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Tuesday, April 21, 2026

‘You Dirty Orange Maniac!’: The President of Ultimate Destruction

Sadly, as crazed as Donald Trump may be — and he clearly is a deeply disturbed (and, of course, disturbing) human being — when it comes to war and the burning of fossil fuels, he’s been anything but alone as president of the United States.



Orange blow-up garbagemen Donald Trump speaks at Green Bay airport
(Photo by Chip Somodevilla/Getty Images)

Tom Engelhardt
Apr 21, 2026
TomDispatch


When he’s on full blast, Donald Trump (not so long ago the “drill, baby, drill” candidate for president) is distinctly a furnace. And he seems intent on turning this planet, our only world, into a version of the same. But here’s the strange thing, when it comes to almost anything — from Iran to suddenly firing two key women, Pam Bondi and Kristi Noem, in his government (but certainly not the no-less-chaotic men) — there’s no minute, it seems, when he’s not flipping himself on his head and then spinning or stumbling or catapulting off in a new direction. There’s only one exception I’ve noticed and, all too sadly, that’s climate change, where everything he does — every single thing — is guaranteed to be a disaster for our children and grandchildren.

Recently, of course, he’s launched a nightmarish war, by definition a gigantic producer of greenhouse gases, that’s literally been all about oil and natural gas, thanks in part to the now chaotic, largely blocked Strait of Hormuz through which a quarter of humanity’s sea-borne oil and a fifth of its natural gas used to pass. And if you don’t believe me about it being a nightmare, just check out the most recent prices at your neighborhood gas station. Consider it an irony, then, that his disastrous Iranian war will undoubtedly lead in a direction — to the use of more green energy globally — that, if he ever thought about it, he would hate more than just about anything else. He has, of course, referred to environmentalists as “terrorists.” (“They are terrorists. I call them environmental terrorists.”) And in this country, over his two presidencies, he’s done his damnedest to attack and try to block wind and solar power projects in every imaginable way, even though, globally, green power is growing fast and getting ever cheaper.

And here’s the reality of our moment for which we do need to give Donald Trump credit: once upon a time, you couldn’t have made any of this up — or, of course, have made up Donald Trump as president of the United States (twice!). If you had, it would have seemed like the least believable science fiction novel ever written. Not that I drive a car in New York City (the subway and buses work fine for me), but as I was writing this piece, of course, the price of gas had also edged up in my city to almost four dollars a gallon and a (possibly global) recession is on the horizon. (Thank you, Donald Trump!)

Of course, in launching his recent war against Iran, however incoherently, “the PEACE PRESIDENT” (and yes, he’s into CAPS when it comes to himself) was, all too sadly, in good company, historically speaking. Since victory in World War II, from Korea to Vietnam to Afghanistan to Iraq and now to Iran (to mention only the big conflicts of that all-American era), our presidents have had quite a knack (if such a word can even be used) for starting wars, none (not a one!) of which has ended in anything faintly like victory. And it’s already obvious — you don’t need to have the slightest knack for seeing into the future to know this — that Donald Trump’s version of the same in Iran will prove to be a global disaster, made worse by the fact that, in the process, whether he faintly grasps it or not, he’s also launched another brutally losing war against Planet Earth.

And the worst thing is that I feel I’ve written all of this before. And before Trump — well, “leaves” is far too mild a word for it — abandons (??) the presidency, I could end up writing it again and again, and we would still be in the world — all too literally his world — from hell. Of course, for all we know, Donald J. Trump could decide to crown himself president and try to launch a third term in office that would, if successful, turn the constitution into an historical relic.

“The Only Orange Monarch I Want Is a Butterfly.”

The other week, feeling as I do about “our” president, I went to New York City’s “No Kings” rally. It was gigantic (though you wouldn’t have known that, had you read my hometown paper, the New York Times, in the days that followed). It started on 59th Street where Central Park ends, with masses of marchers on both Seventh and Eighth Avenue, heading for 34th Street. By getting there early, I made it to the front of the crowd on Seventh Avenue at the head of that vast mass of protesting humanity and, once it started, I wove my way in and out of the crowd, back and forth, downtown and uptown again, jotting in a little notebook some of the thousands of homemade signs people were carrying.

When I finally reached Broadway and 42nd Street, I stepped up on the sidewalk and looked back. To my amazement, I could see all the way to 57th Street where we had begun, and that significant-sized avenue was still totally — and I mean totally — packed right back to Central Park. And mind you, this old man was just one of an estimated more than eight million Americans who turned out at more than 3,000 rallies across the United States that day, in communities huge and microscopic, to protest the world Donald Trump has dumped on, spilled all over, and is continuing to roil and broil.

And, yes, it did seem like every third person (even the two demonstrators dressed as plastic tigers) was carrying a homemade sign. I doubt I had ever seen so many of them at any past demonstration. I was scrawling a number of them down in a little notebook, and they ranged from “Fight Truth Decay” and “Grandma says, ICE is not nice!” to “It’s a good thing Congress isn’t alive to see this” and “The only orange Monarch I want is a butterfly.”

And then there was the one carried by a bearded man that caught my attention: “You dirty ORANGE maniac! You blew it all up! Damn you to hell!” And I thought to myself, boy, is that painfully accurate. In his own fashion, among all the things he hasn’t succeeded in accomplishing, he has indeed been blowing it all up in a striking fashion and, unfortunately, potentially damning my children and grandchildren (and yours) to a literal planet from hell.

And sadly, as crazed as Donald Trump may be — and he clearly is a deeply disturbed (and, of course, disturbing) human being — when it comes to war and the burning of fossil fuels, he’s been anything but alone as president of the United States. After all, in these decades, war has been this country’s middle name and we’ve been burning fossil fuels to fight them as if… well, as if there would indeed be no tomorrow(s). And in his two terms in office, Trump and crew have gone with a passion after any form of clean, renewable energy that wouldn’t blister us all. Only recently, for instance, the Guardian (which is superb when it comes to climate-change coverage) was the only publication I saw that reported on new research in Nature magazine showing that this country has caused “an eye-watering $10tn [yes, that’s trillion!] in global damages to the world over the past three decades through its vast planet-heating emissions, with a quarter of this economic pain inflicted upon itself.”

Consider it something of an unintended irony, then, that the crew President Trump and his administration have put so much of themselves into goes by the acronym ICE. In fact, wouldn’t you have thought that “ICE” would be a curse word for President Trump and that, when it comes to creating an immigration hell on earth, his crew of manic enforcers would have been known as “HEAT”? Which reminds me that, at the No Kings rally, I noted an older woman carrying a homemade sign all too appropriately saying: “Deport Trump! Make ICE useful.”

And thanks to his brutal assault on Iran, this planet is only going to get hotter yet, as war releases staggering amounts of carbon dioxide into the atmosphere! Honestly, back in 2016, even if you had let your mind run in wild and unbelievably crazy directions, you simply couldn’t have made up Donald Trump’s planet as it is now, could you? Who could have imagined that the president of the United States, after launching a war with Iran in the Strait of Hormuz, would attack European countries for not joining him, saying, “You’ll have to start learning how to fight for yourself, the U.S.A. won’t be there to help you anymore, just like you weren’t there for us.”

And remind me, who has Donald Trump been there for, other than the major fossil fuel companies that backed him so radiantly in the 2024 election and are now getting a remarkable return on their investment?

Giving Decline New Meaning

Of course, to put all of this in some kind of perspective, sooner or later great imperial powers do go down and the United States has been the number one imperial power on this planet since the end of World War II, with its only true competitor (until China rose well into this century), the Soviet Union, which collapsed in a heap in 1991. So, it shouldn’t be surprising that this country, which, singularly in human history, once reigned more or less supreme on Planet Earth, should finally have begun its own decline, while turning over investment in present and future green energy to China.

But of course, there’s decline and then, in ICE terms, there’s DECLINE!!! And Donald Trump is threatening to turn imperial decline, something known throughout history, into a distinctly new phenomenon. Even declining imperial powers haven’t usually had such a mad ruler or leader. And he does seem remarkably intent, in his own increasingly confused way, on taking this country down with him. The difference, historically, is that until now no imperial ruler had the chance to take down not just his (almost never her) country, but (after a fashion) our planet (at least as a livable place for us), too. And he does seem remarkably intent on continuing to fossil-fuelize our world in a disastrous fashion.

Of course, at this very moment, we’re all watching his approval ratings generally (and particularly on the economy) begin to tank. (Oh wait, my mistake! A tank is a war vehicle, and right now that reference only applies to Israel, which recently lost a remarkable number of tanks in southern Lebanon.) But “our” president has also focused a significant part of his administration on ending anything that could benefit the climate, while burning fossil fuels in a fashion that should be considered beyond incendiary. That includes recently agreeing to offer almost a billion dollars to a French energy company to abandon a project to construct wind farms off the East Coast of this country (as long as it was willing to reinvest that sum in future oil and gas projects here instead).

Yes, someday he could well be seen not just as the president of decline but potentially of ultimate devastation and that flaming red tie of his could end up having a symbolic significance that, once upon a time, no one might have imagined. No wonder that sign I saw on the No King’s Day march — and let me repeat it here one more time: “You dirty ORANGE maniac! You blew it all up! Damn you to hell!” — sticks in my mind. It predicts the very future that, unbelievably enough, 49.8% of American voters tried to usher in again in 2024.

Once upon a time, who could ever have imagined either Donald Trump as president of these (increasingly dis-)United States or such a possible fate?


© 2023 TomDispatch.com


Tom Engelhardt, co-founder of the American Empire Project, runs the Type Media Center's TomDispatch.com. His books include: "A Nation Unmade by War" (2018, Dispatch Books), "Shadow Government: Surveillance, Secret Wars, and a Global Security State in a Single-Superpower World" (2014, with an introduction by Glenn Greenwald), "Terminator Planet: The First History of Drone Warfare, 2001-2050"(co-authored with Nick Turse), "The United States of Fear" (2011), "The American Way of War: How Bush's Wars Became Obama's" (2010), and "The End of Victory Culture: a History of the Cold War and Beyond" (2007).
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Monday, April 20, 2026

 

New metric identifies at-risk mangroves before they disappear



The tool flagged vulnerable mangrove patches a decade in advance, offering a path toward preventive conservation



University of California - San Diego

Mangroves in La Paz Bay, Mexico 

image: 

Mangroves in La Paz Bay, Mexico, stand at the edge of urban expansion, where development meets one of the most valuable coastal ecosystems on Earth.  Credit: Octavio Aburto/Scripps Institution of Oceanography. 


 

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Credit: Credit: Octavio Aburto/Scripps Institution of Oceanography.



Scientists from UC San Diego’s Scripps Institution of Oceanography and the Centro para la Biodiversidad Marina y la Conservación in Mexico have developed a tool that identifies mangrove patches facing the greatest risk of degradation. 

The tool, called the Mangrove Threat Index and described in a new study published in the journal Frontiers in Ecology and the Environment, aims to provide an empirical argument for conservation before vulnerable ecosystems are lost rather than after, said the researchers. The index yields a single number that local planners and communities can use to prioritize specific mangrove patches for protection.

Mangroves are coastal forests that buffer shorelines from storms, store carbon and provide nursery habitat for many species of fish. Despite the tremendous intrinsic and economic importance of the ecosystem services that mangroves provide, roughly half of the world’s mangrove forests are at risk of collapse

Conservation-minded scientists are often in the position of reporting losses with increasing precision rather than proactively identifying mangroves that face immediate risks from infrastructure, agriculture or urban expansion. Long-term threats such as ocean warming and sea-level rise are captured by climate models, but they don’t account for the pressures driving most mangrove loss today. 

“We are trying to break the trend of simply reporting how many hectares of mangroves we have lost each year,” said Octavio Aburto Oropeza, Scripps marine biologist and study co-author. “We created this index to try to measure the risk of loss so conservation can prevent damage rather than only react to it.” 

To create the index, the researchers tested whether proximity to human activity could reliably identify which mangrove patches would go on to experience degradation.

The study authors analyzed 530 mangrove patches across 13 regions worldwide, from urbanized coastlines to remote deltas. Scrutinizing 2010 satellite imagery, the team manually mapped patch boundaries and calculated each patch's distance to nearby roads, settlements and agricultural areas. These distances were combined into a single score — the Mangrove Threat Index — scaled from 0 (lowest risk) to 1 (highest risk). To test whether patches with high threat scores were more likely to experience degradation, the researchers compared the 2010 mangrove patches with 2020 satellite imagery and compared their risk classifications against actual losses.

The index proved effective at identifying vulnerable sites. Among patches the index classified as medium-high or high risk in 2010, 78% went on to experience measurable loss of area by 2020, and nearly half of those lost more than half a hectare (1.2 acres). Statistical modeling also revealed that patches with higher index values tended to lose more area, with each unit increase in the index corresponding to a 58% greater likelihood of degradation.

“Mangroves are foundational ecosystems that take decades to recover once degraded. If we want to safeguard biodiversity, coastal protection, fisheries productivity and carbon storage, we need tools that allow us to act early,” said Valentina Platzgummer, a scientist at the Centro para la Biodiversidad Marina y la Conservación in Mexico and lead author of the study. “The Mangrove Threat Index provides a science-based way to identify where pressures are accumulating and where timely intervention can prevent long-term ecological and social costs.”

The Mangrove Threat Index gives planners, communities and policymakers a tool to act before damage occurs — a shift from reactive conservation to what the authors call preventive governance. Because the index relies on accessible data and straightforward calculations, it can be applied by local decision-makers without specialized expertise. Local authorities could, for example, require assessments for any development proposed in high-risk zones.

“Conservation costs money, but mangroves provide ecosystem services for free,” said Aburto. “You can calculate the economic value of the ecosystem services, but without some assessment of risk there isn’t a concrete reason for a decision maker to pay for conservation. It’s like car insurance — the premiums are calculated not just based on the value of the car but also on the risk of damage.”

To demonstrate the index’s utility in the real world, the researchers used it to evaluate 17 mangrove sites near La Paz, Mexico. The index identified a site called El Comitán located in a transition zone between urban and undeveloped lands as particularly vulnerable. That assessment guided a community-led restoration effort now underway that was supported by municipal authorities who used the index results to understand the urgency of intervention.

The authors said the framework could also be applied to other ecosystems where degradation risk correlates with proximity to human activity such as seagrass meadows, saltmarshes or freshwater wetlands. The researchers have made all the data and coding needed to reproduce the analysis publicly available, enabling others to apply or adapt the approach.

In addition to Aburto and Platzgummer, Fabio Favoretto of the University of Plymouth co-authored the study. The research was supported by the Baum Foundation and the David and Lucile Packard Foundation. 

Read the full paper in Frontiers in Ecology and the Environment“Beyond conservation pessimism and optimism: a proactive, risk-based approach to protect mangrove systems.”


In this aerial view of mangroves in Punta Abreojos in the Mexican Pacific, water finds its way, weaving through mangroves that have shaped, and  been shaped by, these flows for generations along the Pacific Coast. 


Coastal modification in the Gulf of California reshapes natural hydrology, with mangroves increasingly exposed to human driven change. 


Credit: Octavio Aburto/Scripps Institution of Oceanography. 

 

Physicists refute famous 2025 study claiming daylight saving time poses severe health risks




University of Seville







In 2025, Lara Weed and Jamie M. Zeitzer of Stanford University published an article linking the practice of seasonal time changes (Daylight Saving Time) to negative health outcomes, ranging from acute symptoms (heart attacks and strokes) to chronic conditions (obesity). Now, Professors José María Martín-Olalla (University of Seville) and Jorge Mira Pérez (University of Santiago de Compostela), after analyzing the methodology applied in that study, have concluded that "what the world read as scientific evidence against the time change has turned out to be a mathematical illusion."
The same journal that disseminated the controversial article, PNAS (Proceedings of the National Academy of Sciences), has just published a letter signed by Martín-Olalla and Mira Pérez, demonstrating that the study’s conclusions are not supported by actual evidence.
The original article by Weed and Zeitzer gained significant global traction in the fall of 2025 due to its striking conclusions and its use of the PLACES database (Population Level Analysis and Community Estimates). This database, managed by the U.S. Centers for Disease Control and Prevention (CDC), contains information on the prevalence of 29 syndromes and diseases at the local level. The PLACES data were contrasted against a circadian model developed by the authors.

A Critical Error

The work of Professors Martín-Olalla and Mira Pérez reports a grave error in the study's methodological foundations. The original model computes the difference between the rhythm of the biological clock—the circadian rhythm, determined by the time at which body temperature is at its minimum—and the rhythm of the Earth's rotation. According to the original authors, this difference represents the "regulatory circadian shifting necessary to stay synchronized with the outer world."
Global health effects were inferred from the annual sum of these daily readjustments. However, when performing this calculation, the authors consistently accumulated the magnitude of the readjustment, regardless of whether it was positive or negative. "The use of absolute readjustments instead of real readjustments is the critical error," note Martín-Olalla and Mira. They show that this methodology merely captures the "noise" of the model and, therefore, cannot predict net health effects.
Professor Mira explains: "What the authors did makes little sense; it is as if, while driving, we recorded every small adjustment made by moving the steering wheel back and forth to stay in the lane, but then added them all up in the same direction to report a large value instead of allowing them to compensate for each other. By their logic, maintaining a straight course with small left-and-right adjustments (what actually happens) would be the same as a car drifting further and further in one direction until it ends up facing the wrong way. This alone refutes the study's conclusions."
Professor Martín Olalla adds: "We analyzed the 'guts' of the model and saw that the daily readjustment was small—similar to the model's temporal precision—and fluctuating: one direction one day, the opposite the next, with no global trend leading to significant desynchronization, which is exactly how a readjustment should function. Consequently, the annual cumulative total of these readjustments was zero, even with the time change. The metric used appears to have been chosen with the intent of ensuring the current time-change policy yields the worst possible results; the readjustments triggered by the spring and autumn shifts are made to contribute in the same direction instead of compensating for each other. In this sense, the study’s findings resemble a self-fulfilling prophecy. The fact is that the 'absolute cumulative readjustment' they report is approximately 20 hours per year, which is nothing more than an average of about 3 minutes per day, sometimes in one direction and sometimes in the other. Given the information provided in the study, it is difficult to understand how such a weak value (a mere 0.3%) can be epidemiologically linked to the prevalence of disease."
Concluding their letter, Professors Martín Olalla and Mira pose a fundamental question: What prior expectations did the original authors have when they decided to associate global sociosanitary outcomes with the noise of their own model? "We see no prior hypothesis or causal link that justifies the analysis performed in the original study. This invalidates the methodology and, consequently, the reported findings: the authors cannot conclude that eliminating the time change would lead to a decrease in the prevalence of obesity or acute medical events," they affirm.

 

 

The 2040 milestones that Europe must meet to achieve climate-neutrality by 2050





Potsdam Institute for Climate Impact Research (PIK)





Energy, transport, heating and industrial transition: a major modelling study now provides EU-wide guidance with high sector detail on the required pace of transition to fossil-free technologies. The conclusion is encouraging: the EU Green Deal is realistic, and it will ultimately make the continent stronger and more independent from oil and gas crises. The study was conducted at the Potsdam Institute for Climate Impact Research (PIK) and published in Nature Communications.

To understand the scope for useful policy measures, the research team focuses on how the EU can achieve its 2050 climate neutrality target at minimal cost. It draws on the accurate energy–economy–climate model REMIND, runs through a reference scenario – based on assumptions deemed to be most plausible – and then varies key assumptions: Where does the EU stand in terms of emissions reduction and energy efficiency in 2030? How will the costs of wind and solar power develop by 2050? How available will hydrogen and synthetic fuels be as fossil-free sources of energy? Additionally, how much capacity can the EU create for removing CO₂ from the atmosphere to offset hard-to-avoid residual emissions?

One finding is that the EU climate transition, at minimal cost and under the most plausible scenario assumptions, would require a reduction of 2040 net greenhouse gas emissions by 86 percent, relative to 1990. “This result is grounded in techno-economic optimisation of the EU’s transformation path, without looking at questions of fair global burden-sharing,” says PIK researcher and study co-author Robert Pietzcker. 

The EU climate advisory board had recommended a 90 to 95 percent reduction based on considerations of both what is possible and what is fair globally. In doing so, the board had been drawing, among other things, on preliminary results from scenarios developed for the current study. The recommendation was taken up by the EU Commission’s proposal for a 90 percent reduction target. In order to slightly reduce the pressure on member states, it was allowed that 5 percent reductions can come from projects outside the EU. “Our results now show that the resulting 85 percent EU-internal reductions are in line with a cost-effective transition to climate neutrality,” explains Pietzcker. 

Electricity generation from wind and solar must increase seven-fold

To achieve such a significant emissions reduction within just 14 years, the EU must double down on its achievements until now – having reduced greenhouse gas emissions by 37 percent in 2024, relative to 1990 – and further accelerate the transition. To guide future measures, the research team provides “milestones” for individual sectors by 2040 based on its model analysis. These are shown as a point value (representing the reference scenario under the most plausible assumptions) and as a “sensitivity range” (across the entire set of scenarios with the varied assumptions still deemed to be reasonable).

Two pillars of the transition are the expansion of renewable electricity, and the electrification of energy demands. In the reference pathway to climate neutrality, electricity generation from wind and solar will need to be seven times higher in 2040 than in the period from 2018 to 2022 (sensitivity range: four to eight times higher). The share of electricity in final energy consumption, which was fairly constant at 20 percent in the 2010s, will need to rise to 49 percent by 2040 (range: 45 to 59 percent). 

Although a sevenfold rise in wind and solar electricity by 2040 is ambitious, recent experience indicates that it may well be achievable: the required annual growth rate was already achieved over the period 2021–2025, driven by the policy response to the energy crisis. Similarly for electrification: the EU-wide share of battery-electric vehicles in car sales has increased from 2 percent in 2019 to 19 percent in 2025, with Norway and Denmark reaching sales shares above 80 percent.

Dependence on gas and oil imports falls by 60 percent

The study also provides milestones regarding the capture of CO₂ from the atmosphere and storing it permanently in geological formations – a capability that will be indispensable for climate neutrality, but which has so far been virtually non-existent. Carbon capture and storage capacity must rise by 26 (range: 16 to 30) percent annually between 2030 and 2040, reaching 188 (56 to 257) million tonnes of CO₂ annually

“The path to EU climate neutrality by 2050 is still feasible, as long as the EU now shapes the period up to 2040 with ambitious policies,” says Renato Rodrigues, PIK researcher and lead author of the study. “Successful decarbonisation can make the EU economically stronger and strategically more independent.”

This is because, in the reference scenario of the model analysis, demand for both natural gas and crude oil in 2040 is 60 percent lower than in the period from 2018 to 2022, Rodrigues explains. “Although the EU might still need alternative energy imports – e.g. green hydrogen, ammonia, or e-fuels – the volumes would be much lower than current fossil fuels, reducing the EU’s reliance on off-shore energy producers.” 

Sunday, April 19, 2026

 

New guidance from ACP says all average-risk females aged 50-74 should undergo biennial mammography screening for breast cancer



ACP also offers screening advice for females aged 40-49, frequency of screening, discontinuing screening, and females with dense breasts





American College of Physicians





SAN FRANCISCO, April 17, 2026 – New guidance from the American College of Physicians (ACP) says all asymptomatic, average-risk females ages 50 to 74 should receive biennial screening mammography for breast cancer. Females between the ages of 40 and 49 should discuss with their doctor their risk for breast cancer and the benefits and harms of screening. This is because harms of screening such as false positive results, psychological distress because of it, overdiagnosis, overtreatment, additional testing, and radiation exposure may outweigh the uncertain benefits in this population. ACP's advice, "Screening for Breast Cancer in Asymptomatic, Average-Risk Adult Females: A Guidance Statement from the American College of Physicians", is published in Annals of Internal Medicine. 

ACP also provides guidance on when to discontinue breast cancer screening and how to approach screening for females with dense breasts. ACP says that asymptomatic, average‑risk females who are 75 years or older, or those with a limited life expectancy, discuss stopping routine screening with their doctor. This is because the benefits of screening beyond age 74 are reduced or uncertain, while potential harms, such as overdiagnosis, become more likely with increasing age. For asymptomatic, average‑risk females who have dense breasts, ACP advises doctors to consider supplemental digital breast tomosynthesis (DBT). Decisions should consider potential benefits and harms, radiation exposure, availability, patient values and preferences, and cost. However, ACP advises against using supplemental MRI or ultrasound for screening in this population. 

The guidance statement was developed by ACP’s Clinical Guidelines Committee which defined average risk as females who do not have a personal history of breast cancer or diagnosis of a high-risk breast lesion, a genetic mutation such as BRCA 1 or 2 that is known to increase risk, another familial breast cancer risk syndrome, or a history of high-dose radiation therapy to the chest at a young age. 

“Screening for breast cancer is essential and should be guided by the best available evidence" said Jason M. Goldman, MD, MACP, President of ACP. "ACP developed this guidance to provide physicians and females with the information they need to make breast cancer screening decisions, including when to start and discontinue, how often to screen, and which methods to use for screening."