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Abortion and breast cancer: The manufactroversy that won’t die

Editor’s note: Given the controversial nature of the topic, I think it’s a good time to point out my disclaimer before this post. Not that it’ll prevent any heated arguments or anything…

The Science-Based Medicine blog was started slightly over two years ago, and this is a post I’ve wanted to do since the very beginning. However, since January 2008, each and every time I approached this topic I chickened out. After all, the topic of abortion is such a hot button issue that I seriously questioned whether the grief it would be likely to cause is worth it. (Take the heat generated any time circumcision is discussed here and ramp it up by a factor of 10.) On the other hand, there is so much misinformation out there claiming a link between abortion and the subsequent development of breast cancer when the data simply don’t support such a link, and the name of this blog is Science-Based Medicine. Why should I continue to shy away from a topic just because it’s so religiously charged? More importantly, in my discussion how can I focus attention on the science rather than letting the discussion degenerate into the typical flamefest that any discussion of abortion on the Internet (or anywhere else, for that matter) will almost inevitably degenerate into. Indeed, such discussions have a depressing near-inevitability of validating Godwin’s law not once but many times — usually within mere hours, if not minutes.

My strategy to try to keep the discussion focused on the science will be to stay silent about my own personal opinions regarding abortion and, other than using it to introduce my trepidation about discussing the topic, the religious and moral arguments that fuel the controversy. That’s because the question of whether abortion is the murder of a human being, merely the removal of a lump of tissue, or somewhere in between is a moral issue that, at least as far as I’m concerned, can’t ever be definitively answered by science. That is why it is not my purpose to sway readers towards any specific opinion regarding the morality of abortion. Indeed, I highly doubt that any of our readers care much about my opinions on the matter. On the other hand, I would hope that I’ve built up enough trust over the last two years that our readers will be interested in my analysis of the existing data regarding something another related issue. It is my purpose to try to dispel a myth that is not supported by science, specifically the claim that elective abortion is causes breast cancer or is a very strong risk factor for its subsequent development. That is a claim that can be answered by science and, for the most part, has been answered by science with a fairly high degree of certainty. Despite the science against it, the medical myth that abortion causes breast cancer or vastly increases the risk of it is, like the myth that vaccines cause autism, a manufactroversy that won’t die, mainly because it is largely fueled by religious beliefs that are every bit as immune to science as the ideological beliefs that drive the antivaccine movement.

A bit of background

Let me step back a bit. Several years ago, I didn’t pay much, if any, attention to the ABC (“abortion-breast cancer”) claim. Then two years ago events conspired to force me to start paying attention. The first item was nothing more than a skeptic encountering bad science. The second thing that happened struck a lot closer to home. The first thing that happened was that in the fall of 2007 I saw this article in the Chicago Tribune entitled Snubbing cancer study will only hurt women: Research showing link to abortion ignored by media (also mirrored on John Byrne’s blog):

During National Breast Cancer Awareness Month, it is fitting and proper that women be informed about any newly discovered dangers, even as the public groans under the weight of all the warnings surrounding the mere act of living.

For example, a well-researched Chicago Tribune story last week disclosed that women who have just a couple of alcoholic drinks daily increase their breast cancer risk by 13 percent. Coincidentally, a new study reported that abortion is an important breast cancer risk factor, yet I couldn’t find a word describing the research in mainstream media.

How to explain this disparity? I’ll be vigorously advised that “most” studies disprove an abortion-breast cancer link. Or that the study in question appeared in a “conservative” scientific journal. Or that the study is bogus or unimportant. Or, more rudely, that the whole breast cancer argument has been concocted by anti-abortion rights advocates to make women afraid to have abortions. The issue is dead, I’ll be notified. Kaput. Here I would remind critics that in science it’s not who says it or how many say it that counts. What does count are the data and the rigor with which they are collected, analyzed and held up to a scientifically credible hypothesis.

Curious to find out what this study was, what it found, and whether or not it was evidence that I should change my mind, I decided to go straight to the source. That tends to be my reaction whenever I see such a veritable panoply of crank language, not unlike what we hear from “intelligent design” creationists when whining about why they are not taken seriously. The science that has failed to validate ABC may not be as well settled as the science supporting the theory of evolution, but the arguments against established science used by ABC advocates are disturbingly similar. As for the “disparity,” perhaps it could be because even the mainstream media has learned that the medical “journal” in which this dubious “study” appeared (and I use the terms “journal” and “study” very loosely) is a right wing propaganda rag masquerading as a medical journal. It’s also a “journal” with which regular readers of this blog should be very familiar. Yes, my friends, we’re talking about the Journal of American Physicians and Surgeons (JPANDS for short), and the study was entitled The Breast Cancer Epidemic: Modeling and Forecasts Based on Abortion and Other Risk Factors, by Patrick Carroll.

It’s hard not to note that one significant indication that the study is likely to be really, really, really bad is the very fact that it appeared in JPANDS. As you may recall, I’ve discussed JPANDS before, as has Kathleen Seidel. Of course, the fact that the study appeared in JPANDS does not necessarily mean it’s a bad study, although it does make it highly likely that it is, particularly given that a good study can get into a real scientific journal. In this case, it was a very bad study indeed. In fact, it was one of the most hilariously inept examples of confusing correlation with causation and abusing statistics that I had ever seen anywhere, any time. Truly, the Flying Spaghetti Monster’s example of correlating global warming with the decrease in the number of pirates seemed reasonable by comparison. Unfortunately, the Carroll “study” (if it can be called that) achieved its purpose. It got credulous pundits like Byrne presenting it as if it were actual evidence of an ABC link.

What surprised me, however, was not the incredibly inept attempt at “science” in this article. What actually surprised me was the second thing that made me stand up and take notice of the ABC activists, something that I came across while investigating whether or not there is a link between abortion and breast cancer. What I found was that someone I actually knew, someone who was actually connected to The Cancer Institute of New Jersey (where I was on the faculty from 1999 to 2008) due to her affiliation with one of the private hospitals affiliated with CINJ. I’m referring to Dr. Angela Lanfranchi, who is an anti-abortion activist, cofounder of the Breast Cancer Prevention Institute, which promotes the ABC link, and one of the foremost promoters of the link between abortion and breast cancer. Indeed, as far as I can tell, Dr. Lanfranchi is probably the foremost promoter of the link who actually takes care of breast cancer patients for a living. Worse, she has published arguments in favor of ABC in JPANDS, which, as regular readers of this blog know, is always a bad sign as far as pseudoscience or ideologically motivated anti-science goes. Sadly, after discovering her “other side,” in marked contrast to her generally strong competence as a surgeon, I soon found articles by Dr. Lanfranchi using classic crank language to make incompetent, ridiculously exaggerated, and scientifically unsupported statements:

It amounts to child abuse to take a teenager in a crisis pregnancy for an abortion. At best, it will give her a 30% risk of breast cancer in her lifetime. At worst, if she also has a family history of breast cancer, it will nearly guarantee this. As a mother, I need to be informed of this to protect my daughter. Medical professionals have an unfortunate history of continuing to harm women if it means admitting that they have injured or killed them with their treatments.

This is best illustrated through the well-known story of Ignaz Semmelweis, MD. He was an obstetrician-gynecologist in the 1840s who proved that hand washing would reduce mortality rates from childbed fever from 30% to 2% on maternity wards. His reward for this was ridicule from his professors and loss of his hospital appointments. Women continued to die needlessly for another 30 years until the germ theory proved Semmelweiss was correct. It must have been very embarrassing for a lowly resident to have told the greatest medical professors of his time they were responsible for many women’s deaths.

I’ve occasionally had the extreme chutzpah to propose “laws” and then to name them after myself, such as when I proposed Gorski’s Law of Testimonials at the SBM Conference during my talk at TAM7 or facetiously coined Gorski’s Law of the Pharma Shill Gambit right here on SBM. I’m seriously tempted to do so again here regarding the invocation of Semmelweis’s name. Whenever someone invokes the name of Ignaz Semmelweis in the context of overblown, hyperbolic language, that person is almost certain not to be basing her criticism of medicine on science. It applies to the anti-vaccine movement. It applies to Mike Adams of NaturalNews.com, and it applies here. In any case, the above is an incredible exaggeration that even the research of one of the foremost scientists making the ABC claim doesn’t support. (More on that later.)

Although I still miss CINJ from time to time, it was a really good thing, at least for my comfort level dealing with the local practitioners, that it was within a month after that I decided leave my old job to accept my current position. Less than four months later I was gone from CINJ. I can’t imagine the tension that would have occurred when I ran into Dr. Lanfranchi at her hospital’s tumor board, which I was occasionally assigned to attend because CINJ sent its faculty out as guests to the various tumor boards of its affiliates. In retrospect, I don’t know how I could have been right there in central New Jersey for so long and yet so oblivious to what was going on, but I was.

Back to the future

So what tweaked me to write about the question of whether abortion predisposes women to breast cancer after all this time? Last week, several readers forwarded me this article from WorldNet Daily by Janet Stanek, a prominent activist promoting claims of a link between abortion and breast cancer, in which she claims that a “Top scientist finally admits abortion-breast cancer link,” a sentiment echoed on her blog. Included in this article is an amazing claim about the NCI workshop in 2003 that concluded that there is no link between abortion and breast cancer:

At the time, 29 out of 38 studies conducted worldwide over 40 years showed an increased ABC risk, but the NCI workshop nevertheless concluded it was “well established” that “induced abortion is not associated with an increase in breast cancer risk.”

Brind went on to write a minority report NCI alludes to on its website without publishing or listing its author and did not even mention in its workshop summary report.

Life went on, except for post-abortive women inflicted with breast cancer anyway.

But six years later something happened. Dr. Brinton either flipped her lid, flipped ideologies, restudied the evidence and decided to recant, or couldn’t sleep at night – and she began righting her wrong.

In April 2009, Brinton co-authored a research paper published in the prestigious journal Cancer Epidemiology, Biomarkers and Prevention, which concluded that the risk of a particularly deadly form of breast cancer that attacks women under 40 raises 40 percent if a woman has had an abortion.

Stanek then gloats:

For nine months, that little bombshell of a disaster for pro-abortion ideology was published without the NCI acknowledging it or changing its stance.

Then this month, Brind spotted and wrote about Brinton’s concession and NCI’s hypocrisy.

In case you don’t know who he is, Joel Brind is a born-again Christian and professor of biology and endocrinology at Baruch College who has become one of the most prominent voices in the ABC movement. Arguably the most famous supporter of the idea that abortion causes breast cancer, he has campaigned tirelessly to promote his view that abortion predisposes to breast cancer. I also love how Stanek just counts studies without any consideration of quality or scientific rigor, as if all studies are equivalent. Truly, she’d fit right in with creationists or the alt-med movement. Be that as it may, one has to wonder about her claim that Dr. Brinton “flipped her lid.” To do that, I had to look up the actual study that Stanek is holding up as vindication, although I find it odd that it took the ABC supporters 9 months to discover this study, entitled Risk Factors for Triple-Negative Breast Cancer in Women Under the Age of 45 Years. Do they not keep up with the medical literature? It’s pretty easy to set up an automatic PubMed search for “abortion AND breast cancer risk”) that will send automatic updates every day.

In any case, I decided to see whether this study is such slam dunk evidence of a nefarious plot to hide the ABC link.

Back to the future, take two

Before I continue, it’s worth it to go over a bit of background. First of all, you need to know what “triple-negative” breast cancer is. Clinically, breast cancer is divided by whether or not it makes three different proteins: estrogen receptor (ER), progesterone receptor (PR), and HER2/neu. ER(+) tumors tend to be better differentiated and less aggressive, but, more importantly, they respond to therapies designed to block estrogen action. HER2/neu is an oncogene that a subset of breast cancers express and that tends to portend a worse prognosis. However, when it is present, the tumor can be treated with a targeted therapy designed to counteract its activity, specifically Herceptin. Triple-negative cancers, by contrast, make no ER, PR, or HER2/neu (hence the “triple-negative” moniker). More importantly, they tend to be more aggressive and more poorly differentiated. Paradoxically, they tend to respond well to chemotherapy but have a proclivity to relapse afterward. They’re nasty, nasty tumors and make up around 15% of all breast cancer. (Indeed, one of them killed my mother-in-law nearly one year ago.) More recently, breast cancers have been characterized on the basis of global gene expression into subgroups known as luminal A and B and basal-like breast cancer. Consistent with previous work, we know that the vast majority of triple-negative tumors fall into the basal-like classification, and basal tumors tend to be aggressive histologically, unresponsiveness to typical endocrine therapies, and poor prognosis.

Another critical piece of background that’s important is the known risk factors for breast cancer. Currently agreed-upon risk factors based on history for the development of breast cancer are:

  1. Age (breast cancer becomes more common as women age)
  2. Sex (men can get breast cancer, but it is very uncommon)
  3. Personal history of breast cancer (a history of breast cancer in one breast is probably the strongest risk factor of all for the subsequent development of cancer in the contralateral breast)
  4. Family history of breast cancer and genetic risk factors (BRCA mutations, for example)
  5. Age at first menstrual period (earlier is worse)
  6. Race (breast cancer is slightly more common in Caucasians but African Americans are more likely to die of the disease)
  7. Age at menopause (older is worse)
  8. Age at first live birth (older is worse)
  9. Number of children (more is better, with nulliparity conferring the highest risk)
  10. Previous chest irradiation (for childhood lymphoma in the chest, for example)
  11. Oral contraceptive use (this is a very weak and somewhat controversial risk factor; women who have not taken OCPs for 10 years are at no higher risk than those who have not taken them)
  12. Hormone replacement therapy
  13. Certain pathological findings on breast biopsy (such as atypical ductal hyperplasia, lobular carcinoma in situ, etc.)
  14. Breastfeeding (a weak protective effect)
  15. Alcohol
  16. Obesity

Also, before I get to the study, for purposes of my discussion of the alleged link between abortion and breast cancer, one theme that runs through the risk factors due to reproductive history is that the more time a woman spends having menstrual cycles uninterrupted by pregnancies, the higher the risk of breast cancer. That’s why more pregnancies are protective and why an earlier age at menarche and a later age of menopause are thought to be risk factors. Leaving aside family history, a personal history of breast cancer, or a biopsy with a high risk lesion (the three strongest risk factors of all), the woman at highest risk of developing breast cancer is one who has never been pregnant, had an early menarche, and has a late menopause. This relationship between reproductive history and breast cancer is thought to be due to a higher lifetime exposure to estrogen unopposed by progesterone and other pregnancy hormones. One consequence of these observations observed thus far is that the tumors that develop in women with these risk factors are more commonly ER(+), which makes sense from a biological standpoint. Indeed, strategies designed to decrease breast cancer risk in women at high risk by blocking estrogen action do decrease the risk of ER(+) breast cancer but have no effect on the risk of ER(-) breast cancer, which makes sense from a biological standpoint.

Triple-negative breast cancer, being ER(-), has become a hot research topic lately because it tends to strike younger women, especially African-Americans, and it tends to be deadlier than other forms. Worse, because it does not make ER or HER2/neu, there are no targeted treatments for it. Tamoxifen and aromatase inhibitors (which block the action of estrogen) don’t work; neither does Herceptin (which blocks the action of HER2/neu). All that leaves is chemotherapy. Paradoxically, triple-negative tumors tend to respond well initially to chemotherapy, but they have a high propensity to recur after an apparently good initial response. No doubt much of the impetus for this study were these well-known facts, coupled with how little is known about the risk factors for triple-negative breast cancer as opposed to other more common subtypes

Another thing that you need to know about the ABC claim is that the evidence is quite conclusive that spontaneous early miscarriages neither protect against nor decrease the risk of breast cancer. Other than possibly for women who have suffered more than three spontaneous miscarriages (the data are equivocal), pregnancy loss appears to be more or less neutral with respect to influencing breast cancer risk, neither increasing nor decreasing it. These observations are fairly strong suggestive evidence that an elective abortion would probably not behave any differently than a spontaneous miscarriage at the same point in pregnancy from a biological standpoint. These data are not enough to dismiss the ABC link in and of themselves, but they do lessen the biological plausibility of such a link. Not enough to reject further study, but enough to cast a skeptical eye on the retrospective studies that exist.

The final thing you need to know is about this study itself, specifically that it is not really a new study at all. Rather, it is a reanalysis of existing data from two studies of women from the 1980s and 1990s, as the methods section shows:

The cases included in this study were originally ascertained for two previous studies through the population-based Seattle–Puget Sound Surveillance, Epidemiology, and End Results cancer registry. Eligible cases from the first study population included all primary invasive breast cancers within the three-county Seattle metropolitan area, diagnosed between January 1, 1983, and April 30, 1990 (ages, 21-45 y). The methods for this study have been described elsewhere (17, 18). The study was confined to Caucasians because of the small representation of minorities in the region.

And:

The second population included the Seattle site participants of the multicenter Women’s Interview Study of Health, the methods for which have been described (19). Eligible cases included women in the Seattle area diagnosed with invasive breast cancer between May 1, 1990, and December 31, 1992 (ages 21-44 y).

References 17 and 18 are:

White E, Malone KE, Weiss NS, Daling JR. Breast cancer among young U.S. women in relation to oral contraceptive use. J Natl Cancer Inst. 1994 Apr 6;86(7):505-14.

Daling JR, Malone KE, Voigt LF, White E, Weiss NS. Risk of breast cancer among young women: relationship to induced abortion.J Natl Cancer Inst. 1994 Nov 2;86(21):1584-92.

And reference 19 is:

Brinton LA, Daling JR, Liff JM, Schoenberg JB, Malone KE, Stanford JL, Coates RJ, Gammon MD, Hanson L, Hoover RN. Oral contraceptives and breast cancer risk among younger women. J Natl Cancer Inst. 1995 Jun 7;87(11):827-35.

For two out of the three studies, the purpose was to ascertain whether oral contraceptives pose a risk for breast cancer. In the current study, pooling the two studies ended up with subjects that included 897 women who had developed breast cancer before age 45 and 1,569 controls. These studies were all retrospective, with all the potentials for confounding factors to which retrospective studies are prone. Moreover, it was a study based on interviews, in which women were interviewed about their health history and known and suspected causes of breast cancer. Recall bias is a well-known confounding factor that plagues studies of abortion. One reason is that, because of the social stigma associated with abortion, women tend not to tell everything about their history when it comes to abortions, either not admitting to the procedure or, if they’ve had more than one, not admitting to all of them. This may have been particularly true for older studies, when abortion had even more of a stigma attached to it. The other reason is that women with breast cancer who have had an abortion in the past tend to be more likely to admit to having had an abortion they think it might be a cause of their predicament. It’s very hard to evaluate the significance of recall or response bias and how much they might have affected the results of individual studies. In any case, such problems are why prospective studies are less likely to produce spurious associations. Also, many of the cases of breast cancer in these studies occurred before one of the commonly used markers that we test all new breast cancers for, HER2/neu, was routinely tested for, meaning that the investigators had to locate the pathology specimens and have them tested for HER2/neu, because separating triple-negative tumors from the rest depends upon it.

Now, on to the study. Here’s what Malek and Brind are crowing about. It’s part of the “money table” that summarizes the results:

ncitable1

Note the yellow at the bottom pointing out the line referring to abortion, thanks to Colby Cosh. According to the table, the odds ratio (OR) for breast cancer in women who have had one or more abortions is 1.4 (95% confidence interval 1.1 to 1.8), a barely statistically significant result. One thing that leapt right out at me and bothered me was not so much this result. For one thing, the original study (18) of the group that looked at this question found an OR = 1.5 (95% CI = 1.2 to 1.9). I would have been shocked if the odds ratio was significantly different in this study. In any case, it’s barely statistically significant and comes from a pooled retrospective study where the most recent cases date back to the early 1990s, both factors that make it very prone to bias or spurious results. More recent research done prospectively should have (and does have) greater weight.

Stranger still is an odd consistency in the data on abortion and breast cancer in this study when they broke down the numbers into triple-negative versus non-triple-negative breast cancers. For all potential breakdowns (all cancers, triple-negative cancers, non-triple-negative cancers), the OR is the same, 1.4. That struck me as quite odd. Under either of the common biological justifications posited by advocates of the ABC concept, there should be a difference. If it’s estrogen overexposure unopposed by progesterone, then we would predict that abortions would result in more ER(+) tumors than ER(-) (including triple-negative) tumors if abortion is truly a risk factor for breast cancer. If it’s the newer straws that the ABC movement is grasping at, namely stem cells, one might hypothesize that abortion would increase the risk of ER(-) or triple-negative tumors, since stem cells don’t make ER. True, there weren’t that many triple-negative tumors in this study (187); so who knows? But it’s still rather odd that the numbers are basically identical. It tends to suggest more of a statistical fluke than a specific biological mechanism.

What also makes this OR of 1.4 less convincing is that, if you look at the 1,569 controls, they broke down pretty similarly between having had one or more abortions and never having had one; i.e., 27.1% of controls had an abortion and between 32% and 35.5% of women with breast cancer had one or more. Nowhere is it analyzed whether that difference is statistically significant, but even if it is it’s not a huge difference. Moreover, this study only addressed breast cancer risk in women under 45. This is a relatively small fraction of the total cases of breast cancer; so even if this study did show a “40%” increased rate of breast cancer, it would only apply to a relatively small portion of the population. Given the problems with the study and in light of data gathered over the 15 years since the last of the three studies whose subjects make up this reanalysis was completed, I am completely underwhelmed with this study as any sort of strong evidence for an ABC link.

Finally, an OR = 1.4 is not a large odds ratio, particularly in a retrospective study. Colby Cash is not correct when he dismisses any OR under 2.0 as being insignificant, but small odds ratios do require multiple replications from different groups in different populations all converging around similar numbers before epidemiologists take them seriously. That’s what it took before secondhand smoke exposure, which routinely results in odds ratios around 1.3 for heart disease and lung cancer, was accepted as significant risk for health problems. Other aspects that might make ABC more credible would be if there were a “dose-response” effect, in which more abortions would increase the risk even more, or some apparently biological specificity for certain subtypes of cancer. Neither of these exist, and this study sure doesn’t provide such evidence. In light of that, more than likely this is simply a spurious result that has been refuted by later studies. Certainly it doesn’t even approach slam-dunk evidence that an ABC link exists, much less is being “covered up.”

The evidence

Here’s what the American Cancer Society says about the ABC link:

The Collaborative Group on Hormonal Factors in Breast Cancer, based out of Oxford University in England, recently put together the results from 53 separate studies conducted in 16 different countries. These studies included about 83,000 women with breast cancer. After combining and reviewing the results from these studies, the researchers concluded that “the totality of worldwide epidemiological evidence indicates that pregnancies ending as either spontaneous or induced abortions do not have adverse effects on women’s subsequent risk of developing breast cancer.”

And here’s what the National Cancer Institute says about it:

The relationship between induced and spontaneous abortion and breast cancer risk has been the subject of extensive research beginning in the late 1950s. Until the mid-1990s, the evidence was inconsistent. Findings from some studies suggested there was no increase in risk of breast cancer among women who had an abortion, while findings from other studies suggested there was an increased risk. Most of these studies, however, were flawed in a number of ways that can lead to unreliable results. Only a small number of women were included in many of these studies, and for most, the data were collected only after breast cancer had been diagnosed, and women’s histories of miscarriage and abortion were based on their “self-report” rather than on their medical records. Since then, better-designed studies have been conducted. These newer studies examined large numbers of women, collected data before breast cancer was found, and gathered medical history information from medical records rather than simply from self-reports, thereby generating more reliable findings. The newer studies consistently showed no association between induced and spontaneous abortions and breast cancer risk.

And here’s what the American College of Obstetrics and Gynecology said about it in 2009:

The relationship between induced abortion and the subsequent development of breast cancer has been the subject of a substantial amount of epidemiologic study. Early case-control studies that reported an association between induced abortion and subsequent development of breast cancer had significant methodological problems, most notably reliance on retrospective reporting of abortion history. A key methodological consideration in interpreting the evidence for any relationship between abortion and breast cancer risk is the sensitive nature of abortion, which could affect the accuracy in retrospective studies that rely on participant reports of having had an abortion.

[...]

Early studies of the relationship between prior induced abortion and breast cancer risk were methodologically flawed. More rigorous recent studies demonstrate no causal relationship between induced abortion and a subsequent increase in breast cancer risk.

A few of the most recent studies that have failed to find an ABC link include the California Teacher’s study, a large, prospective cohort study with detailed pregnancy history data; the Nurse’s Health Study II, which included over 100,000 women; and the EPIC Study, which included over 250,000 women. Numerous studies (including some of the above) that failed to support an ABC link are linked to here1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17.

Given the preponderance of evidence, although it is still possible that there may be a link between abortion and breast cancer, it is unlikely that there is, and, if there is, it’s likely to be very, very small, given that numerous epidemiological studies have failed to uncover it. In this, the evidence for the ABC link is not unlike the state of evidence regarding vaccines and autism. Early studies, not as large, well-designed, or rigorous, suggested that there might be an association, but the larger and better-designed the study, the smaller the OR became until it converged on 1.0. Current evidence does not support the ABC link, and there are enough studies to allow us to conclude either that there probably is none or that it’s very small. That’s as good as it gets in epidemiological studies, which, unfortunately, can never entirely eliminate the possibility of a correlation. They can only conclude that the chance of a significant correlation is very, very low. Moreover, contrary to the inflated claims of some activists, even Joel Brind’s own infamous meta-analysis from 2003 does not show a 30% risk of breast cancer if a young woman has an abortion before the age of 18, much less a virtual certainty that she’ll develop breast cancer if she has a strong family history as well. In fact, Brind’s own work, which is held up as “proof” of an ABC link, only suggests at the most an OR = 1.3 to 1.5, which is nowhere near high enough to produce the 30% lifetime risk of breast cancers claimed by overwrought activists like Dr. Lanfranchi.

Despite the evidence, however, if you do a Google search for “abortion and breast cancer” what you will find is a preponderance of websites pushing a link that is not scientifically supported. The purpose of trying to push a link between breast cancer and abortion, as far as ideologues go, is clearly to frighten women about abortion. However, ABC is also being pushed to make physicians who perform abortion fearful of malpractice lawsuits by women who have abortions and later develop breast cancer, which, given how common breast cancer and abortion are, there are many by chance alone. The grounds for suing being advocated by ABC promoters is an alleged failure to inform women of the increased risk of breast cancer due to an abortion. In other words, if scaring women won’t work, then maybe threatening doctors with malpractice suits will.

Whatever you think of abortion, whether it’s murder, a necessary evil that’s not murder, a morally neutral surgical procedure, or a moral good (the last of which to me is going too far), I would hope that we could all manage to agree that attributing risks to the procedure that are not supported by strong science and epidemiology does not contribute anything to the debate other than confusion and fear. Of course, that’s exactly what such claims are meant to place in the minds of women of reproductive age: confusion and fear. They serve primarily as a means of frightening women with the specter of breast cancer if they consider the option of terminating a pregnancy. Indeed, dubious studies such as the Carroll study and putting dubious spins on studies that are not themselves dubious (like the study Stanek made such hay over) are a transparent attempt to abuse epidemiology to find a link between abortion and breast cancer that probably does not exist. They only serve to obfuscate the issue.

It’s one thing for anti-abortion activists to consider abortion to be evil and to lobby and demonstrate to have it outlawed. That is their religious belief, and the First Amendment guarantees that they can believe what they want and say nearly anything they want. However, it’s quite another to spread misinformation about an ABC link based on either horrifically bad science or on putting a deceptive spin on existing studies. If anti-abortion activists think that abortion is morally wrong because of their religion, then they should argue that. If they have any actual evidence that the procedure causes serious harm, they have every right to present that evidence. However, when they spin and distort science, behaving just like every other denialist, be it a creationist, a 9/11 Truther, an alt-med believer, or whatever, they should expect to be called on it.

Posted in: Cancer, Obstetrics & gynecology, Religion, Surgical Procedures

Leave a Comment (127) ↓

127 thoughts on “Abortion and breast cancer: The manufactroversy that won’t die

  1. Fifi says:

    Dr Gorski – Thanks for covering such a potentially hot button topic in such a non-sensationalized way rather than exploiting the controversy for attention. This is exactly the kind of SBM post that combats sensationalization (you’ll probably get flamed for it but it seems to me that your approach is dampening the fires using SBM rather than firestarting or throwing the fuel of additional sensationalism on already roaring ideological cultural bonfires).

  2. ninjaplatypus says:

    This may be a stupid question, but if having children reduces the risk of breast cancer due to having fewer menstrual cycles, would being on birth control that reduces the amount of menstrual cycles a woman has have a similar affect? Or would the exposure to estrogen in the B.C. raise the risk of breast cancer even more?

  3. windriven says:

    Did any of these studies look at the pattern of live births following elective abortions? I’m wondering if any slight apparent link between elective abortion and breast cancer might be explained by a later age at first live birth. So many potential confounding factors here.

  4. David Gorski says:

    Fifi,

    Since today’s a holiday in the U.S., the flames may not show up until tomorrow. Maybe I’ll be lucky and they won’t show up at all, but I doubt it. I will say, however, that if Malek or Stanek or Brind or whoever just e-mails me I will tell them to register and comment if they wish to respond to anything I’ve written. I’m not going to get into prolonged e-mail debates. There was a time when I used to do that, but I don’t have time for it anymore. If I’m going to get into debates, it’ll be on the blog.

    ninjaplatypus,

    Actually, it isn’t so much the decreased number of menstrual cycles (or so it is thought) but rather the increased time being exposed to unopposed estrogen untempered by pregnancy hormones like progesterone. In any case, as far as OCPs go, they do appear to increase the risk of breast cancer slightly, but not nearly as much as hormone replacement therapy:

    http://www.cancer.gov/cancertopics/factsheet/Risk/oral-contraceptives

    http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Study_Birth_Control_Pills_Increase_Breast_Cancer_Risk.asp

  5. ninjaplatypus says:

    Well poop. I guess my work around for not wanting children won’t actually work.

    Thanks for the links! :)

  6. Harriet Hall says:

    In the comments to my circumcision article I was attacked for trying to objectively present the evidence without stating an ethical position. I was told that not being anti-circumcision automatically meant that I was pro-circumcision. It will be interesting to see if you are accused of being pro-abortion on the same basis.

  7. Zoe237 says:

    Thanks for this! The reverse could also be true- pro-choice individuals being biased towards finding no link between abortion and breast cancer. The difference is using actual evidence to support one’s position.

    My question would be the same as windriven’s/

  8. SD says:

    Ah, Cde. Gorski! Happy New Year!

    While the data are of somewhat dubious (and politically-biased) provenance, I wonder if the data from the former Soviet Union (and other Iron Curtain countries) might provide evidence for a correlation or a lack thereof. There were several shifts in the fSU’s abortion policy over the years, more than in the United States; this might provide a decent forcing-function to identify periodic differences in the breast-cancer statistics.

    It would be tough if not impossible to claw it out of the noise, of course. Those ‘stix have been cooked multiple ways, and there’s also plenty of environmental factors to consider. Still, it might be worthwhile.

    “quod erat demonstratum”
    -SD

  9. David Gorski says:

    In the comments to my circumcision article I was attacked for trying to objectively present the evidence without stating an ethical position. I was told that not being anti-circumcision automatically meant that I was pro-circumcision. It will be interesting to see if you are accused of being pro-abortion on the same basis.

    Well, I was raised Catholic, but presently am about as lapsed a Catholic as there is. That’s about all the hint I’ll give for purposes of this discussion; I suspect such a history could support any range of views on abortion. :-)

    Personally, my view is that, when it comes to looking at the science, it shouldn’t matter what side of this issue you’re on.

  10. J_ says:

    Harriet is correct that she was attacked, but she stretches the truth when she says those attacks were made on her objective presentation of the evidence. Harriet’s response to men who disliked their forced circumcisions was to “get over it,” and she hypothesized that women who underwent forced amputation of their clitoral hoods should also get over it too. By guaranteeing an enraged response, Harriet trashed her own post.

    Gorski take note.

  11. Plonit says:

    Even if there is a increased risk of breast cancer associated with abortion (perhaps attributable to later childbearing, fewer pregnancies to term, less breastfeeding, more use of combined hormonal contraception, whatever…) it is a different matter entirely to give any weight to this.

    After all, not aborting (spontaneously or by induction) an existing pregnancy gives you close to 100% absolute risk of becoming a mother at that time, an outcome that women seeking induced abortion strongly wish to avoid. Not terminating may also (by the most optimistic studies) provide a tiny absolute risk reduction for breast cancer. How many rational women are going to become mothers involuntarily for the sake of very marginally reducing the risk of breast cancer in later life?

  12. Fifi says:

    Dr Gorski – “Personally, my view is that, when it comes to looking at the science, it shouldn’t matter what side of this issue you’re on.”

    Well said. At the end of the day, even if having an abortion did increase the possibility of breast cancer that would still be a risk that it should be a woman’s choice to assume or not assume (and obviously having a baby carries risks too, as we’ve just discussed in the c-section post). No doubt believing that women and people in general have the right to decide what we do with our own bodies is an ideological position. Anyway, I’m not exactly sure how an increased risk of breast cancer associated with abortion actually supports an anti-abortion/anti-choice stance in any way (but no need to explain if it opens up a can of worms).

    As usual, I’m pro patient choice and people having as unbiased as possible information on which to base their choice. (And an honest recognition of bias when one exists.)

  13. If the anti-choice folks are truly concerned about preventing breast cancer (and they surely have only the purest motives for their interest in this issue), they ought to move swiftly to act on the most compelling information in the table that you posted:

    The BEST way to lower your risk of breast cancer is to have 4 children before the age of 20.

    I look forward to their forthcoming campaign aimed at high school girls: “Sleep with your boyfriend, get pregnant, stop breast cancer!”

  14. Scott says:

    @ Plonit:

    You assume that the decision is of a binary nature (women either wish to become mothers at that time or they do not). In reality, like most things, it’ll be more of a continuum of pros vs. cons. Women who firmly felt that they did not wish to become mothers at that time are unlikely to change their minds, true, but those who are uncertain (e.g. planned to have children, but intended for it to be in 2-3 years) might well be swayed by such an effect. If the decision is close, a relatively small factor can certainly change the outcome. It might also sway some women from abortion to adoption.

    So while it’s true that it would be a relatively smaller factor, that does not make it insignificant.

    This discussion also presumes that the effect is modest, along the lines of that suggested by the mentioned study. At the level of the exaggerated claim that an abortion is an effective guarantee of developing breast cancer, that would very often be enough to completely change the woman’s mind.

  15. Fifi says:

    Actually, most Fundamentalist religions do promote girls getting married very young and having lots of children.

  16. Traveler says:

    Did any of the original articles give the average ages of the women in the never aborted and had aborted groups? I would expect the had aborted group to have an older average just because an older woman has had more opportunities to have an unwanted pregnancy. Given the large effect that age has on the risk of developing cancer, any other lifestyle grouping that doesn’t correct for age is likely to have a skewed result. You could probably prove that home ownership or having taught a child to drive “cause” breast cancer.

  17. LovleAnjel says:

    @Fifi

    An ABC link would support a pro-life stance because it would be another reason to discourage women from getting abortions, and could be seen as a form of punishment for the abortion & the immoral behaviors that led to an unwanted pregnancy.

    Also ABORTION GIVES U TEH CANCERZ!!!1

    Flame on!

  18. Fifi says:

    LovleAnjel – Ah, thanks for explaining that…seems just like more of the same! I was wondering if this was more of a Discovery Institute type pseudoscience approach rather than a “you’ll burn in hell” one. I can’t see anyone who’d actually opt for having an abortion being put off by more “you’ll burn in hell” type stuff, I figured this might be an attempt to use science to promote a religious belief to non-religious people or influence public policy.

    There are already lots of people out there claiming that women get breast cancer because they’re teh evil or bad (aka not nurturing enough, have “bad” thoughts or feelings, aren’t positive enough, etc). A lot of the alt med breast cancer quackery revolves around this idea, it’s just as prevalent in new age circles as it is in Fundamentalist ones.

  19. LovleAnjel says:

    Fifi– it’s also a piece of evidence that could be used to help overturn Roe v. Wade, I suppose. Altho then the scientific credentials of the research, researchers and journal get scrutinized. I figure it’s more of a way to wrench people’s guts, since any “chemical” linked to any cancer in any way gives people the screaming meemies and has a vigorous campaign to ban it from the universe.

    The pro-life movement does not need scientific evidence, since its position overall is moral/religious in nature.

    @Scott– Apparently you have not yet been introduced to the delightful Quiverfull movement.

  20. Scott says:

    @LovleAnjel:

    Indeed I had not, but I don’t see the relevance. Could you expand on that a bit?

  21. LovleAnjel says:

    Scott, sorry I read the wrong name on the comment. I do agree with you about the shades of grey in the decision-making process. If it were a true yes or no situation, pro-lifers would have no luck reducing the abortion rate by showing women ultrasounds of their fetus or “counseling” them, but in fact that can be very effective.

  22. LovleAnjel says:

    @Amy

    You were who I was going for!

    The Quiverfull movement attempts to fulfill a particular part of scripture that makes an analogy between children and arrows used to defeat the enemy at the gates, such that each patriarch should keep his quiver (family) full of arrows (children or sons, depending on your translation) to raise up an army for the lord.

    The Quiverfull folks marry young, often as young as the law allows, and pop out as many offspring as physically possible. The most popular Quiverfull family is the Duggers (who have a series of TLC shows called “[X number] of Kids and Counting”). Andrea Yates was also in a Quiverfull marriage, although the tragedy for which she is known is, as far as I know, not any more common among Quiverfull families than “normal” families.

    The ABC issue is not about preventing breast cancer. It is about preventing abortions (and the immoral behaviors that lead to them). It’s in the same vein as the sex ed that tells kids they’ll die of AIDS if they touch another person’s wee-wee without being married to them first.

  23. Zoe237 says:

    “Harriet’s response to men who disliked their forced circumcisions was to “get over it,” and she hypothesized that women who underwent forced amputation of their clitoral hoods should also get over it too. ”

    Hmm, hadn’t read the comments on that one. As someone who sees absolutely no need for circ in infants and the procedure as an archaic religious intrustion, I’ve been attacked irl for taking the exact same position. I’m ita with Dr. Hall on that one.

    To get into the controversial area, I’m not sure that’s there’s nothing that SBM can contribute to the abortion debate, particularly late term abortion. Is there really a “medical reason” for abortion or not? Is partial birth abortion medically justified? Should we have 20 week u/s so women with fetuses with birth defects can abort? Should women and individual doctors have free license to make these judgements for themselves? (my use of the word fetus rather than infant should give away my own bias). No, I don’t blame Dr. Gorski for not touching those issues with a ten foot pole.

    *runs away* :P

  24. windriven says:

    @LovleAnjel

    Roe v. Wade is settled law. Under the legal principle of stare decis, overturning Roe v. Wade would be just this side of impossible. Even the most rock-ribbed, bible-thumping, drooling rube understands that abortion is here to stay. Rolling that argument out in a discussion of abortion induced breast cancer is a stretch.

    Your observation that the pro-life movement does not need scientific evidence though is right on the money. Fear and superstition win out over science and technology nine times out of ten. Ten times out of ten where deeply held religious or political beliefs are involved.

    And this is why I think we have to be careful to keep to the high road and avoid purely emotional arguments like the specter of overturning Roe. The weight of the scientific evidence is pretty clear in the matter. Confronting the fundamentalists’ irrational arguments with an irrational argument of our own adds heat but no light and is IMHO terribly unlikely to change wavering minds.

  25. J_ says:

    The data suggest the best way for women to minimize the risk of breast cancer is – surprise – to do what comes naturally, which is to have children at a young age. Perhaps breast cancer is to some degree a disease of our industrial-materialistic society that rewards women who have no children, or who have them later in life, far past their sexual prime, when they are financially and materially successful.

    B.F. Skinner had it right. Wouldn’t it be better to live in a society where we encourage young people to have children when it’s best biologically; to support those young families instead of penalizing them; to remove the stigma and shame promulgated by both secular and religious authorities; to see young families as a joyous and precious thing to nurture, instead of sneering and calling it a problem to be stamped out?

    Teenagers are having sex – like we did – because they are *supposed* to be having sex, and they are *supposed* to be starting families. If these tables are correct, breast cancer rates could plummet if we just make some cultural adjustments that put us more in sync with nature.

  26. rork says:

    @Traveler and others:
    That Dolle paper (with the table) actually did adjust for age, though there are several ways to make that adjustment, and one could quibble about their method, and the way they chop age into groups.

    “Those variables that produced ≥10% change in the odds ratio for any triple-negative breast cancer risk factor were considered as adjustment factors in the final model. All final risk estimates are adjusted for age, family history, lactation history, and oral contraceptive duration (that is, multivariate adjusted).” These are in logistic regression models.

    Note that I think this is saying several other factors that are significant, and may be correlated to abortion (mentioned by several above) like number of births, wealth, etc, were NOT adjusted for in the model where they are checking if abortion is significant. So when they say “multivariate adjusted” in the results and legend for that table, they do not mean that all variables were in the model at the same time, which is what you might have expected (and is what I would usually mean when I write that and show such a table). That is not-so-terrible perhaps, since after all, we are clearly told in Methods that the OR change was less than 10% for EACH variable not included in the model, still I worry that with 2 or 3 of those other variables, abortion significance might go poof. I’m fairly sure that their “leave in just a few other variables” method does give you more main factors that end up giving significant results compared to “leave them all in”, but I’m stopping well short of accusing them of fudging on purpose. It’s just a happy circumstance I guess (that’s a joke).

    Tricks of the trade:
    Just which other variables are in a final logistic regression or cox model is a common method to fudge in other science papers though, with folks saying they had all the other important stuff in there, but when you look carefully, the one other variable you were most concerned was confounded with their latest and greatest prognostic marker – it’s not there.
    Trick 2 is that, yes, it is in there, but coded in a brain-dead or not-sufficiently-informative way (age either >40 or <40), so that their marker still remains significant. The urge to do that is pretty strong when failure to get p<.05 means not publishing. That's not the case here I think.

  27. LovleAnjel says:

    @windriven

    I wasn’t trying to make an appeal to emotions. Not being knowledgeable about the law, I always assumed that there was a chance that the Supreme Court could overturn Roe v. Wade (are SC decisions more set in stone than constitutional amendments?) or at least weaken it to an ineffective state, and that any bit of evidence would be utilized in the process. I am aware most of the legal arguments concern fetus-as-person, but I confess ignorance as to what a real attempt at overturning the law would actually boil down to.

    I would not ever say that something was or was not true because I disagreed with it or its ramifications for whatever reason, or advocate suppression of the truth under any circumstances. If ABC was true, it’s another thing women should informed about (in a straightforward way). Facts is facts.

  28. DLC says:

    Thanks for the article, Dr Gorski.
    If this study is all the ABC theorists have, I’m fairly confident their theory can be dismissed, at this time.
    Considering that pregnancies often spontaneously terminate, would it really make a difference ?
    I recall seeing that some women become pregnant and miscarry without ever noticing, other than being “late” . But, it’s not my area of expertise.

  29. Calli Arcale says:

    I tend to think that if there really is an effect at all, it’s that women who have abortions are not pregnant as long as women who carry the babies to term. Also, the women who had abortions obviously aren’t breastfeeding. (Or at least, they’re not breastfeeding that particular infant.) But I’m not yet convinced the estrogen exposure idea is correct. It seems plausible to me (a software engineer) but it also wouldn’t be the first time that correlation did not imply causation.

    Personally, I feel when it stoops to falsehoods, the pro-life movement makes a big mistake. There are excellent moral arguments for carrying most pregnancies to term. Lies should not be required. Personally, I see the abortion rate more as a sign of what a bad job we’re doing of supporting young mothers.

    J has a very interesting point that perhaps our society would be happier if it were more supportive of young families. I’m not entirely convinced of that; if we did have as many children as are “natural”, then overpopulation would be an even bigger problem than it already is. I don’t think the breast cancer benefit would be worth that price. On the other hand, I do agree that we don’t support young families sufficiently. We expect them to support themselves, and if they don’t, woe betide them. Is it any wonder young, unwed, pregnant ladies feel trapped? They know they can’t support their children without going on welfare, and then, oh, then they’re lazy slobs sponging off the system. It’s a tough place to be, and a great many people are content to let them face that tough place, saying that “they brought it on themselves”. But then their child has to suffer for it too, and just to punish the original perceived wrongdoers (who did nothing illegal) we end up breeding a group of people who have difficulty climbing out of the hole they’ve been put into. The sins of the fathers and mothers, basically. We as a society do not think these things through adequately.

  30. Zoe237 says:

    CalliArcale, I’ve read a couple of places that the majority of abortions are for older women who already have two or three kids. I wonder if there’s any truth to that.

    Unlike a lot of religious right positions, I also find being pro-life perfectly defensible without the ABC link, even if I disagree. I have a lot of respect for pro-life individuals who really try to help young pregnant women.

  31. Harriet Hall says:

    J_’s comment misrepresents what I wrote.

    Apart from all the other issues, I was attacked for not condemning circumcision as an evil mutilation and was told that not condemning it made me an advocate (an obviously false dichotomy).

    My exact words about “getting over it” were:”If some men are psychologically damaged by circumcision and mourn their lost foreskin, their mental health must be pathologically fragile. Get over it, guys!”

    Since most men who were circumcised without consent in infancy show no signs of psychological damage, and since mourning the lost foreskin won’t reverse the loss, I think “get over it” is excellent advice. What would you recommend? Constant rumination? Wallowing in victimhood? Recriminations against well-meaning parents? Reconstructive surgery?

  32. Danio says:

    J has embraced the naturalistic fallacy full-on. In fact, we humans are also “supposed” to endure cycles of famine, myriad assaults by bacterial, viral and parasitic organisms, and early death (after having passed on our genetic material in our teens, of course). ‘Natural’ ≠ ‘Better’, and if you reject any other things on that list in favor of the modern science and medicine that makes it possible for humans live better and longer, selectively supporting adolescent procreation doesn’t make much sense.

    The timing of reproduction should be a personal choice, and if some women want to factor in the protective effect on breast cancer that breeding young seems to have, more power to them, but there seem to be far too many other contributing factors (race, genetics, etc.) to generalize about this.

    In general, I find the suggestion that women should yield to their biology at the expense of other aspects of their professional or social lives is offensive on several levels, regardless of any implied ‘reward’ (i.e. cancer protection). This position seems emblematic of the sentiments of some in the anti-choice movement who dislike the fact that abortions (along with contraception) allow women to effectively dodge–or at least control the timing of–their ‘natural’ place in society.

  33. Danio says:

    @Zoe237
    From here:

    In 2006, as during the previous decade (1997–2006), women aged 20–29 years accounted for the majority (56.8%) of abortions and had the highest abortion rates (29.9 abortions per 1,000 women aged 20–24 years and 22.2 abortions per 1,000 women aged 25–29 years); by contrast, abortion ratios were highest at the extremes of reproductive age. Adolescents aged 15–19 years accounted for 16.5% of all abortions in 2006 and had an abortion rate of 14.8 abortions per 1,000 adolescents aged 15–19 years; women aged ≥35 years accounted for a smaller percentage (12.1%) of abortions and had lower abortion rates (7.8 abortions per 1,000 women aged 35–39 years and 2.6 abortions per 1,000 women aged ≥40 years).

    I don’t know if there are data available more recently than 3 years ago, but I’d be surprised if the demographics had shifted dramatically in that time period.

  34. Basiorana says:

    Zoe237: “Is there really a “medical reason” for abortion or not?”

    I cannot imagine the naivete of people who believe this. To believe that we can prevent every single maternal death? After all, how often do we have the teary-eyed stories in the news of a woman who has sacrificed her life by not undergoing needed cancer treatment to save her child? Type 1 diabetes, severe heart disease, autoimmune disorders, HIV/AIDS, and some other STDS can in some cases put the mother at risk for dying during pregnancy or labor. Anyone who actually has ever read the news and isn’t intentionally deceiving people can tell you that, however rare these scenarios are, there are definitely times when it does come down to save the woman, or save the child (or, the more common one, save the woman, or lose both). Now, some argue not that it doesn’t happen, but that the excuse is overused– I can’t speak to that, since that gets into the moral question of what amount of harm to the mom justifies abortion and what the chances of that harm occurring are.

    “Is partial birth abortion medically justified?”

    What we call partial-birth abortion is called intact dilation and extraction, or intrauterine cranial decompression. According to Dr. LeRoy Carhart, the doctor who was involved in Stenberg v. Carhart and Gonzales v. Carhart (both of which addressed the issue of IDX) and who has taken over Dr. George Tiller’s clinic (thus making him one of very few doctors who ever performed late-term abortions except in emergencies), has stated in interviews that he himself only uses IDX in very rare cases, usually relating to hydrocephalus and/or difficulty in delivery– basically, the fetus/baby is already dead from the injection that stops their heart, then delivery attempts stall or vaginal delivery is inadvisable for any number of reasons. For him, it’s basically an alternative to performing a C-section when the slight increased risk to the mother (or her preference) outweighs the emotional ramifications of the procedure. It’s a method of delivering after the fetus/baby is dead, not a method of termination. Whether or not this option is best is debatable, and some mothers will opt for a C-section instead.

    Those were the only ones that were actually medical questions. The other are purely legal/moral questions– far trickier, but thankfully not the province of this blog.

  35. J_ says:

    “. . .their mental health must be pathologically fragile. Get over it, guys!”

    You totally miss the point of my advice to Dr. Gorski: don’t be clueless and shoot yourself in the foot – in your case over and over – by tossing out hurtful quips like the one above, when they damage your case. Do you really think that statements like that are constructive and help anybody? It’s true you were savaged right off the bat – but like Tuteur it was your choice to open the circumcision wound, and you handled it badly. If I’m pathologically fragile, it might have something to do with the extensive hypertrophic scarring on my penis that would rip and bleed on either side of the scar when I was teenager. I did not consent to this sexual damage. It’s infuriating to read flippant remarks like yours, even worse because you call yourself a doctor.

    And, I have an answer to your question: stop amputating sexual tissue from little boys!

    The editors and contributors to this forum have a different responsibility than their readers. We readers are not your cheerleaders, and you are not automatically the doctor-cum-hero. Your job is to present the case for science based medicine. It’s not a job for the thin-skinned, but it’s also something that requires better bedside manner than to say “get over it.”

    ***

    In response to Danio, what is this naturalistic fallacy? What is, by the way, “modern science?” For that matter, what is the Residue Theorem? Why does our society make women decide between a career and a family? Is having children at 40, with fertility clinics, artificially inseminated embryos, risk of Down Syndrome, higher complications of pregnancy, higher risk of breast cancer, etc. really the best choice our society can offer? What’s wrong with 18 year old adults having sex, having children, and getting all the help they need and deserve to start beautiful, healthy families? When medical science can make a 60 year old woman conceive, is that going to be the new age of readiness to start a family, and at what cost?

  36. windriven says:

    @J

    I’m sorry but you real do come across as a bit off-center. It strikes me as ridiculous to suggest that a pair of 18 year olds are generally prepared to raise a family regardless of their financial situation. 18 year olds are not equipped to survive in the modern world – they aren’t even fully educated at that age. In a simpler, perhaps agrarian, society it would be much easier to justify 18 year olds raising families.

    You can bemoan the demands of modern society and pine for an idyllic yesteryear. But on close examination you might find that yesteryear to be not so idyllic as you imagine.

    Young people might be biologically well-suited for breeding. But those same years are also their best for education and creative output. Mathematicians, for instance, are generally considered past their prime at 35 (when it comes to new contributions).

    You might also be surprised to learn that many women actually want to be educated and to use that education – before they have children. Are you suggesting that we go Taliban here and keep women uneducated and pregnant?

  37. David Gorski says:

    The editors and contributors to this forum have a different responsibility than their readers. We readers are not your cheerleaders, and you are not automatically the doctor-cum-hero. Your job is to present the case for science based medicine. It’s not a job for the thin-skinned, but it’s also something that requires better bedside manner than to say “get over it.”

    Your apparent vision of what we SBM bloggers “should” be writing is far too constraining and even borders on concern-trolling, as far as I’m concerned.

    Our job is to write what we want to write that interests us relating to the topic of science-based medicine. Sometimes that involves “presenting the case” for science-based medicine; sometimes it involves discussing issues related to SBM without necessarily “presenting a case.” Sometimes, it involves getting a bit silly, as Kimball Atwood used to do with his sadly defunct “Weekly Waluation of the Weasel Words of Woo” feature. Sometimes it even involves posting humorous videos. Sometimes it involves being sarcastic, as Mark and I frequently are.

    That being said, please back off on the circumcision stuff in this thread. This post is not about circumcision. It’s off topic. Given how circumcision seems to be invading even this thread, I’m beginning to wonder if it is an even more contentious issue than abortion.

  38. Chris says:

    Basiorana:

    After all, how often do we have the teary-eyed stories in the news of a woman who has sacrificed her life by not undergoing needed cancer treatment to save her child? Type 1 diabetes, severe heart disease, autoimmune disorders, HIV/AIDS, and some other STDS can in some cases put the mother at risk for dying during pregnancy or labor.

    Do not forget the death of fetus from factors like other non-STD communicable diseases, especially rubella. Something that was unfortunately too common in the early 1960s.

    I knew someone whose wife was actually excommunated from the Catholic church because she had an abortion. She had rubella and her baby died, and she did not expell the dead fetus. So she had it removed. I am not sure what her priest expected her to do. Was she supposed to live the rest of her life carrying a dead baby? I don’t know if that is actually healthy (it actually sounds very dangerous to me). In the end she adopted and then later gave birth to a healthy son.

    Personally I am not fond of abortion as a form of birth control. I believe actual reproductive education works better than abstinance education. Especially now that I know one of my college age children is now sexually active. I am also the absolutely last person to judge a woman for her decision.

    My last pregnancy was when I was over thirty-five, and I did have my amniotic fluid checked for genetic disorders. No woman does that unless she is willing to abort a child with disabilities. I am not proud that I was willing to not give birth to a child with a known genetic disability. I was already dealing with one (and that time possibly two) disabled child, I did not want anymore. While I was pregnant with third child the neurologist evaluating my younger son’s language delay told me it was possibly genetic.

    As it turns out, younger son’s only issue was language. He was one of Thomas Sowell’s “late talking children.” After a couple of years of good speech/language therapy he was perfectly fine before starting kindergarten (his older brother is still quite disabled).

    Of course this leads to the horrible “Pun Syndrome.” Last night he popped in to grab some stuff before returning to his dorm (which he gets to pay for since we live less than five miles from the university). I had found a pot I didn’t need and thought he might find it useful for cooking (mostly ramen noodles) in the little kitchen on his floor (which is just across the hallway). He takes the little cooking pot, the revised health insurance card, his mail and whatever he needed from his room and went down to the friend’s car, where he yelled as he entered “Hey, guys! I got the pot!”.

  39. SF Mom and Scientist says:

    @j – “Perhaps breast cancer is to some degree a disease of our industrial-materialistic society that rewards women who have no children, or who have them later in life, far past their sexual prime, when they are financially and materially successful.”

    Even if breast cancer is a disease for our industrial society, this industrial society, with all of its progress, has greatly increased our overall life expectancy. It is easy to forget that the past was not all that great for most people.

  40. Zoe237 says:

    Zoe237: “Is there really a “medical reason” for abortion or not?”

    “I cannot imagine the naivete of people who believe this. To believe that we can prevent every single maternal death? ”

    Thanks Basiorana (and Danio for the stats). I’m hoping you don’t mean me, because I agree with you. There are some out there who would get rid of medical exemptions for late term abortions. Dr. Tiller was one of the few left doing them.

    There are also the people who refuse to selectively reduce 6 or 8 embryos because it goes against nature. And then the science for “plan b” was endlessly manipulated as well.

    RE: partial birth abortion. I was under the impression that they are very rare, and wasn’t sure under what circumstances they could be performed. And yet, the procedure seems to be on the front line of the debate, and even some pro-choicers are against it.

    Clearly there is some overlap between the medical/moral issue of abortion. It’s probably even a reason that some very religious people (not I!) see medicine as “godless.”

  41. crowepps says:

    In a simpler, perhaps agrarian, society it would be much easier to justify 18 year olds raising families.

    It wasn’t at all common for a pair of 18 year olds to be raising a family in simpler, agrarian societies. It was far more common for the girls to marry at or before 18 with their husbands being men in their late 20′s or early 30′s (or older if a widower needed a new household worker) and the 18 year old boys waited until they had accumulated the assets to provide a home/farm.

    The age matching of modern relationships has a lot more to do with the compulsion to age sort students in large modern schools than it does with what’s ‘natural’.

  42. Chris says:

    j:

    “Perhaps breast cancer is to some degree a disease of our industrial-materialistic society that rewards women who have no children, or who have them later in life, far past their sexual prime, when they are financially and materially successful.

    Orac, a breast cancer surgeon, pointed out this essay on breast cancer surgery a couple of centuries ago:

    Nabby was a well-informed woman, and breast cancer was as much a dread disease in the early 1800s as it is today.

    I also know from reading the biography of Lord Byron’s daughter, Ada, the Countess of Lovelace, that she also died of a different kind of cancer after having at at least three children.

    So obviously the conditions of the early 1800s were also conducive to cancer.

  43. Yvi says:

    The data suggest the best way for women to minimize the risk of breast cancer is – surprise – to do what comes naturally, which is to have children at a young age.

    Natural for whom or in what way?

    For women? I never had any desire to have children. And I know a lot of women who think like that. I am grateful to live in a society where I can make this ‘unnatural’ choice.

    Or are you referring to ‘natural’ as in ‘without contraception available’? In which case having less than 5 children would be unnatural, which is also a significant health risk to women. Pregnancies and childbirth are no walk in the park.

  44. BillyJoe says:

    Danio:

    “But I’m not yet convinced the estrogen exposure idea is correct. It seems plausible to me (a software engineer) but it also wouldn’t be the first time that correlation did not imply causation.”

    The case is pretty strong that oestrogen is a risk factor for breast cancer rather than just a correlation, because nearly all the factors that have been correlated with breast cancer have this factor in common (ie early menarche, late menopause, number of preganancies, breastfeeding, OCP, HRT)

    BJ

  45. Qualine says:

    You had my attention until I got to the section entitled “The Evidence.” Your evidence is the same old stuff that has been discredited and the studies have been shown to have serious methodoligical flaws. The major ones:

    Danish study:
    - Misclassified 60,000 women as having NOT had abortions when records
    indicated they did.
    - Used 1973 instead of 1939 as the year abortion was legalized in Denmark.
    - Scientists violated the rule of temporality, tracking abortions from a different point in time than the tracking of breast cancer cases.

    Harvard study:
    - Researchers did not allow sufficient follow-up time between exposure to abortion and development of breast cancer.
    - Excluded cases of in situ breast cancer, which show up sooner than do cases of invasive breast cancer.
    - Did not adjust for miscarriages, having the effect of lowering risk, statistically.

    California Teachers study
    - Nearly one in five women with breast cancer in the study were counted as not having breast cancer.
    - Did not compare pregnant women who aborted to pregnant women who carried pregnancies to term. Because of the permanent changes in the breast from pregnancy, pregnant women who abort should be compared to pregnant women who give birth after a full term pregnancy.

    Melby’s own later work, 1999, shows a relationship between premature birth and breast cancer and gives biological support for a link between abortion and breast cancer because the same process, the interruption of differentiation, occurs in each case.

    Also, you “shoot the messenger” in this case the medical journal, without commenting on the citations in the medical journal. The studies cited in JPANDS don’t lack credibility just because they are cited in JPANDS. Look at where else they are cited: NEJM, J Nat Cancer Institute, Contraception, Bri J Cancer, Mayo Clinic Proceedings, Journal of Reproductive Medicine, The Lancet, Journal of Epidemiology and Community Health, and so on.

  46. Qualine says:

    That should be “Studies have serious methodological flaws…”

  47. David Gorski says:

    JPANDS is a crank journal that is anti-vaccine, anti-abortion, and pro-ideologically motivated pseudoscience, as I have documented in excruciating detail here. Obviously you didn’t read that or don’t care, even though I documented numerous examples of JPANDS’s abuse of science. That JPANDS would publish a study that’s a textbook example of the flamboyantly incompetent confusing correlation with causation and abuse of statistics tells you all you need to know about its standards. Do those low standards mean that anything published in JPANDS should be rejected a priori as pseudoscience. No (although JPANDS is so bad, this is not as resounding a “no” as I normally would say when asking this rhetorical question in other settings).

    As for your other complaints, I’m afraid that the preponderance of evidence against an ABC link outweighs the less rigorous studies based on self-reporting of abortions that suggested such a link in the 1960s through 1990s.

    But let’s put it this way. Even Joel Brind’s own highly flawed meta-analysis only found an approximately 30% increased risk. Even if that were true, that would be a relatively minor risk compared to other known risk factors, in particular family history. If such a risk were identified, sure, it should be communicated to women, but it would still be a small risk. It would not be the “30% lifetime risk” claimed by Dr. Lanfranchi, nor would it be the “virtual certainty” in women with a strong family history of breast cancer who undergo an abortion as a teenager also claimed by Dr. Lanfranchi. I mean, come on! Even documented mutations in the breast cancer susceptibility genes BRCA1 “only” produce around an 80% lifetime risk of breast cancer, and Dr. Lanfranchi’s claim seems to suggest that abortion plus family history is an even stronger risk factor than that.

    The ABC movement is not based on science.

  48. Qualine says:

    Would you elaborate on the flaws in Dr. Brind’s meta-analysis?
    Thanks.

  49. Kristen says:

    @Chris

    My last pregnancy was when I was over thirty-five, and I did have my amniotic fluid checked for genetic disorders. No woman does that unless she is willing to abort a child with disabilities.

    I disagree, at least in my case. I was not over thirty-five, but I also had my amniotic fluid checked for genetic disorders. But my reason was so I could be prepared for what may come.

    My first child had a birth defect which could be genetic, we will never know if it was or not (it can be idiopathic), but I wanted to be ready and know what to expect. I did this even though I knew I would keep the child regardless.

    My first son was diagnosed with a fatal birth defect at twenty weeks gestation. I decided to wait for him to be born. This was my personal decision, but I would not condemn a mother for making a different one. When faced with this kind of heartbreak, nobody should be judged for their decision, especially by someone who doesn’t know what it’s like to be faced with this.

    One also needs to be prepared for the effects of their decision whether it be physical or emotional. In my case I had a placental abruption and needed an emergency c-section, and had a son who lived for 68 minutes. While I don’t regret my decision, someone else may decide they wouldn’t take the risk of this outcome for a non-viable fetus, and that is fine too.

    Everyone needs to make their own well-informed choices. Woman should not be pressured into a decision by fear-mongering and misinformation. If you want to convince woman that keeping a pregnancy is better, use facts, give assistance when needed. Don’t threaten her with breast cancer.

  50. Yvi says:

    Has there ever been any mechanism proposed by the people who think there is a connection between abortions and breast cancer that is only present for abortions and not for miscarriages? And present for all abortions, whether they are done surgically or medically.

    I’d be interested in hearing how they think any link would work physiologically.

  51. daedalus2u says:

    It is my understanding that the “best” way to reduce breast cancer is to have a prophylactic mastectomy. It is my understanding that can reduce the chances of breast cancer to near zero. If there is no breast tissue remaining, there is no breast tissue that can become cancerous.

    Of course what constitutes “best” is a matter of opinion.

  52. Kristen says:

    @Chris

    I knew someone whose wife was actually excommunated from the Catholic church because she had an abortion. She had rubella and her baby died, and she did not expell the dead fetus. So she had it removed.

    This is horrible! I don’t care how apposed to abortion you may be (although to me this would not be an abortion) no woman should be expected to carry around what amounts to essentially a rotting corpse. I know that is an insensitive description, but it makes my point.

    This poor woman had already lost her baby, but to be ostracized for deciding to have the dead body removed just adds insult to injury.

  53. NewsCat says:

    David

    Thanks so much for this post. However long it took you to write it I want you to know it was time well-spent. It’s where I will be sending anyone in the future who wants to argue the ABC. Also I found it an excellent primer on “everything you wanted to know about those promoting the abortion causes breast cancer link.”

    As someone who has been trying to suss out what the hell is going on in the recent claims about the ABC link who is not a scienctist or a doctor, nor knew all the players involved (this was the first time I learned about JPANDS), I think you wrote a piece that few others could have written.

    I will definately be reading your blog from now on. Thank you very much for writing it.

  54. Qualine says:

    Yvi on 19 Jan 2010 at 9:06 am
    “Has there ever been any mechanism proposed by the people who think there is a connection between abortions and breast cancer that is only present for abortions and not for miscarriages? And present for all abortions, whether they are done surgically or medically.

    I’d be interested in hearing how they think any link would work physiologically.”

    The following studies are regarding the hormonal effects and differences between miscarriage and induced abortion. Note that two of the studies were published in the J Natl Cancer Institute and one study is published in The Breast, a reference manual used by breast cancer surgeons and specialists.

    1. Bland IE, Copeland, EM. The Breast: Comprehensive management of benign and malignant diseases, 3rd ed. Saunders 2004. (Ch.3. Breast physiology: normal and abnormal development and function).

    2. Vatten LJ, et al. Pregnancy related protection against breast cancer depends on length of gestation. Br J Cancer 2002;87:289-90.

    3. Daling JR, et al. Risk of breast cancer among young women: relationship to induced abortion. J Natl Cancer Institute 1994;86:1584-1592.

    4. Russo J, et al. Developmental, cellular, and molecular basis of human breast cancer. J Natl Cancer Institute Monographs. No. 27, 2000;17-37.

    5. Russo J, et al. Cancer risk related to mammary gland structure and development. Microscopy Research and Technique 2001;52:204-233.

  55. Qualine says:

    Yvi on 19 Jan 2010 at 9:06 am
    “Has there ever been any mechanism proposed by the people who think there is a connection between abortions and breast cancer that is only present for abortions and not for miscarriages? And present for all abortions, whether they are done surgically or medically.

    I’d be interested in hearing how they think any link would work physiologically.”

    The following studies are regarding the hormonal effects and differences between miscarriage and induced abortion. Note that two of the studies were published in the J Natl Cancer Institute and one study is published in The Breast, a reference manual used by breast cancer surgeons and specialists.

    1. Bland IE, Copeland, EM. The Breast: Comprehensive management of benign and malignant diseases, 3rd ed. Saunders 2004. (Ch.3. Breast physiology: normal and abnormal development and function).

    2. Vatten LJ, et al. Pregnancy related protection against breast cancer depends on length of gestation. Br J Cancer 2002;87:289-90.

    3. Daling JR, et al. Risk of breast cancer among young women: relationship to induced abortion. J Natl Cancer Institute 1994;86:1584-1592.

    4. Russo J, et al. Developmental, cellular, and molecular basis of human breast cancer. J Natl Cancer Institute Monographs. No. 27, 2000;17-37.

    5. Russo J, et al. Cancer risk related to mammary gland structure and development. Microscopy Research and Technique 2001;52:204-233.

  56. Qualine says:

    The basic explanation as to why early miscarriage (spontaneous abortion) and induced abortion are not the same event with respect to the breasts is because it is lowered progesterone (known as “the pregnancy hormone”) that prompts the actual miscarriage by making the uterus impermeable to the developing baby

    See: The role of progesterone in pregnancy http://www.crinoneusa.com/patients/progesterone_role.html)

    The ovaries (which also release progesterone in early pregnancy) release lowered amounts of estrogen to the breasts in the case of abnormal pregnancies.

  57. David Gorski says:

    Thanks so much for this post. However long it took you to write it I want you to know it was time well-spent. It’s where I will be sending anyone in the future who wants to argue the ABC. Also I found it an excellent primer on “everything you wanted to know about those promoting the abortion causes breast cancer link.”

    You’re welcome, although I did check out your website and now I do have to say that, even though she gave my post a nice shout-out, I’m a bit irritated at Amanda Marcotte for characterizing me as having “huge hang-ups about abortion”:

    http://www.rhrealitycheck.org/blog/2010/01/19/pseudoscience-and-pseudosympathy-abortion-and-breast-cancer-debate

    She seems to be conflating acknowledgment that abortion is a very controversial issue and my desire to stay away from the whole question of its morality instead in favor of focusing like a laser just on the science addressing the question of an ABC link with having “hang-ups.” I explicitly stated why I didn’t state my opinions regarding the morality of abortion; it’s because, while science-based medicine can inform such a moral debate, it can’t decide on the morality of the procedure. Moreover, I think I’ve mostly succeeded in that the discussion has been amazingly civilized for a discussion of abortion.

  58. Danio says:

    @Billy Joe: That was not my question–it was Callie Arcale, a few comments above my own from yesterday. FTR I agree with you.

    @J_:

    what is this naturalistic fallacy? What is, by the way, “modern science?” For that matter, what is the Residue Theorem?

    Naturalistic fallacy and ‘modern science’ are pertinent to this discussion, whereas the Residue Theorem is not. I suspect you’re attempting to be glib here, but please do consult Google University if you genuinely don’t know what I’m talking about.

    The rest of your questions are far beyond the scope of this particular post topic. However dissatisfied you are with the current roles and personal freedoms enjoyed by women in our society, hopefully you can at least acknowledge that the science in this case does not support the position that fewer abortions would result in an appreciable reduction in breast cancer rates.

  59. micheleinmichigan says:

    J – You don’t see anything problematic about changing a whole societal trend (based on individual choice) to moderate one disease risk factor? Have you considered other diseases and their risk factors? Maybe having less children, no children or children later is protective in other ways. Maybe being born to slightly older parents is protective in some ways to the children.

    But then again I’m not big on Utopian society constructs.

    I do agree that we could be more supportive of young families, though. In many countries the grandparents basically move in and help raise young children, in the U.S, well I guess it varies alot, but there is one thought process that leaving young parents to cope alone with their babies “teaches them to be responsible”. I don’t agree with that one.

    As for me, I waited to meet the right guy and then we adopted after two unsuccessful courses of fertility treatment. I’m thinking that puts me in a higher risk bracket for a couple on cancers. But what the heck, I wasn’t planning on being immortal. And jeesh, I have to pay taxes too.

  60. micheleinmichigan says:

    Interesting article, as much for the outline of risk factors, types of breast cancers and hormones relationships as for how the studies are being misrepresented, which seems to be par for the course in the abortion/pro-choice debate.

  61. Calli Arcale says:

    Just to clarify my comment about not being entirely convinced about estrogen levels being the causative agent in some breast cancers, it’s not that it doesn’t make sense, nor that there’s no evidence in favor of the correlation. (There’s lots of evidence, and certainly we know about estrogen-receptor-positive breast cancer.) I just have a hunch that there’s more to it than that. I’m neither a doctor nor a medical scientist (whereas Dr Gorski, for instance, is both), so do not give my hunch much credence.

  62. David Gorski says:

    Actually, there is more to it than that, and it’s hideously complicated, to the point where I’m not sure I understand it. Suffice it to say that, under some conditions, actually treating breast cancer with estrogen can inhibit its growth after it’s become resistant to anti-estrogen drugs, specifically aromatase inhibitors, even going so far as to restore its sensitivity to aromatase inhibitors. Here’s a pretty good lay article about the research:

    http://www.cnn.com/2008/HEALTH/12/12/healthmag.breast.cancer.estrogen/index.html

    However, it should be remembered that these are breast cancers that have undergone selection for anti-estrogen therapy resistance; they aren’t early cancers.

  63. Zoe237 says:

    Huh, Dr. Gorski must be timely, because there was a viewpoint from a medical doctor in my (small local) newspaper today on this exact topic. He says it’s because the anniversary of Roe v Wade is on January 22.

    Here’s what he has to say about the ABC link, in case people are wondering the supposed biological reason:

    “Another unappreciated complication is beast cancer. /this makes sense because with the start of pregnancy, estrogen, and the other hormones and substances dramatically increase to prepapre the woman’s body for pregnancy. If this normal progression is shocked by an abortion, the frustrated breasts may stimulate any cancer prone cells present. Several studies back this up.

    A July 2009 study from Turkey shows a 66 percent increased risk of breast cancer after an abortion. A recent Chinese study showed a 17 percent increase, and in 1994, Dr. Janet Darling of the Fred Hutchinson Cancer Research Center found a 50% increase in breast cancer in women who had had abortions. Why does the Susan G. Komen foundation ignore this abortion-breast cancer connection?”

    Grrr…

  64. Danio says:

    Considering that spontaneous abortion can happen for a lot of different reasons, how can these people be so sure that the ‘shock’ to the system purported to exist in (presumably surgical) abortions is never comparable to something experienced in a woman who miscarries? And wouldn’t that mean that medical abortions via mifepristone *don’t* carry the same breast cancer risk, due to the reduction of progesterone and estrogen receptors in response to this drug?

    Grrrr indeed!

  65. A. Noyd says:

    Zoe237

    “If this normal progression is shocked by an abortion, the frustrated breasts may stimulate any cancer prone cells present.”

    This sentence makes my brain hurt. And did he really write “the frustrated breasts”? Really?!

  66. Margaret says:

    Great analysis Dr. Gorski.

    “I knew someone whose wife was actually excommunated from the Catholic church because she had an abortion. She had rubella and her baby died, and she did not expell the dead fetus. So she had it removed.”

    –Sorry, I don’t know what happened in this case, but I can’t let this go unchallenged. Removing a dead unborn baby from a womb is not an abortion (because it isn’t), and the Church does not consider it so. Neither is removing a tubal pregnancy.

  67. David Gorski says:
    “If this normal progression is shocked by an abortion, the frustrated breasts may stimulate any cancer prone cells present.”

    This sentence makes my brain hurt. And did he really write “the frustrated breasts”? Really?!

    Yes, really. That seems to be the attitude of the ABC crowd. I’ve heard far worse.

  68. Scott says:

    Suffice it to say that, under some conditions, actually treating breast cancer with estrogen can inhibit its growth after it’s become resistant to anti-estrogen drugs, specifically aromatase inhibitors, even going so far as to restore its sensitivity to aromatase inhibitors.

    That’s fascinating. Is anyone looking into the possibility of urging cancers to evolve in desirable directions (e.g. to become less aggressive, or to increase susceptibility to a chemotherapy that will be applied later)? As a layperson, it seems like influencing the evolutionary pressures at work might be a valuable tool.

    (Evolution being important to cancer treatment – I have to wonder what Egnor would say!)

  69. Dawn says:

    @Margaret: re: “Removing a dead unborn baby from a womb is not an abortion (because it isn’t), and the Church does not consider it so. Neither is removing a tubal pregnancy.”

    I can’t address the first part without more details, but I unfortunately have to disagree with you on the second part. I was an employee at a local Catholic hospital when I developed an ectopic pregnancy (diagnosed by ultrasound…I got pregnant several years after a tubal ligation, so as soon as I had a positive preg. test I knew it had to be tubal). Because the fetus had a heartbeat on the ultrasound, the hospital either would not or could not treat me until either a) the heartbeat ceased or b) my tube ruptured.

    It was the scariest 2 days of my life, waiting to see if the heart would stop beating or if I would rupture. Fortunately for me and my family’s sake, the heart stopped first and they could treat me. Now, I don’t know if that was representative of all Catholic hospitals or not. Just my experience with this one. (And no, the doctor wanted to treat me, but her hands were tied…she appealed all the way up the medical levels she could in the hospital).

  70. crazyred says:

    To risk the mothers life (in the event of a tubal rupture that causes hemhorraging) because of a non-viable tubal pregnancy seems to violate common sense on the part of the Catholic hospital system. Dawn, I am so sorry that you had to endure that.

    I am always leery of religion when it it is used to justify medical policies.

  71. Calli Arcale says:

    I believe the Catholic Church does condone removal of dead fetuses, and abortion of ectopic pregnancies (most of which, if left alone, would be fatal for mother and child alike). That doesn’t mean all Catholics agree, nor that all Catholic organizations will follow that stated opinion. There is certainly diversity of opinion within the organization. It is, after all, a very large organization.

    My mother-in-law had some run-ins with a Catholic hospital. She was pregnant with my husband and developed hepatitis. Any treatment for the disease was frowned upon severely by the nuns at the hospital, because it could affect the fetus. They certainly didn’t condone abortion to save her life. She ended up delivering him about a month late and underweight (7 pounds is a normal birthweight, but not for a baby at 10 months gestation). Very sickly baby at first, but has been healthy since. Her second pregnancy ended when the baby died in utero. The Catholic hospital refused to remove the baby’s corpse. She was having trouble getting pregnant again and saw a different doctor, who performed dilation & extraction to remove the fetus, who had been dead for quite a while by that time. She later did get pregnant, and gave birth to my brother-in-law, who is now a talented web developer. ;-)

  72. Chris says:

    Calli Arcale:

    That doesn’t mean all Catholics agree, nor that all Catholic organizations will follow that stated opinion. There is certainly diversity of opinion within the organization. It is, after all, a very large organization.

    The incident I related occured in the early 1960s during the rubella epidemic. It really had nothing to do with the hospital or any medical personnel, but a priest in a parish in Georgia.

    In short, don’t let those whose business is religion dictate medical issues.

  73. Ash says:

    The Catholic church is even worse with respect to abortion in some other countries, such as this story: http://www.msnbc.msn.com/id/29531755/ (more details can be found at other sites)

    Essentially, a 9 year old girl was raped by her step-father, got pregnant with twins, and had an abortion to save her life. The church excommunicated her mother for allowing the abortion, and the doctors who performed it, but not the step-father who raped her (I guess they didn’t consider his crime to be as serious).

  74. Qualine says:

    Dr. Gorski,

    Would you please elaborate on the flaws in Dr. Brind’s meta-analysis?

    Thanks.

  75. Calli Arcale says:

    Chris, my point was just that we can’t expect absolute consistency within Catholic institutions or even individuals, and shouldn’t make assumptions about doctrine based on them.

    I’m a Lutheran, so my knowledge of Catholicism is purely that of an outsider.

  76. Chris says:

    Sorry, Calli, I should have started my response with “Exactly, that is very true.” My experience has always been with individual priests, who each interpret things differently. And things change over time.

    For instance, I wanted an outdoor wedding some thirty years ago. My mother-in-law went to the priests in her parish, and they both refused. Now at least one priest is quite willing to accomodate couples (he is a very nice man, we met him at late father-in-law’s memorial service and burial). And yes, I get to hear about the church often since my mother-in-law volunteers there every week.

  77. tcw says:

    A version of Godwin’s law is validated a few paragraphs into your post when you make sure that Joel Brind is labeled as a born-again Christian. If he was Jewish, black, agnostic, would you have used the ad-hominem argument? Christians cannot do science correctly, right?
    As “Qualine” has stated, the induced vs. spontaneous Ab issues have already been addressed. Looking at the links Dr. Gorski provided, the recall bias issue has been addressed rather convincingly by the ABC people. I am going to have to say, Dr. Gorski, that this post is heavy on ad hominem, lighter on addressing the scientific issues (Stanek is 2nd or 3rd hand, what did Brind or LaFranchi say?); the ABC people have gone through each study, and perhaps we would have been better served if you actually bounced your arguments off of LaFranchi or Brind or whoever. This post raises good questions, but Dr. Gorski hasn’t convinced me that the ABC researchers can be waved off as mere deluded activists. The ABC link is at least plausible (change in breast duct lobules is stunted with Ind Ab). There’s more to this issue than perhaps a blog is capable of presenting in one post. But congrats on the courage of posting on a controversial topic. More to come?

  78. Karen Malec says:

    Dr. Gorski:

    Anyone in your position who denies the link between abortion and breast cancer (and can’t even admit the obvious – that women who abort lose the protective effect of an early first full term pregnancy) is either uninformed or lying to the public.

    That is why the Coalition on Abortion/Breast Cancer is challenging you to a debate with its experts. If you are like the other individuals and organizations whom we’ve challenged over the years (i.e. Susan G. Komen for the Cure, Science Blogs, Redbook and Glamour), we expect you will duck our challenge. That should be a clue to women that the people they trust are not giving them the truth.

    What you are doing is truly shameful.

  79. BillyJoe says:

    Karen Malec,

    “Anyone in your position who denies the link between abortion and breast cancer (and can’t even admit the obvious – that women who abort lose the protective effect of an early first full term pregnancy) is either uninformed or lying to the public.”

    You have the answer to your own confusion right there: It’s not that abortion causes breast cancer, it’s that pregnancy protects against breast cancer.
    Maybe women should be advised to start as early as possible and have as many pregancies as possible to reduce their risk of breast cancer.

  80. Karen Malec says:

    Billy Joe:

    You are uninformed. A little bit of pregnancy does not protect women from breast cancer. Check any standard medical text. Childbearing protects against breast cancer. A woman who aborts does not bear a child. Saying that pregnancy is protective (not childbearing) is one of the methods that emotionally invested abortion enthusiasts in medicine and science confuse the public.

    Secondly, no man has the right to downplay research supporting the abortion-breast cancer link. Had this debate been about a statistically significant 40% risk increase in prostate cancer among men with vasectomies, the Gorskis of the world would reconsider having vasectomies, instead of downplaying the evidence, especially if a branch chief at the U.S. National Cancer Institute had been listed as a co-author in such a study.

  81. David Gorski says:

    Actually, there is a movement among some sects of conservative Christians who are so enamored of the ABC link to advocate just that: Marrying early and having lots of children at a young age. Perhaps you’ve heard of the “quiverfull” movement? Then there are Roman Cathoics, with whom I’ve very familiar given that I was raised Catholic, where the Church preaches against any form of birth control other than keeping track of ovulatory cycles.

    In any case, why is it so frequently the first reaction of people like Karen Malec to “challenge” someone who defends currently accepted science to public “debates”? Notice how her first tactic is the logical fallacy of the ad hominem attack (calling me either uniformed or a liar), and her second is the logical fallacy of the straw man argument, namely her claim that I deny the known science showing that full term pregnancies slightly decrease the risk of breast cancer, when in fact I explicitly pointed out that fact. (I do find it rather amusing, though, that Malec is apparently reduced to this sort of obvious straw man argument.) Finally, Malec’s challenge to a “debate” involves the the logical fallacy of an appeal to authority. No data presented, no refutation of my arguments. In any case, regarding the call for a “debate.” I’ve had anti-vaccinationists “challenge” me to such debates. I’ve had supporters of various forms of quackery challenge me to “debates.” Under my other blog persona, I’ve had HIV/AIDS denialists “challenge” me to a debate–including even a person claiming to represent Christine Maggiore herself! I’ve had creationists, Holocaust deniers, and even 9/11 Truthers “challenge” me to debates. Seemingly, every crank wants a “debate.”

    In general, I do not oblige them for a simple reason. Science is not decided in public debates, and such debates only serve one purpose: Propaganda. Such “debates” allow the “experts” arguing for discredited science to do the Gish Gallop and then claim a win based on their ability to sway an audience that is either sympathetic or not sufficiently scientifically sophisticated to see through the rapid-fire pseudoscience. It is not “ducking” the challenge to recognize the true purpose of such rigged “debates,” namely to try to take a scientist or physician and put him or her on the defensive for propaganda purposes, and refuse to oblige their request. I’m also not foolish enough to be so overconfident as to think that, having science on my side (which it is), I would be guaranteed to win such a debate, at least not in the eyes of the observers. Many supporters of pseudoscience are quite glib and good in a staged debate. Be that as it may, Ms. Malec’s “experts” have plenty of places to air their point of view and can, as evidenced by Ms. Malec herself, comment here if they so desire. Of course, if they comment here, they have to deal with our commenters, many of whom are quite savvy, but if their arguments are sound they shouldn’t fear debate online, right?

    I do understand the debate over debating cranks. Others whom I admire have decided to engage in such spectacles, including our fearless leader Steve Novella, who a while back debated homeopaths (about which a certain blogger explained his doubts about debating cranks). Michael Shermer agreed to debate Deepak Chopra. To debate or not is a thorny issue in the skeptical movement about which there is great disagreement. I come down on the side that such staged “debates” rarely serve any useful purpose and in general serve primarily to give the appearance that a real scientific controversy exists when in reality there is only manufactroversy.

  82. David Gorski says:

    Had this debate been about a statistically significant 40% risk increase in prostate cancer among men with vasectomies, the Gorskis of the world would reconsider having vasectomies, instead of downplaying the evidence, especially if a branch chief at the U.S. National Cancer Institute had been listed as a co-author in such a study.

    Not if the totality of the evidence didn’t support such a link, as the totality of evidence doesn’t support a link between abortion and breast cancer. One retrospective study cited by you, even one meta-analysis of retrospective studies, would not outweigh the totality of evidence.

    I do find your choice of an example (vasectomy) illuminating, however.

  83. Karen Malec says:

    Mr. Gorski:

    You have not accepted our challenge to a debate because science is not on your side. If science is on your side, then why not leap at the opportunity to prove us wrong? Instead, you choose to make the debate about religion. This is an abnormal response to a reasonable request.

    What can one say about a man who implies that a little bit of pregnancy is protective against breast cancer when the data over the last quarter of a century by Irma and Jose Russo at Fox Chase Cancer Center makes it clear that only a first full term pregnancy matures 85% of the mother’s cancer-susceptible breast lobules into permanently cancer-resistant lobules?

    What can one say about a man who is not intellectually honest enough to admit what Dr. Lynn Rosenberg (Boston Medical School) was forced to admit while testifying under oath as an expert witness for Florida abortion providers in a 1999 lawsuit against that state? She agreed with the statement that the 15-year-old girl who has an abortion has a greater risk than does the 15-year old girl who has a baby? Experts universally agree that childbearing protects women from breast cancer, but choosing not to have a child is not protective.

    When science is not on your side, it’s always best to label your opponent a “crank,” label the scientific evidence “pseudoscience” and call the debate “rigged” or “staged” when specific plans for a debate have not even been proposed.

    Please tell us, Dr. Gorski. What exactly is your emotional involvement in abortion that you would strike at thousands of unsuspecting women much like a sniper shooting at innocent bystanders from a rooftop?

  84. Karen Malec says:

    Dr. Gorski:

    Once again, you mislead women by suggesting only retrospective studies support an abortion-breast cancer link. Abortion enthusiasts are having a great deal of difficulty dealing with the study Howe et al. 1989, a prospective study in which the authors matched fetal death certificates with breast cancer patients’ medical records. They reported a statistically significant 90% risk increase for New York women with abortions. It’s incredible to watch our opponents who don’t know what to do with this study, so they will often pretend it does not exist or misrepresent the findings.

    Moreover, the abortion-breast cancer link is supported by biological evidence. Please explain, Dr. Gorski. How is it possible that premature birth before 32 weeks gestation more than doubles breast cancer risk, but (as you argue) abortion does not? Both pregnancies involve the same hormonal and structural changes to the breasts, leaving them with more places for cancers to start. The intellectually dishonest will challenge studies reporting an abortion-breast cancer link, but none challenge studies reporting a link between premature birth before 32 weeks and breast cancer.

  85. “She agreed with the statement that the 15-year-old girl who has an abortion has a greater risk than does the 15-year old girl who has a baby?”

    I take it that you advise 15 year olds to get pregnant. After all, we can all agree that a 15 year old who has a baby has a lower risk of breast cancer than a 15 year old who is celibate, right? Isn’t that what the scientific evidence shows?

    So when will we see your new campaign: Sleep with your boyfriend, have a baby, prevent breast cancer”?

  86. weing says:

    So, Karen Malec thinks all 15 year old girls should be impregnated in order to slightly lower their risk of getting breast cancer. She wants to debate the wisdom of this?

  87. Karen Malec says:

    “So, Karen Malec thinks all 15 year old girls should be impregnated in order to slightly lower their risk of getting breast cancer. She wants to debate the wisdom of this?”

    Give me a break, Weing! Does the pregnant 15-year-old girl who presents herself to a doctor and says she wants an abortion have the right to know that by having the abortion her breast cancer risk will be greater than it would be if she has a baby? Does the physician have a legal obligation to obtain informed consent from his patient before performing a surgical procedure? Does the 15-year-old have the right to choose between having breast cancer and being healthy?

    Abortion enthusiasts say “no” too all three questions because they think they know what’s best for the pregnant woman better than she does.

  88. “Does the pregnant 15-year-old girl who presents herself to a doctor and says she wants an abortion have the right to know that by having the abortion her breast cancer risk will be greater than it would be if she has a baby?”

    Does a 15 year old who has never been sexually active have the right to be informed by her doctor that abstinence increases her risk of breast cancer?

    Shouldn’t promoters of “abstinence only” sex education revise their curriculum to include the information that teen childbearing is good for you because it prevents breast cancer?

  89. “Does the pregnant 15-year-old girl who presents herself to a doctor and says she wants an abortion have the right to know that by having the abortion her breast cancer risk will be greater than it would be if she has a baby?”

    And of course she should be counseled that having an abortion decreases her risk of death compared to carrying the baby to term, right? Since protecting that girl’s health is your fundamental aim, you WOULD counsel her to have that abortion, wouldn’t you?

  90. Danio says:

    Decisions in medicine, and in life, often come down to relative risk assessment. The data (by which I mean the recent, rigorous studies discussed thoroughly by Dr. Gorski in the original post, not the balderdash from 1986) indicate that the risk of breast cancer for a 15 year old terminating a pregnancy would be no greater than her risk had she never gotten pregnant at all, at this point in her life. The risk conferred by either condition, however, is dwarfed by the risk to her health and life–and to that of her child–were she to continue the pregnancy to term at such a young age.

  91. Zoe237 says:

    “And of course she should be counseled that having an abortion decreases her risk of death compared to carrying the baby to term, right? Since protecting that girl’s health is your fundamental aim, you WOULD counsel her to have that abortion, wouldn’t you?”

    Good question. I hope Karen Malec would advise for abortion in this instance, given her thought process.

    Love the term abortion enthusiast, btw. Geez!

  92. Karen Malec says:

    “Does a 15 year old who has never been sexually active have the right to be informed by her doctor that abstinence increases her risk of breast cancer?”

    Somebody seems to be ignoring the scenario that was presented. The question that I presented has to do with a doctor’s procedure and a doctor’s legal obligation to secure informed consent, which is completely irrelevant to the individual who is not seeking a medical intervention (the healthy, non-sexually active person). I asked, “Does the pregnant 15-year-old girl who presents herself to a doctor and says she wants an abortion have the right to know that by having the abortion her breast cancer risk will be greater than it would be if she has a baby?” Will you answer the question or not?

    The healthy 15-year-old who has never been sexually active is not a person seeking medical intervention. You are using a red herring and proposing a situation that is completely irrelevant because it is not in a medical context. It is a phony, disingenuous argument. Abortion is a surgical intervention which is sought by largely healthy people.

    Abortion has meaning only within the context of the woman who is already pregnant. You are introducing ludicrous arguments in a desperate attempt to get away from the incontrovertible truth about abortion, which is an artificial interruption of a normal process. Only abortion is subject to the rules of informed consent, not abstinence.

    I am talking about what women have the right to know when they are considering medical intervention. I am advocating that teenagers who are already pregnant should have the right to know it’s safer and better for their health to carry their pregnancies to term because it increases the risk of breast cancer and premature births, among other things.

    If you want to obfuscate about what a doctor’s legal duty is and, instead, talk about abstinence education, that’s a different discussion.

  93. “Somebody seems to be ignoring the scenario that was presented.”

    Hardly. Doctors are supposed to counsel patients on preventive care. If getting pregnant and having a baby at 15 reduces the risk of breast cancer, shouldn’t a doctor be required to tell that tho the patient?

    “Abortion has meaning only within the context of the woman who is already pregnant.”

    Absoutely. That’s why if asked you the following:

    “And of course she should be counseled that having an abortion decreases her risk of death compared to carrying the baby to term, right? Since protecting that girl’s health is your fundamental aim, you WOULD counsel her to have that abortion, wouldn’t you?”

    It is incontrovertible that continuing the pregnancy increases the 15 year old’s risk of death. Clearly preventing her near term death from the risks of pregnancy is more important that preventing a long term theoretical (and likely non-existent) risk of breast cancer.

    By your reasoning, all 15 year old girls should be counseled to abort any pregnancy in order to protect their health.

  94. Karen Malec says:

    Danio said: “The data (by which I mean the recent, rigorous studies discussed thoroughly by Dr. Gorski in the original post, not the balderdash from 1986) indicate that the risk of breast cancer for a 15 year old terminating a pregnancy would be no greater than her risk had she never gotten pregnant at all, at this point in her life.”

    So I assume, Danio, that you agree that the young woman who has an abortion has a greater breast cancer risk than does the one who has a baby? You, too, seem to be avoiding the question.

    The following statement is an assertion, but you didn’t provide scientific support for it:

    “The risk conferred by either condition, however, is dwarfed by the risk to her health and life–and to that of her child–were she to continue the pregnancy to term at such a young age.”

  95. Karen Malec says:

    Dr. Tuteur:

    Why are you avoiding my question? “Does the pregnant 15-year-old girl who presents herself to a doctor and says she wants an abortion have the right to know that by having the abortion her breast cancer risk will be greater than it would be if she has a baby?”

    Do you really believe that doctors are legally obligated to obtain informed consent from the non-sexually active 15-year-old? That’s ludicrous! I suspect you know better than that which is why you are trying to change the subject.

    You make an assertion about the supposed safety of abortion vs. childbearing, but provide no scientific support to back up your assertion.

    I expect you to at least make an attempt to be intellectually honest.

  96. “I expect you to at least make an attempt to be intellectually honest.”

    Oh, the irony!

    So let me get this straight. You are concerned about the long term risk of developing breast cancer in choosing between aborting or continuing a pregnancy, but you are thoroughly unconcerned about the short term risk of death?

    That’s inexcusable.

  97. Karen Malec says:

    Excuse me, Dr. Tuteur, but YOU are the doctor!

    If you want to tell the healthy, non-sexually active 15-year-old girl that abstinence will raise her breast cancer risk, or if you want to withhold life-saving information about breast cancer risk from a pregnant 15-year-old girl who is contemplating an abortion, then I hope your medical malpractice insurance is paid in full. Oh, the irony!

    Two American women (who had abortions as minors) and three Australian women have successfully sued their abortionists for failing to warn them about the risks of breast cancer and emotional harm. The U.S. lawsuits took place in liberal jurisdictions – Portland, Oregon and Philadelphia County, Pennsylvania. The former involved an offer of judgment – meaning that the defendant agreed to pay a sum of money to the plaintiff and she did not have to prove negligence. The latter was a settlement.

    In both cases, they involved women who had had abortions as minors and had not yet developed breast cancer. They won, in part because they had aborted before first full term pregnancy and had lost the protective effect of an early first full term pregnancy. In the Pennsylvania case, the plaintiff had an abortion during the second trimester, and the defendant who was relying on the study, Melbye et al. 1997, to deny the abortion-breast cancer link, forgot that these researchers found a statistically significant 89% risk increase for women with abortions after 18 weeks gestation.

    I suggest that you read up on your legal liability:
    http://www.abortionbreastcancer.com/Your_Rights.htm

    Your claim that pregnant 15-year-old girls are dying in the streets of America because they did not get abortions is absolute nonsense.

  98. Aborting a pregnancy has a lower risk of death than carrying a pregnancy to term. Period. There’s simply no question about it. So your supposed “concern” for the health of a pregnant teen is exposed as hypocrisy if you ignore the risk of death.

    As I have repeatedly pointed out in discussion of childbirth interventions, pregnancy is and has always been, in every time, place and culture, a leading cause of death in young women. For young teenagers the risk is even greater. Therefore, teens must be counseled that abortion is safer than continuing a pregnancy.

  99. Karen Malec says:

    Try telling that to the court, Dr. Tuteur! And assertions won’t be accepted in court, so you’d better have science on your side.

    The protective effect of early first full term pregnancy is well established and has been replicated in many studies. The landmark study, MacMahon et al. 1970 (Bull World Health Org), comes to mind. Harvard researchers reported that the woman who delays her first full term pregnancy until age 35 triples her breast cancer risk over that of the woman who has a first full term pregnancy at age 17. Other researchers have reported higher risks than that.

    Then you have to figure in the additional risk increasing effect of the independent link between abortion and breast cancer, which according to Daling et al. 1994 (Journal of the National Cancer Institute), reported a more than double breast cancer risk for the young woman who aborts before age 18. If she’s under age 18 at the time of abortion and has a family history of the disease, her risk is incalculably high. So be sure to screen your patients for family history (even though for some women, their family history of breast cancer is in their future).

    Finally, you have to add the risk of premature birth. The Institute of Medicine lists abortion as a risk factor for having a premature birth. At least four studies have reported that premature birth before 32 weeks gestation increases breast cancer risk.

    Don’t forget to count all three breast cancer risks associated with abortion, and don’t forget that premature birth before 37 weeks is associated with cerebral palsy, mental retardation, etc.

    And make sure your medical malpractice insurance is paid up.

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