrical engineering from Jenin in the northern West Bank, who attended the welcome rally. “When they realize that nothing has changed, they will be angry.”

Khaled Abu Aker contributed reporting.

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Survivor's Jonathan Penner: I Worked Every Trick I Had

TV Watch

Survivor

By Steve Helling

12/03/2012 at 09:30 AM EST

Competing on Survivor for the third time, Jonathan Penner skated through with few alliances, yet he survived until day 30 by using every trick up his sleeve. He tells PEOPLE how he worked every angle, held no grudges, and had the time of his life.

How was playing Survivor different the third time around?
I think I played better than before, because I had experience of having been out there three times. This time, I went out to play hard and win challenges. I was lucky or smart enough to find the idol and play it at the right time. I won immunity when I needed it. I worked every trick that I had.

You just never had the numbers.
A lot of things happened. Dana went home sick. Our tribe lost some key challenges and we went into the merge with a 7-4 disadvantage.

Yet there was some good luck. You won immunity for the first time in your 80 days playing the game. I hear you cried when you won.
I did cry. I cried because I thought about my daughter watching me win immunity on TV.

So, with you gone, who's playing the best game out there now?
Malcolm is playing a great game. He's a superstar. I wish I could grow up to be like him. He has an incredible way about him, and people like him a lot. I liked him a lot.

You seemed to connect with Lisa Whelchel out there, but it also seemed like you were manipulating her. Which was it?I don't know that those things are mutually exclusive. We really did connect. I didn't mean to manipulate her; I tried to engender trust with her. I just wanted to turn her head. I wanted to influence her.

But that sounds like a nice way of saying you were being manipulative.
Perhaps you're right. When I knew my name came up, I tried everything I could. I tried to use guilt, sadness, fear, anger. I wanted to find the key to get her to keep me in the game. I played on her intellectually, emotionally, spiritually. I was playing the game.

You said that Lisa and Mike Skupin could beat you in the finals. I'm not sure that's true.
I did say that, but I think I could have beaten them in the end.

So were you lying?
I was giving them hope. I was making the best argument that I had, that Denise and Malcolm are well-liked and that they stood a better chance against me than against them.

You did a lot of strange things out there, like throwing a vote in Abi's direction for no reason. Can you explain?
I was playing for the jury. I wanted to say to people, "I didn't vote for you." I never wanted there to be a tie where I was responsible for someone being voted out.

You also turned down a final three alliance with Lisa and Mike, which is why they aligned with Malcolm and Denise.
I didn't want to lie to them and make a commitment I couldn't keep. Lisa had voted for me twice, and I felt it wasn't fair for me to make a commitment. I should have made the alliance with them.

That's what cost you the game.
Lisa made other plans when I turned down the alliance and she didn’t want to break her word. And Mike was happy to see me go, because he saw me as a threat.

Any bitterness towards them?
Absolutely not. I had a great time out there with Mike and Lisa – and with everyone else out there. I have no sour grapes, no anger towards anyone. I had a fantastic time playing Survivor and I'm very fortunate to get to play it three times. 

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Asperger's dropped from revised diagnosis manual

CHICAGO (AP) — The now familiar term "Asperger's disorder" is being dropped. And abnormally bad and frequent temper tantrums will be given a scientific-sounding diagnosis called DMDD. But "dyslexia" and other learning disorders remain.

The revisions come in the first major rewrite in nearly 20 years of the diagnostic guide used by the nation's psychiatrists. Changes were approved Saturday.

Full details of all the revisions will come next May when the American Psychiatric Association's new diagnostic manual is published, but the impact will be huge, affecting millions of children and adults worldwide. The manual also is important for the insurance industry in deciding what treatment to pay for, and it helps schools decide how to allot special education.

This diagnostic guide "defines what constellations of symptoms" doctors recognize as mental disorders, said Dr. Mark Olfson, a Columbia University psychiatry professor. More important, he said, it "shapes who will receive what treatment. Even seemingly subtle changes to the criteria can have substantial effects on patterns of care."

Olfson was not involved in the revision process. The changes were approved Saturday in suburban Washington, D.C., by the psychiatric association's board of trustees.

The aim is not to expand the number of people diagnosed with mental illness, but to ensure that affected children and adults are more accurately diagnosed so they can get the most appropriate treatment, said Dr. David Kupfer. He chaired the task force in charge of revising the manual and is a psychiatry professor at the University of Pittsburgh.

One of the most hotly argued changes was how to define the various ranges of autism. Some advocates opposed the idea of dropping the specific diagnosis for Asperger's disorder. People with that disorder often have high intelligence and vast knowledge on narrow subjects but lack social skills. Some who have the condition embrace their quirkiness and vow to continue to use the label.

And some Asperger's families opposed any change, fearing their kids would lose a diagnosis and no longer be eligible for special services.

But the revision will not affect their education services, experts say.

The new manual adds the term "autism spectrum disorder," which already is used by many experts in the field. Asperger's disorder will be dropped and incorporated under that umbrella diagnosis. The new category will include kids with severe autism, who often don't talk or interact, as well as those with milder forms.

Kelli Gibson of Battle Creek, Mich., who has four sons with various forms of autism, said Saturday she welcomes the change. Her boys all had different labels in the old diagnostic manual, including a 14-year-old with Asperger's.

"To give it separate names never made sense to me," Gibson said. "To me, my children all had autism."

Three of her boys receive special education services in public school; the fourth is enrolled in a school for disabled children. The new autism diagnosis won't affect those services, Gibson said. She also has a 3-year-old daughter without autism.

People with dyslexia also were closely watching for the new updated doctors' guide. Many with the reading disorder did not want their diagnosis to be dropped. And it won't be. Instead, the new manual will have a broader learning disorder category to cover several conditions including dyslexia, which causes difficulty understanding letters and recognizing written words.

The trustees on Saturday made the final decision on what proposals made the cut; recommendations came from experts in several work groups assigned to evaluate different mental illnesses.

The revised guidebook "represents a significant step forward for the field. It will improve our ability to accurately diagnose psychiatric disorders," Dr. David Fassler, the group's treasurer and a University of Vermont psychiatry professor, said after the vote.

The shorthand name for the new edition, the organization's fifth revision of the Diagnostic and Statistical Manual, is DSM-5. Group leaders said specifics won't be disclosed until the manual is published but they confirmed some changes. A 2000 edition of the manual made minor changes but the last major edition was published in 1994.

Olfson said the manual "seeks to capture the current state of knowledge of psychiatric disorders. Since 2000 ... there have been important advances in our understanding of the nature of psychiatric disorders."

Catherine Lord, an autism expert at Weill Cornell Medical College in New York who was on the psychiatric group's autism task force, said anyone who met criteria for Asperger's in the old manual would be included in the new diagnosis.

One reason for the change is that some states and school systems don't provide services for children and adults with Asperger's, or provide fewer services than those given an autism diagnosis, she said.

Autism researcher Geraldine Dawson, chief science officer for the advocacy group Autism Speaks, said small studies have suggested the new criteria will be effective. But she said it will be crucial to monitor so that children don't lose services.

Other changes include:

—A new diagnosis for severe recurrent temper tantrums — disruptive mood dysregulation disorder. Critics say it will medicalize kids' who have normal tantrums. Supporters say it will address concerns about too many kids being misdiagnosed with bipolar disorder and treated with powerful psychiatric drugs. Bipolar disorder involves sharp mood swings and affected children are sometimes very irritable or have explosive tantrums.

—Eliminating the term "gender identity disorder." It has been used for children or adults who strongly believe that they were born the wrong gender. But many activists believe the condition isn't a disorder and say calling it one is stigmatizing. The term would be replaced with "gender dysphoria," which means emotional distress over one's gender. Supporters equated the change with removing homosexuality as a mental illness in the diagnostic manual, which happened decades ago.

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AP Medical Writer Lindsey Tanner can be reached at http://www.twitter.com/LindseyTanner .

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Wall Street up on China, U.S. data on tap

NEW YORK (Reuters) - The S&P 500 rose for a fourth straight day on Monday as upbeat Chinese factory data lifted sentiment, but concerns over budget dealings in Washington are expected to keep traders cautious.

China's economy picked up in November even as a broader global recovery remains fragile, with factory activity patchy elsewhere in Asia as demand from the developed world remains weak.

"The good news out of China is encouraging and that's adding to the risk trade this morning," said Peter Cardillo, chief market economist at Rockwell Global Capital in New York.

Markets have focused for weeks on negotiations in Washington over some $600 billion in spending cuts and tax hikes scheduled to kick in next year that could tip the U.S. economy back into recession.

Treasury Secretary Timothy Geithner pushed Republicans on Sunday to offer specific ideas to cut the deficit and predicted that they would agree to raise tax rates on the rich to obtain a year-end deal to avoid the "fiscal cliff."

"Right now for both sides it's all about staying firm and determined to go to the very end," Cardillo said about the negotiations. "But we all know the stakes are high and (Congress) can't be that stupid as to induce another recession."

The Dow Jones industrial average <.dji> rose 53.45 points, or 0.41 percent, to 13,079.03. The S&P 500 <.spx> gained 6.79 points, or 0.48 percent, to 1,422.97. The Nasdaq Composite <.ixic> added 18.21 points, or 0.61 percent, to 3,028.45.

The S&P 500 on Friday closed its fifth positive month in six and is up 8 percent since the end of May.

The Institute for Supply Management releases its November manufacturing index at 10 a.m. (1500 GMT). Economists in a Reuters survey expect a reading of 51.3 for the main index versus 51.7 in October.

Also at 10 a.m., the Commerce Department releases October construction spending data. Economists forecast a rise of 0.5 percent compared with a 0.6 percent rise in September.

(Reporting by Rodrigo Campos, editing by Nick Zieminski)

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