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The relationship between the use of antibiotics and the risk of breast cancer was studied. The study reveals that the use of antibiotics is associated with increased risk of incident and fatal breast cancer.

Breast implants may make breast cancer diagnosis by mammography more difficult, according to a study of approximately 1 million women. Among women with breast implants, mammography only identified 45% of the women who had breast cancer. Among women without breast implants, mammography identified 67% of those who had breast cancer. Breast implants do not make breast cancer worse.

A carefully constructed preventive medicine plan that takes a population-based approach to problem identification and develops prevention strategies for both the community and individual may be an effective way of improving overall public health. A group health cooperative in Washington state developed a program that looked at the population as a whole to identify problem areas that could be verified through medical records. Physicians and community members were then allowed to develop prevention programs that involved intervention at the individual and community levels. Such intervention stressed the role of the patient and gave physicians freedom to target underlying factors of larger health trends. Twenty years after the program began, late-stage breast cancer rates had fallen 32%, the percentage of patients who smoked fell from 25% to 17% and head injuries from bicycle accidents decreased 67% due to increased use of helmets., This article reviews lessons from 20 years of experience in development and provision of clinical preventive services at Group Health Cooperative of Puget Sound, a large health maintenance organization. Critical factors for enhancing service include the use of a population-based epidemiologic viewpoint coupled with specific evidence-based criteria to examine issues; involvement of practitioners in the process; a systems approach to implementation focused on predisposing factors of the practitioners and enabling factors in the practice, organizational, and community environments; feedback of program outcomes; and the use of automated clinical information systems. Outcome results from our clinical prevention efforts include a 32% decrease in late-stage breast cancer (1 989 to 1990); 89% of 2-year-old children with complete immunizations (1994); decrease in adult smokers from 25% to 17% (1985 to 1994); and an increase in bicycle safety helmet use among children from 4% to 48% along with a 67% decrease in bicycle-related head injuries (1987 to 1992). Systematic population-based approaches to the development and provision of clinical preventive services targeting the one-to-one level of primary care and multiple infrastructure levels of care are forging a synthesis of clinical medicine and public health approaches. This approach will become pervasive as clinical information systems improve, risk information is captured routinely, and practitioners gain skills in the art of patient risk behavior change and population-based care.

Presents a reply by Christine Velicer and colleagues to letters to the editor about their article "Antibiotic use in relation to the risk of breast cancer," in a previous issue.