See Online for appendix

pelvic CT when a small (5 mitoses per 50 HPFs at these sites are associated with much greater risks, 16%, 73%, 50%, and 52%, respectively.4 These estimations need to be interpreted cautiously, since mitotic counting is challenging to standardise, and the risk of metastases does not increase abruptly when the count exceeds 5 mitoses per 50 HPFs. Such abrupt changes in outcome estimations can be avoided in risk stratification schemes that consider tumour size and mitotic count as continuous variables. For example, using such a scheme, a 3-cm gastric GIST is estimated to have virtually zero rate of metastasis when mitotic count is ≤2, 10–20% risk when the count is 5, and 20–40% risk when 10 mitoses are counted from 50 HPFs.5 Small gastrointestinal tumours judged to be GIST should be biopsied for tissue diagnosis and for estimation of the risk of recurrence. Bleeding tumours and those with risk for metastasis should be excised. Small GISTs with a low mitotic count might be considered for endoscopic surveillance depending on tumour site, patient comorbidities, and risks related to surgery. Most macroscopic non-gastric GISTs should be excised irrespective of size, since even small tumours might give rise to metastases.2,3,5 We declare that we have no conflicts of interest.


*Heikki Joensuu, Peter Hohenberger Department of Oncology, Helsinki University Central Hospital, 00029 Helsinki, Finland (HJ); and Division of Surgical Oncology & Thoracic Surgery, Mannheim University Medical Center, Mannheim, Germany (PH) 1





Joensuu H, Hohenberger P, Corless CL. Gastrointestinal stromal tumour. Lancet 2013; 382: 973–83. ESMO/ European Sarcoma Network Working Group. Gastrointestinal stromal tumors: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012; 23: vii49–55. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: soft tissue sarcoma (version 1.2013). http:// pdf/sarcoma.pdf (accessed Oct 15, 2013). Miettinen M, Lasota J. Gastrointestinal stromal tumors: pathology and prognosis at different sites. Semin Diagn Pathol 2006; 23: 70–83. Joensuu H, Vehtari A, Riihimäki J, et al. Risk of recurrence of gastrointestinal stromal tumour after surgery: an analysis of pooled population-based cohorts. Lancet Oncol 2012; 13: 265–74.

Germany and global health: an unfinished agenda? One day before the national elections, a Lancet Editorial (Sept 21, p 999)1 commented on Germany’s role in global health. The Editorial suggests that Germany’s low visibility and engagement does not match its economic and political influence. This has been different in the distant past. Physicians like Rudolf Virchow (1821–1902) had emphasised the social determinants of health. His statement “Medicine is a social science, and politics is nothing else but medicine on a large scale” marked the beginning of the discipline of public health in Germany and echoed in the Declaration on Primary Health Care in 1978, and the Millennium Declaration in 2000.2 After World War 2, public health in Germany was confined to specific prevention services, whereas basic medical research and a rapidly developing curative medicine absorbed most funds. 3 Activities in the field of international health were largely restricted to biomedical

research projects of universities beside bilateral and multilateral monetary contributions. Only few German institutions such as the Public Health Institute, Heidelberg University, had a clear focus on health systems research and capacity building and developed close ties with institutions in developing countries while interacting with German development agencies and international organisations.4 If Germany is to live up to its responsibility in global health, it needs to substantially invest in capacity building, domestically (eg, creating the first Centre of Global Health Research) and internationally (eg, promoting a sustainable Global Health Fund), beside a serious engagement in global health governance. In analogy to a recent Comment from the Prime Minister of Japan,5 we hope to see soon a commentary in The Lancet from the recently elected German Government emphasising its commitment to global health. We declare that we have no conflicts of interest.

*Olaf Müller, Claudia Beiersmann, Hans Jochen Diesfeld, Albrecht Jahn [email protected] Ruprecht-Karls-University, Medical School, Institute of Public Health, INF 324, 69120 Heidelberg, Germany 1 2




Lancet. A new German Government: leadership for health? Lancet 2013; 382: 999. Diesfeld HJ. Von Rudolf Virchow zu den Millenniums-Entwicklungszielen 2000. In: Razum O, Zeeb H, Laaser U, eds. Globalisierung, gerechtigkeit, gesundheit – einführung in International Public Health. Bern, Switzerland: EVerlag Hans Huber, 2006 (in German). Müller O, Razum O. 30 Jahre Primary Health Care: Neuauflage einer revolutionären Idee. Deutsches Ärzteblatt 2008; 9: 407–09 (in German). Becher H, Kouyaté B. Health research in developing countries. Heidelberg: SpringerVerlag Berlin, 2005 (in German). Abe S. Japan’s strategy for global health diplomacy: why it matters. Lancet 2013; 382: 915–16.

After years of subordinating global health, the German Government recently released a concept note for global health (for a summary of the concept note, see appendix).1 This effort is highly appreciated. The major strengths of the concept are a clear commitment to Universal Vol 382 November 23, 2013

Germany and global health: an unfinished agenda?

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