NEJM 12 Jul 2007 Vol 357

Carriers of BRCA1 and BRCA2 mutations are of course much more likely to get breast cancer, but is it also true, as sometimes stated, that their cancers are more aggressive? There’s a crumb of comfort for such women in this Israeli study: this is not the case, and their survival rates do not differ from other women with breast cancer. For a guide to the management of inherited breast cancer risk, there is a later piece.

The only argument I can think of against fortifying flour with folic acid is the theoretical risk that it may encourage some colonic polyps to become cancerous; we already know that it prevents neural tube defects and reduces the risk of stroke. Canada introduced folic acid fortification of cereal products in 1998, and this study observes a 46% reduction in neural tube defects, the greatest drop being in areas of previous high incidence. Figures for stroke and bowel cancer would be interesting.

The introduction of pay for performance in UK general practice was regarded around the world as an exciting experiment – hence the appearance of this paper about our humble discipline in the New England Journal. To me, New Labour seems largely a continuation of Thatcherism by other means, but until Tony Blair went mad about two years ago, he was doing some good to the NHS. To suppress health spending, Thatcher introduced disincentives to diagnosing and treating chronic illness (called fundholding): Blair introduced positive incentives in 2004 (called the Quality and Outcomes Framework) and the money to pay for them. When this succeeded beyond expectation, his ministers ran a press campaign against greedy bastard GPs. Make the targets tougher! Make the bastards sweat! We wait to see if Gordon Brown will take a more rational approach. In the meantime, this paper shows that for coronary heart disease, diabetes and asthma, GPs were already improving their care of patients steadily before the introduction of QOF, and that since 2004 there has been little evidence of acceleration. It’s almost as if we had professional standards before the government started bribing us.