Legal implications of a link between abortion and breast cancer

Dozens of studies have shown that the greater the number of abortions, the higher the incidence of breast cancer. Three states expressly require physicians to disclose to patients seeking abortion that the procedure may increase the risk of breast cancer. Three other states have more general disclosure requirements about abortion.

There is a legal obligation of informed consent for any medical procedure. With the majority of studies showing that abortion increases breast cancer risk, and even the minority studies reinforcing the well-established principle that childbirth is protective against breast cancer, patients seeking abortion have an obvious right to this information. The patient who had an abortion and later develops breast cancer may have a valid claim against the provider. Already there have been at least two settlements in the United States in lawsuits brought for such failure to disclose.

Unfortunately, misinformation has circulated in the media following an article published last year in the British medical journal . The article did not deny that increased abortions result in greater incidence of breast cancer. Rather, the article merely claimed that abortion does not increase the risk of breast cancer, compared to the risk of someone who delayed pregnancy altogether. The article and data are consistent with the prevailing medical view that the more abortions in a society, the greater the number of breast cancer cases.

Failure to diagnose breast cancer has now become the most common malpractice case. While only a small percentage of physicians perform abortions, most physicians will encounter a patient who has an abortion in her medical history. The total rate in the U.S. of a patient contracting breast cancer is 1 in 7.5, and tragically continues to rise. The likelihood of a patient developing breast cancer may be higher if there is an abortion in the patientís medical history, and physicians may be held accountable for a heightened duty to screen that patient for cancer.

There is also a public policy issue about who should pay for the enormous costs of increased breast cancer cases. Tobacco companies are now held liable for medical costs imposed by increased risk of cancer from smoking. Attorneys General of various states have sued to obtain enormous settlements from the tobacco industry. Should the logic be any different for physicians who perform abortions?

There is a general duty at common law for physicians to procure informed consent from a patient before an operation. Washington State, for example, required informed consent by physicians more than 30 years ago, and shifts the burden to the defendant to justify omission of material information. Lack of informed consent is the basis for many lawsuits, as consent is plainly not meaningful if not fully informed. Consent to an operation based on an understanding that there are no long-term adverse effects is invalid if the operation does increase a risk of a long-term condition, and the patient was not informed of this fact. The right resides with the patient alone: if there is a body of research suggesting a risk, then the patient has a right to be informed of that risk, even though there is not a generally accepted view about it.

Accordingly, lack of fully informed consent by a patient can impose liability on the physician. New York State courts have held that even emotional distress brought on by misinformation about abortions serves as the basis for a valid claim, and the acting physician can thereby be held liable. In 1987, the New York Court of Appeals allowed recovery by a patient because she had received incorrect information resulting in an abortion that caused emotional distress.

In 2004, a trial court in New York upheld a claim of medical malpractice where a breach of duty by a physician and misinformation caused emotional distress. The mother had been told that her condition of fibroid tumors rendered it unlikely that she could carry her pregnancy to term. She then submitted to a chemical abortion, but it failed to be completed. The patient ultimately decided to give birth. Her child was then born with severe defects, which were caused by the attempted chemical abortion. If the patient had been correctly informed, she would have chosen to continue her pregnancy and given birth to a healthy child.

Lawsuits may be filed against physicians who perform abortions and fail to disclose that the procedure might increase the chance of breast cancer. One such suit in Pennsylvania has already settled on confidential terms, after a lawsuit on similar grounds succeeded in Australia. Pennsylvania does not have a law expressly requiring that abortion providers disclose a connection with breast cancer, but the common law imposes a duty of informed consent in nearly all states. Similarly, an Oregon judge recently approved a settlement paid on behalf of an abortion provider there to a 19-year-old girl with a family history of breast cancer, who was not told of an increased risk from the procedure at age 15. She recovered monies, even though she has not yet developed breast cancer at her young age.

Three states do expressly require that abortion providers inform their patients that the operation may increase the risk of breast cancer: Texas, Mississippi, and Minnesota. Minnesota mandates this disclosure, but its health department adds a disclaimer to its publications as described below. A fourth state, Kansas, provides the information through state publications including its website. Two other states, Alabama and Louisiana, have backed away from disclosing the possibility of an increased risk. NeitherAlabama nor Louisiana, however, has altered the common law duty to provide all relevant information to a patient in procuring consent.

Texas, the second most populous state, has a statutory mandate that informed consent be given 24 hours prior to an abortion. Texas law expressly establishes that consent is informed only if ìthe physician who is to perform the abortion...informs the woman... [of] the possibility of increased risk of breast cancer following an induced abortion and the natural protective effect of a completed pregnancy in avoiding breast cancerÖ.î Additionally, the woman having an abortion must certify in writing that she has been informed of this increased risk. This law was enacted in 2003, and its effect on abortions in that state is not yet known.

Mississippi law requires that women preparing to have an abortion sign a form indicating they have been specifically told about an increased risk of breast cancer from abortion when medically accurate. Effective in 1996, this requirement and others have had a dramatic effect on the numbers of women obtaining abortions in that state. In response to the requirements, abortions have fallen in Mississippi. In 1991 the number of abortions performed was 8,814; in 2002, the latest year for which data is available, this number had dropped to 3,605, a decline of 59 percent.

Minnesota law requires informed consent and disclosure of the abortion/breast cancer link at least 24 hours prior to an abortion. According to Minnesota law, ì[n]o abortion shall be performedî unless the woman is told of ìthe particular medical risks associated with the particular abortion procedure to be employed including, when medically accurate, the risks of Ö breast cancer.î

Additionally, the Minnesota Department of Healthís ìReport of Informed Consent for Induced Abortionî lists the risk of breast cancer associated with abortion. Although the state mandates this disclosure and the department does claim the risk exists, they also add a disclaimer: two recent studies claim there is no link, adding that ì[w]omen who have a strong family history of cancer, or who have clinical findings of breast disease, should seek medical advice from a physician regardless of their decision to become pregnant or have an abortion.î

Kansas law expressly requires that women be informed of ìa description of risks related to the proposed abortion method,î and the state-mandated pamphlet handed out to potential patients warns, ì[s]everal studies have found no overall increase in risk of developing breast cancer after an induced abortion, while several studies do show an increase[d] risk Ö.î However, Kansas does not specifically require informing patients of abortion and its related increased risk of breast cancer.

In Louisiana, a state-mandated brochure and its Department of Health and Hospitals had been informing women of the potential risks of the abortion procedure, voluntarily including information on the increased risk of breast cancer. Under pressure from media representations of the article, Louisiana hastily removed the abortion/breast cancer link information.

In June 2004, a U.S. District Court judge approved a settlement involving a challenge to the 2002 Alabama ìWomenís Right to Know Act.î The constitutionality of the law, which required disclosure of the effects of abortion on the body, the risks involved, and the alternatives available, was well established. But the courtapproved settlement specifically stated that the warning of the increased risk of breast cancer due to an abortion was to be removed from the state-mandated brochures. Apparently abortion providers oppose informing patients about the increased risk of breast cancer more than they oppose other disclosure requirements.

In March 2004, Lancet published an article that was widelyñand inaccuratelyñportrayed as disproving the link between abortion and breast cancer. The article did not deny that more abortions increase breast cancer incidence, a fact observed by the vast majority of studies and by changes in breast cancer rates worldwide in response to changes in abortion rates. Delaying or avoiding childbirth elevates the risk of breast cancer, and abortion has that adverse effect. According to most studies, abortion also causes additional risk.

The article did claim, ì[p]regnancies that end as a spontaneous or induced abortion do not increase womanís risk of developing breast cancer.î This was the strongest assertion in the article, but it does not deny that abortion increases the risk of breast cancer. Instead, this assertion compares the risk of breast cancer from an abortion to a hypothetical case in which no pregnancy occurred in the first place. Once a pregnancy occurs, aborting that pregnancy does increase the risk of breast cancer for that individual. For society as a whole, more abortions do cause greater incidence of breast cancer in the future. Not even the article doubts this.

Reports in the news media ignore the fact that the article relies entirely on a hypothetical comparison, first between pregnancy followed by an abortion, and second, no pregnancy at all. But neither the patient, nor the abortionist physician, nor the government, has the option of turning back the clock and undoing a pregnancy after it occurs, and childbirth is beneficial to health. The only possible alternatives are childbirth and abortion, and the article tacitly concedes that the latter increases the risk of breast cancer compared to the former. Nearly all studies have concluded likewise. The medical consensus is that carrying a pregnancy to term is healthier than terminating it by abortion. Women consenting to an abortion need this information in order for their consent to be informed.

Countries that have banned or restricted abortion illustrate this effect. During two decades of rule by the dictator Nicolae Ceausescu, Romania prohibited abortion and enjoyed one of the lowest breast cancer rates in the entire world during that time, far lower than comparableWestern countries. Romaniaís breast cancer rate was an astounding one-sixth the rate of the United States. But after the execution of Ceausescu on Christmas Day, 1989, Romania has taken the entirely opposite approach, embracing abortion to the point that Romania now has one of the highest abortion rates in the world. Science predicts that breast cancer rates will rise as the women having abortions reach ages susceptible to the disease. Indeed, that is exactly what is happening, with the worst still ahead as women who had abortions in the 1990s as teenagers or in their 20s reach ages more susceptible to breast cancer.

Similar observations of cause and effect are evident in Poland and Ireland: Poland limits abortion and now enjoys one of the lowest breast cancer rates in Europe, despite a high rate of cancer in men, while Ireland prohibits abortion and benefits from a breast cancer rate of only 1 in 13, about half the U.S. rate.

Even in the Far East, where breast cancer rates have historically been much lower than in the West, increased abortions have apparently caused alarming increases in breast cancer incidence. In Taiwan, for example, abortion was traditionally rare, but Taiwan has imitated its pervasive practice in theWest. A sharp increase in abortions in Taiwan would predictably lead to relatively higher breast cancer incidence among the younger age group affected by the change. This has indeed occurred, as ìbreast cancer patients younger than 40 years of age account for only 6 percent of total breast cancer victims in West European countries, but the ratio reaches a high of 29 percent in Taiwan.î No plausible explanation for this phenomenon, other than abortion, has been advanced. The data republished in the article do show an increased risk among breast cancer victims asked if they had obtained an abortion. Specifically, the article reveals that about 33 out of 39 large studies of breast cancer patients had an increased risk of breast cancer from abortion beyond the effect of avoiding a pregnancy.

The article disingenuously excludes the studies showing the highest correlation and includes dubious studies, but even then its data still illustrate a clear correlation. Its tables show studies in France, Greece,Australia, and Germany displaying relative risks of breast cancer of 1.35 or above for abortion compared to no pregnancy at all. The risk of breast cancer from abortion compared to childbirth, which is the real alternative, is of course far higher, given the protective benefits of childbirth.

The article errs, however, in emphasizing small ìprospectiveî studies that rely on self-reporting of abortion by patients who do not have cancer and may not even be sick. In contrast to the cancer patients, who have every incentive to disclose a medical history of abortion, women who are not ill have an incentive to keep that personal information private. The only healthy women who have reason to disclose a prior abortion are those preparing for childbirth, which has beneficial effects that mask the health impact of the abortion.

By effect if not design, the article relied on samples consisting of the least likely breast cancer victims among women who had abortions. For the small prospective studies used by the article, ì[o]n average, the age of the women with breast cancer was 50.4 years and they had 2.4 births.î But about 80 percent of breast cancer victims are over 50, and the typical breast cancer patient has had fewer than 2.4 births. The obvious disincentives for healthy women to report their own abortions, and the masking effect of the large average number of childbirths, negate any effect of abortion in this sample. It is no surprise that the effects of abortion are offset by other factors in this unrepresentative group. The article has many additional flaws, already explained elsewhere. It contains political language favoring abortion, such as the phrase that certain women ìhave been at risk of illegal abortion for part of their reproductive lives.î The authors apparently picked studies advancing their agenda, and admitted to excluding studies showing higher correlations between abortion and breast cancer. They also excluded older women, who are most likely to contract breast cancer, by an irrational elimination of studies pre-dating legalization of abortion in many countries. The article did not accomplish its purported goal of surveying other studies when it selectively excluded studies that did not serve its conclusion.

Moreover, the article failed to include details about how the prospective studies were really performed.

Regional variations in breast cancer rates among similar ethnic groups confirm the link between abortion and breast cancer. In Great Britain, for example, the rate of breast cancer decreases steadily as one travels from England, where abortion has been common, to Northern Ireland, where abortion has been uncommon, to Ireland, where it has been prohibited.

In the United States, similar relationships between abortion and breast cancer can be observed. The San Francisco Bay Area, including Berkeley, known for its long-standing acceptance of abortion, has a breast cancer rate 9 percent higher than the rest of the state, according to information from the state Department of Finance and the state Office of Vital Records. In another example, Long Island has suffered from a high rate of breast cancer that politicians have blamed on the environment. But Long Island has long had a thriving abortion industry, dating back to 1970 when the state legalized the procedure even before (1973), and many of the earliest and busiest abortion clinics in the United States have been on Long Island. In contrast, Wyoming has one of the lowest abortion rates among states, and has one of the lowest breast cancer rates among women nationwide.

The alarming increase in breast cancer in the wake of abortion has been well documented. But the question of who is paying the costs has not been addressed.

Physicians are. Not the small percentage who perform abortions, but the large percentage who do not. The physicians bearing the costs here are those sued for failure to diagnose breast cancer, and the other physicians who have endured rising liability insurance premiums.

The most common type of malpractice case is now failure to diagnose breast cancer. This kind of lawsuit now surpasses all others against physicians. The average payout for these failure to diagnose cases is substantial: about $200,000 apiece. Added to that are substantial costs of defense, lost time and income for the defendant physician, and significant administrative costs.

These legal and administrative costs are borne by all physicians in the form of rising liability insurance premiums. The more than 50 percent increase in breast cancer in America since has likely caused a greater than 50 percent increase in lawsuits for failure to diagnose it, as lawyers develop practices specializing in this type of action. (Abortions and breast cancer both increased before also.) And even when breast cancer is detected, a failure-to-diagnose lawsuit can be filed for not detecting it sooner.

About 5 percent of breast cancer is inherited, and thus delineated in a routine medical history that documents parental illness. But a physician faces a difficult task of defending against a failure-to-diagnose claim in everyone else. About 80 percent of women with breast cancer are the first in their families to be stricken by the disease. Even a proper diagnosis can lead to a malpractice lawsuit, if the attorney wants to argue that the breast cancer should have been detected sooner.

With abortion recognized as a risk factor for breast cancer by consensus in the medical literature and by several state laws, physicians should be aware of the likelihood of being sued for failure to diagnose breast cancer in a patient who had an abortion.A physician can save lives and protect himself against lawsuits by being vigilant for the possibility of breast cancer in patients with a medical history of abortion.

The Alan Guttmacher Institute estimates that about 1 in 3 American women will have had an abortion by the time she reaches age 45. Accordingly, physicians can expect that roughly a third of their patients around that age will have had an abortion, though this can vary widely by location and demographics.

It is helpful to know what percentage of those patients will ultimately develop breast cancer, in order to screen for it early and save lives. The total rate is 1 in 7.5 in the U.S. But more abortions mean more breast cancers under the prevailing medical view, thereby implying a higher rate of breast cancer among women who have had an abortion.

About 80 percent of breast cancer victims are over age 50, but that population was already past the teenage years when abortion rates increased sharply after the national legalization of abortion.

Half of all abortions are in women aged 24 or younger, and the numbers of abortions in the United States did not reach its highest levels until many years after . The vast majority of abortions performed in the United States, and the world, occurred after 1980, and a woman aged 24 or less then is still younger than age 50 today. Any increase in breast cancer by abortion already witnessed would be merely the beginning of much greater increases in breast cancer in the future. The largest expense to physicians and society from the effect of abortion on breast cancer lies ahead.

While ultimately a third of American women will have abortions by age 45, far fewer women had abortions in the 1960s and 1970s than in the 1980s and 1990s. Among women who have reached age 50 today (and thus were already aged 25 years or older by 1980), perhaps only about a fifth of that group has had abortions.

If the 50 percent rise in breast cancer rates since abortion became legal nationwide is primarily attributable to this fifth, that implies a 3.5-fold increase in relative risk for it. Given that the total lifetime risk of breast cancer has risen to 1 in 7.5, a relative lifetime risk of 3.5 for breast cancer by the fifth who have reached 50 years and have had an abortion translates into an absolute lifetime risk for them of about 1 in 3. The risk would be even higher if all types of cancer are included.

The United States has not yet felt the full impact of the abortions performed on more than 20 million young women since 1980. The vast majority are well under 50 years old; many millions of them have not yet reached age 30. If 1 in 3 of these younger women develops breast cancer, or even half that rate at 1 in 6, the costs in terms of lives lost, medical expenses, failure-to-diagnose lawsuits, and forgone opportunities would be staggering.

The tobacco companies were finally held liable for the costs they impose on individuals and society.Will the same occur for the abortion industry, or will those costs continue to be borne by other physicians in the form of liability premiums, and by society? Are we currently in a period of denial similar to what happened for decades about tobacco?

The states of Mississippi andTexas, and the countries of Ireland and Poland, have adopted abortion policies that will minimize the occurrence of breast cancer in the future. Meanwhile, Romania is changing from having among the lowest incidence of breast cancer to having the highest. ìThe liberalization of abortions in Romania in 1990, the significant increase of the number of abortions at relatively short intervals, determined a rise in the incidence of breast and uterine cervix cancer in my country.î Its population faces increasing breast cancer for the next few decades, cutting short many womenís lives and devastating its health system. Fewer than 20 years after , the rate of breast cancer in the U.S. had risen to 1 in 10, and magazine sounded a national alarm with a cover story describing it as the ìpuzzling plague.î Yet the article did not mention abortion. Now the breast cancer rate has risen further to 1 in 7.5, but articles about causation have vanished from the established media.

The consensus in the medical literature is that abortion does increase the incidence of breast cancer. This information is of obvious significance to women who may consider having an abortion, and their consent without it is legally deficient. Failure to diagnose breast cancer has become the most popular type of malpractice lawsuit. To save lives and guard against possible lawsuits, physicians should warn of the link prior to the operation and be vigilant looking for breast cancer in patients who have a medical history of abortion.

The costs to individuals and society from withholding or ignoring this information about abortion and breast cancer are enormous. Diagnosis and treatment of breast cancer involves far more misery for women than a diagnosis of appendicitis, for example.Yet in sharp contrast to the tobacco industry, the abortion industry pays nothing to offset the substantial costs to society of increased cancer. States and countries, already strained to their breaking point in their health budgets, face a rising tide of costly breast cancer cases. Disseminating information is the best way to save lives and conserve scarce resources.

Breast Cancer and Abortion

Q-A: Why would a woman who has an induced abortion before her first full-term pregnancy (FFTP) suffer an increased risk of developing breast cancer?

A woman’s breast is especially sensitive to carcinogenic (ie, cancer producing) influences before she delivers her first child. When a woman becomes pregnant, a number of hormone levels increase dramatically in her body. Three especially notable ones are estradiol, progesterone (ie, the female sexual hormones), and hCG (human Chorionic Gonadotropin). All of these hormones, especially the latter, serve to stimulate immature breast cells to mature into fully differentiated cells [1]. If this process is artificially interrupted by way of an induced abortion, the hormone levels drop suddenly and dramatically, thereby suspending the natural process of maturation of many of the woman’s breast cells. This is referred to as a “hormonal blow” by researchers. These cells are now “vulnerable” to carcinogens because they started the maturation process but were never able to complete it. (Cells that have fully matured are less vulnerable to carcinogens than cells that are in the process of maturation).

Q-B: Do any animal models support the claim that abortions early in life increase breast cancer risk?

Yes. Russo and Russo, in their classic work published in 1980 [2], studied several groups of rats which were given a specific carcinogen (cancer producing agent) called DMBA. They noted that 77% of the rats who underwent an abortion developed breast cancer and 69% of the virgin rats developed breast cancer, but 0% of the rats who were allowed to complete their pregnancy developed breast cancer.

Q-C: Could you tell me about the history of the abortion/breast cancer debate?

As early as 1957, Segi et al noted that women who had induced abortions had at least a 2-fold increased risk of breast cancer [3]. In 1981, Pike et al [4] published their notable work showing that young women (under the age of 32) who had experienced an abortion before their first full-term pregnancy (FFTP) had a 140% increased risk of breast cancer. A number of studies followed but in 1994, Daling et al [5] published a large study which noted that women who had an abortion before their FFTP suffered a 40% increased risk. This risk increased to 150% if the adolescent had her abortion before the age of 18. In addition, Daling et al noted that if adolescents under the age of 18 aborted a baby that was more than 8 weeks old, they suffered an 800% increased risk of developing breast cancer.

Finally, in 1996, in what is openly regarded as the most meticulous and comprehensive meta-analysis (ie, a synthesis of all the major studies done in a particular field concluding in an overall risk for the pooled studies) of all the abortion/breast cancer research articles ever done, Brind et al [6] found that women who had an abortion before their FFTP had a 50% increased risk of developing breast cancer whereas women who had an abortion after their FFTP sustained a 30% increased risk.

Q-D: If Dr. Brind et al’s study was so conclusive, then why is the subject still being debated?

Because of the controversy regarding abortion, Dr. Brind’s study came under intense scrutiny; however, the results seemed irrefutable. Janet Daling — a prominent epidemiologist (a researcher who studies trends in the medical field) — was quoted in the Wall Street Journal as stating that Brind et al’s results were “very objective and statistically beyond reproach.” [7] Then in early 1997, the New England Journal of Medicine published the results of a large prospective study by Melbye et al [8] which claimed to show that abortion did not increase the risk of breast cancer.

Q-E: Was there any problem with the study by Melbye?

Yes. It is astonishing that the New England Journal of Medicine allowed it to be published in its submitted form. It had several glaring problems that have been pointed out in a follow-up letter to the New England Journal of Medicine [9]. The main ones include the following: 1) Melbye’s data actually pointed to a 44% increased risk of breast cancer due to abortion, but they never printed this result; 2) The follow-up period for the “cases” (ie, women who had an induced abortion) was less than 10 years, whereas it was over 20 years for the “controls” (ie, women who did not have an induced abortion). A follow-up period of less than 10 years is not long enough to show the effect of an abortion (ie, too short of a latent period); 3) Over 30,000 women in the study who had abortions were “misclassified” as not having them — thus 30,000 women were counted as not having abortions, when in fact they really had abortions; and 4) The study did note that women who had an abortion after the 12th week sustained a 38% increased risk of breast cancer, whereas women who had late-term abortions (ie, after 18 weeks) had a statistically significant increase of 89%. Both of these results received little media attention.

Q-F: Dr. Melbye claimed that his study did not suffer from “recall bias.” What did he mean by this?

Some researchers have claimed that retrospective studies suffer from “recall bias.” (An example of a retrospective study is one in which women with breast cancer would be interviewed and asked questions about their risk factors such as family history, induced abortion, etc.) The recall bias hypothesis can be defined as the following: “The hypothesis that people who develop a disease (eg, breast cancer) are more likely than people who do not develop that disease to admit that they participated in a ‘controversial risk factor’ (eg, an induced abortion or oral contraceptive pill [OCP] use) for that disease.” In essence they claim that women who have breast cancer are more likely to be truthful about the fact that they had an induced abortion than women who do not have breast cancer.

Q-G: On what basis do such researchers make such a claim?

This claim of recall bias is based on a study by Lindefors-Harris et al [10] from Sweden. She compared the responses of “cases” and “controls” to the national register which reportedly keeps an accurate record of all women who had an abortion. The study claimed to show that in the group of women who indeed had an induced abortion (according to the national register), the women who had breast cancer were about 50% more likely to admit that they had the abortion than the women who did not have breast cancer. The study has been criticized by Daling, a prominent epidemiologist, who noted that the study actually showed only a 16% “recall bias” (versus the reported 50% figure), when analyzed properly [5].

Q-H: Were there any problems with the study?

Yes. The study noted that 7 out of the group of 26 women with breast cancer who stated that they had an abortion at a young age, actually did not have an abortion according to the national register. This implies that 7 women out of the 26 women, or 27% of these “cases,” stated that they had an abortion at a young age, when they really did not. Obviously, this undermines the credibility of the study. Who would place any confidence in a study in which more than one quarter of a group of women with breast cancer reportedly lied and said they had an abortion when they actually had not?

Q-I: Is there any way to get around the “recall bias” problem?

Yes. A direct way to “get around it” is to measure it. Researchers did this already in the oral contraceptive and breast cancer debate in which some researchers claimed that women with breast cancer would be more honest about their history of oral contraceptive use. A number of studies refuted this claim by going back to a woman’s medical records and comparing the results of her interview response to that of the written record. All three of the studies that did this found less than a 2% difference between “case” and “control” responses [11,12].

Q-J: Can the same technique be used in regard to the abortion and breast cancer studies?

Absolutely. Most good obstetricians and gynecologists obtain a thorough medical history of their patients especially on their initial visit. A standard question would be to ask a woman how many miscarriages and/or induced abortions she had. If one wished to measure the degree of “recall bias” between “cases” and “controls,” one could simply compare their oral responses to that of the written medical record. Any degree of bias would be recorded and accounted for.

Q-K: This seems so basic. Why has it not been done?

That is a good question. Perhaps the question that should be asked is: Has someone done it and not reported it for fear of going against the bureaucratic forces within the political and medical establishments?

Q-L: Do women who had an abortion or miscarriage, or used oral contraceptive pills (OCPs) early in their reproductive life develop a more aggressive breast cancer?

Yes. Olsson et al has noted [13]: “These results indicate that the rate of tumor cell proliferation [ie, rate of growth of cancer cells] is higher in patients with breast cancer who have used oral contraceptives at an early age or who at a young age have had an early abortion. . .”

Q-M: Do miscarriages carry the same risk of breast cancer as induced abortion?

Women whose pregnancies end in miscarriage usually do not experience the same increase in estradiol and progesterone (ie, the female sexual hormones) or hCG levels that would result from a healthy pregnancy. Therefore, when a woman experiences a miscarriage, there is a less dramatic shift in hormone levels and less of a “hormonal blow” to the breast. Studies have shown that miscarriages, in general, have less of a risk than induced abortions. However, several studies show that miscarriages before a first full-term pregnancy (FFTP) may still carry a significant risk of developing breast cancer as noted in Table 2A below. (Further research in this area is critical to determine if an early miscarriage does indeed increase the risk of breast cancer.)

Table A:

RISKS OF BREAST CANCER IN WOMEN WHO HAD A MISCARRIAGE BEFORE THEIR FIRST FULL TERM PREGNANCY

AUTHOR	YEAR OF PUBLICATION	PERCENT CHANGE	CONFIDENCE INTERVAL

Pike et al [138]	1981	151% increase	unknown
Brinton [101]	1983	9% increase*	0.8-1.5
Hadjimichael [107]	1986	250% increase	1.7-7.4
Rosenberg [149]	1988	10% decrease*	0.7-1.4**
Ewertz/Duffy [106]	1988	163% increase*	0.83-8.32***
Adami [96]	1990	20% increase*	0.7-2.0
Daling [103]	1994	10% decrease*	0.6-1.3
Rookus [141]	1996	40% increase*	1.0-1.9

* This result reflects a trend towards an increased or decreased risk but does not attain statistical significance

** Inappropriate age matching in this study: median age of "cases" and “controls” were was 52 and 40 respectively

Q-N: Is the prognosis of a pregnant woman who currently has breast cancer improved if she has an induced abortion?

No. Clarck and Chua noted that: “Those (pregnant women with breast cancer) undergoing a therapeutic abortion had a poorer prognosis compared to a live birth and even a spontaneous abortion.” [20] King et al obtained a similar result. “. . .patients who had termination of the pregnancy had a five year survival rate of 43 percent, whereas patients who underwent mastectomy and who went to term had a five year survival of 59 percent.” [21].

Q-O: What should women be told in general about having an abortion at a young age and the risk of breast cancer?

Women who have an elective abortion before their firstborn baby suffer at least a 50% increased risk of developing breast cancer according to the best meta-analysis done to date. The risks are almost certainly higher for women who have had an abortion before the age of 18, or those who have additional risk factors, such as a positive family history or use of oral contraceptives before a FFTP. (The person who is interested in an excellent review article describing the physiologic reasons behind the link between abortion and breast cancer should see Canty’s article [22].)

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