Obamacare and AIDS

One would assume that if anybody should benefit from Obama's changes to the healthcare laws, it would be people with AIDS. HIV positive people have been lobbying for government assistance since the nature of the disease first became evident in the 1980s, and Democratic politicians have led the charge to find a cure--or at least a treatment--for a disease that now affects millions of people, heterosexual and homosexual alike, around the world.

So it comes as something of a shock to learn that AIDS advocates are unhappy with Obamacare, as the Washington Post notes today:

But people who expected the new plans to provide pharmaceutical coverage comparable with that of employer-sponsored plans have been disappointed. In recent years, employers have compelled workers to pick up a growing share of the costs, especially for brand-name drugs. But insurers selling policies on the exchanges have pared their drug benefits significantly more, according to health advocates, patients and industry analysts. The plans are curbing their lists of covered drugs and limiting quantities, requiring prior authorizations and insisting on “fail first” or “step therapy” protocols that compel doctors to prescribe a certain drug first before moving on to another — even if it’s not the physician’s and patient’s drug of choice.

The disruption to the existing market leaves many AIDS patients who were covered worse off than they were before:

Paul Prince, 52, a former information technology manager from Houston, said he was surprised that some of the health plans in the new federal marketplace wouldn’t pay for one or more of his HIV medications. The policy that seemed to provide the best coverage, he said, would cover only about two-thirds of his monthly $2,400 drug tab, leaving him responsible for $840.

“There was no way I could pay that,” said Prince, who is studying to become a teacher after being laid off from his previous job and losing his insurance.

Insurers have responded Obamacare's prohibition against discrimination on the basis of pre-existing conditions by cutting costly benefits--like expensive drugs.  The Post cites a study by Avalere Health:

A new analysis of health plans sold in the federal exchange — which covers 36 states — and 14 state exchanges found that the benefits tend to be skimpier than in most other private insurance in the United States, with drug benefits a particular weak spot.

Right now, this only affects the 5% of Americans who get their insurance on the individual market, but the Post reports that many employers are already thinking about cutting costs the same way.

Dan Mendelson, Avalere’s chief executive, predicted that employers may soon adapt some of the benefit designs in the exchanges’ health plans. “We are already seeing interest,” he said, because they are less expensive for companies, shifting more of the expense to patients.

The Washington Post article makes it clear that (a) this problem affects a larger group of illnesses, including cancer, multiple sclerosis, rheumatoid arthritis and autoimmune disease and (b) AIDS activists are working hard to change the rules to solve the problem--for people with HIV.

If you care about someone with AIDS, read the Washington Post article and pass it on.

If you care about someone with cancer, multiple sclerosis, rheumatoid arthritis, autoimmune disease, or another disease that involves expensive medications, you may want to subscribe to this blog.

Does Childbirth Cause Cancer?

There's no scientific debate on this one--women who give birth have an increased risk of breast cancer for the next fifteen years. Journals reporting this link include:

• New England Journal of Medicine (1994)
• American Journal of Epidemiology (2000)
• Cancer Causes Control (2002)

Why haven't you heard about this? First, because it's only temporary, and second, because the overall effect of childbirth is to reduce a women's lifetime risk. Young women have a very low risk of breast cancer, so a small increase in a very low risk is not a big problem. Older women have a much greater risk of breast cancer, so a long-term reduction in risk makes a big difference. That's why having children is generally associated with lower breast cancer risk.

 That's good news. But it leaves us with two questions. Why does breast cancer risk go up after childbirth? Why does it go down again after 15 years?

Jose and Irma Russo, of Fox Chase Cancer Center in Philadelphia, have done countless studies on the physiology of breast tissue. They have demonstrated that breast tissue specializes during the latter stages of pregnancy, leaving mature tissue at a lower risk of cancer. The early stages of pregnancy, by contrast, are a time of rapid cell division. (Women who have had babies know about this--tender breasts are one of the earliest signs of pregnancy.) These rapidly-replicating cells are a higher risk of mutation.

The prime suspect for the transient risk after childbirth is estrogen.  Estrogen helps prepare a woman's body for birth. It is the "gasoline" that keeps the human race going--but gasoline can be dangerous. All it takes is a spark to create an explosion. If you add enough estrogen to just one abnormal breast cell you can grow a tumor.

The good news is that the hormones of later pregnancy may actually stop some tumors in their tracks. The research to date is consistent with research on rats which indicates that tumors which have already begun to grow are redirected into normal tissue. (If you enjoyed biology in high school, read this article--it spells out the mechanism by which stem cells of one type are converted to another, and zeroes in on the precise tissue types that are at risk in early pregnancy.) If estrogen is the "gasoline" that catches fire, the hormones of later pregnancy are "rain" that puts fires out.

These are plausible answers to our two questions (why does risk go up after childbirth? Why does it go down after 15 years?), but if they turn out to be correct, they lead directly to a third question. What happens if a woman's breast cancer risk is raised by early pregnancy without the protective effect of later pregnancy? What if there's gasoline but no rain?

Research on rats proves that an interrupted pregnancy confers no protective effect. How about humans? If women have an elevated risk after any pregnancy (not just a full-term pregnancy), then women who choose abortions should have an elevated risk for at least 15 years after the procedure, just like other women who were pregnant. Carefully designed studies of breast cancer in young women find exactly that. Dr. Janet Daling, of Seattle's Fred Hutchinson Cancer Research Center, found:

Among women who had been pregnant at least once, the risk of breast cancer in those who had experienced an induced abortion was 50% higher than among other women (95% CI = 1.2-1.9). While this increased risk did not vary by the number of induced abortions or by the history of a completed pregnancy, it did vary according to the age at which the abortion occurred and the duration of that pregnancy. Highest risks were observed when the abortion was done at ages younger than 18 years—particularly if it took place after 8 weeks' gestation—or at 30 years of age or older. 

To answer the question posed by the title: childbirth does not cause cancer. Pregnancy does--in the sense that it adds "gasoline" that can burst into flame. Full-term pregnancy is the rain that puts fires out and reduces the risk of fire thereafter.

Debate the Abortion/Breast Cancer Link

What scientific paper could possibly open up a subject as controversial as "death panels" or "global warming"? How about the latest Chinese research that finds a statistically significant 44% increase in breast cancer risk after induced abortions. For those who are new to the debate, here are the arguments for and against the Abortion/Breast Cancer link.

The Argument

• Estrogen is to breast cancer what carbon dioxide is to global warming--with a twist.




• CO2 is a "greenhouse gas" that traps heat, so anthropogenic global-warming ("AGW") theorists argue that the rise in temperatures around the world is the result of humans burning fossil fuels.


• Steroidal estrogen is a recognized carcinogen. Pregnancy loads a woman's body with estrogen, but abortion interrupts the process before other hormones can mature breast tissues. Abortion/breast cancer ("ABC") theorists argue that this can explain the global epidemic of breast cancer since oral contraceptives and abortions became common.


• The twist: people who question the AGW hypothesis are called "deniers" and are told "the science is settled." People who articulate the ABC hypothesis are called "fanatics" and are also told "the science is settled."

Research on Rats

• Pro: Rat breast tissue is more susceptible to mutations in early pregnancy, which raises the risk of cancer. Fortunately, breast tissue becomes specialized in later pregnancy, which reduces the lifetime risk of cancer. Rats that give birth have a lower incidence of cancer, but research shows that interrupted pregnancies confer no protective effect. Although the A/BC link was first hypothesized in 1957, nobody has done a study on rats that is specifically designed to find out whether induced abortions raises the risk of cancer.


• Con: Rats aren't people. The science is settled. We don't need more research.

Research on Pregnancy

• Pro: The age at first live birth is a well-known risk factor for breast cancer. Earlier is better--the sooner a woman has a baby, the lower is her lifetime risk of breast cancer. This is true despite the fact that child-birth itself
  raises a woman's risk of breast cancer in the 15 years after birth. This transient risk is due to the impact of estrogen on breast tissue. Abortion leaves a woman with the worst of both worlds--all the elevated risks of pregnancy without the protective effects of birth.


• Con: Women don't care about raising their risk of cancer when
  they're considering terminating their pregnancy, and doctors shouldn't
  tell them about it. It would only confuse and distress them.

Research on Estrogen

• Pro: The suspected link between abortion and breast cancer is based on the high levels of estrogen during pregnancy. Estrogen has been tied to breast cancer time after time.  Hormone replacement therapy is a recognized breast cancer risk. Steroidal estrogen is a recognized carcinogen.  Injectable contraceptives appear to raise breast cancer risk. Studies on oral contraceptives have been more controversial, but the World Health Organization identifies estrogen-containing oral contraceptives as a "Class 1 carcinogen."


• Con: Only Catholics object to oral contraceptives. This is just another case of religion hiding behind the mask of "science."

Research on Populations

• Pro: Breast cancer is rising around the world, especially in
  populations that have begun to use oral contraceptives or induced
  abortion. Breast cancer incidence is elevated in every group that tends
  to choose abortion: (i.e., young black women, more educated women,
  higher status women, etc) and lower in most groups that tend to avoid
  abortion (older black women, more religious women, Hispanic women in
  Hispanic neighborhoods, etc.).


• Con: Claims of a "global epidemic" of breast cancer have been
  overblown. Most of the alleged increase in breast cancer in the United
  States is simply the result of better publicity and longer lifespans.

Breast Cancer Studies:

Case-Control Studies: Matching women with breast cancer to otherwise-identical women 

• Pro: Study after study finds a modest increase in breast cancer risk. The studies that distinguish women who had abortions from women who took the Pill are consistent with an increase in risk of 3% per week of terminated pregnancy. Studies designed to correct for the possibility of "recall bias" fail to find any.


• Con: Any apparent increase can be explained by "recall bias," which holds that women who get sick tell the truth while women who are healthy tend to maintain their privacy.

Cohort Studies: Following large groups of previously-identified women over time

• Pro: Cohort studies, which track large groups of women over
  time, necessarily fail to address the multiple variables that affect
  breast cancer risk. Studies funded by big drug companies should be
  scrutinized as carefully as studies by tobacco companies.


• Con: Cohort studies are the most reliable because they are the largest and are not subject to recall bias.

Recall Bias: Do Healthy Women Conceal Abortions?

• Pro: Janet Daling, of Seattle's Fred Hutchinson Cancer Research Institute, is personally pro-choice but is even more anti-cancer. Her research on the abortion/breast cancer link was elegantly designed to detect any evidence of recall bias. She included three groups of women in her study: some with breast cancer, some with cervical cancer, and some who were healthy. The recall bias theory suggests that women with cancer (whether breast cancer or cervical cancer) would tell the truth, while healthy women might be shy. She found no evidence of an increase in risk among women with cervical cancer, but a statistically significant increase among women who chose abortion.


• Con: Recall bias explains all the apparent increase in risk.

Hypothesis Or Theory?

• Pro: Before the National Institute of Health convened its panel to discuss this issue in 2003, almost every paper on the topic concluded with "more research is needed." The research done since then is consistent with a modest, transient increase in breast cancer risk after induced abortion as long as one recognizes the confounding effect of oral contraceptives. With the latest meta-analysis from China, it's time to stop calling this the "abortion/breast cancer hypothesis" and recognize it as a valid scientific theory.


• Con: The hypothesis has been disproved. The science is settled. The continuing obsession about this is just more right-wing, anti-choice obfuscation.

Conclusion

The link between abortion and breast cancer has been so vigorously and officially denied that many people have decided it simply must be false. Talking about abortion and breast cancer these days is like insisting that Obamacare will create "death panels" or denying global warming.



That's why the new Chinese research matters. It's time for open-minded people to review the arguments and make up their own minds. This page is a place to begin the discussion.

Oral Contraceptives and Cancer

The National Cancer Institute admits there is some evidence that women who use oral contraceptives face an increased risk of breast cancer for several years. That is no surprise, since the Pill delivers estrogen to a woman's body, and increased exposure to estrogen is associated with elevated breast cancer risk. The mystery is not that oral contraceptives raise breast cancer risk, but that they don't appear to raise the risk anywhere near enough to account for the global epidemic of breast cancer since they became widely available in the 1960s.

What the National Cancer Institute won't tell you is that oral contraceptives are just one way a woman can get an abnormal exposure to estrogen. Pregnancy also delivers "sudden and dramatic increases in estrogen." There's nothing abnormal about pregnancy, of course, but doctors are well aware of a "transient" increase in breast cancer risk after birth. A full-term pregnancy matures and specializes breast tissue, reducing a woman's lifetime risk of breast cancer--but only after an elevated risk for the fifteen years after birth.

If a full-term pregnancy raises risk in the short term but lowers risk overall, what about an interrupted pregnancy? Miscarriages, which are often associated with insufficient estrogen levels, don't seem to have a measurable effect on breast cancer risk, but interrupting a viable pregnancy seems to produce the worst of both worlds--elevated short-term risk (due to estrogen) without the long-term benefit of mature, milk-producing tissue. In other words, it would seem that abortion must increase the risk of breast cancer in young women.

How come you don't hear that from the National Cancer Institute? The reason may disturb you. Study after study has been published on the abortion/breast cancer link, with varying results. Some, such as the most recent meta-analyis from China, find an elevated risk of cancer after abortion.

A systematic review and meta-analysis of 36 Chinese studies by Dr. Yubei Huang and his colleagues in the prestigious journal, Cancer Causes Control, last week reported a significant 44% increased breast cancer risk among women with at least one induced abortion...

Others find no increase in risk--but those studies simply compare women who have abortions to women who don't have abortions. That's like comparing pipe smokers to non-pipe-smokers instead of comparing pipe smokers to cigarette smokers to non-smokers. If estrogen is what elevates the risk of breast cancer, it makes no sense to compare one group of women with elevated estrogen levels (pill takers) to another group of women with elevated estrogen levels (whose pregnancies were terminated by induced abortions).

Once you include all sources of elevated estrogen, the "global epidemic" of breast cancer suddenly makes sense. Breast cancer is on the rise among all groups that routinely use oral contraceptives or choose abortion, while it tends to remain at normal levels among women without an artificially high exposure to estrogen.

If this is true, why isn't everybody talking about it? First of all, in our ultra-politicized world, anybody who mentions the abortion/breast cancer link is instantly marginalized--just like Sarah Palin was when she claimed Obamacare would lead to death panels. (If you haven't noticed, the mainstream media finally admits that death panels are real.)  Second, many of the biggest (and most questionable) studies on abortion and breast cancer have been funded by the same drug companies that produce the Pill. And finally, the political and legal implications of an abortion/breast cancer link are overwhelming. At a minimum, Planned Parenthood would be bankrupted by malpractice suits, and Roe v. Wade itself would have to be reconsidered in light of a genuine medical danger. The stakes in America are too high to let science be science.

But that can't be all there is to it! Science is science, and even the tobacco industry had to hide the evidence that smoking led to cancer. How can drug companies hide the evidence of an abortion/breast cancer link? The answer is, they don't. They just attribute it to "recall bias," arguing that women who choose abortion tend to be ashamed of their choice, and so don't tell the truth about their own medical history until they get cancer--at which point, life trumps privacy. With this approach, study after study that shows an elevated risk can be ignored every time. Without direct experiments on living human beings (which violates every principle of medical ethics), indirect evidence of increased risk gets ignored time after time.

Except in China. Abortion there has none of the personal stigma that it has in the United States, and medical records on abortions are easily available. With nearly a billion people and a state-mandated one-child per couple policy, China is the next best thing to a laboratory for conducting direct experimentation on living human beings. This makes it especially significant that Chinese researchers are pointing out the consistent elevated risk after abortion.

Convinced?  Then tell a friend--or ten. Forward this link to folks who need to know.

Skeptical? I haven't scratched the surface of the evidence for this link. Post your questions or critiques in the comment section below and I'll respond to them as time permits.

Angry?  That's what the comments are for--but please keep it clean, or I'll delete it, whether you're roasting me or toasting me. This blog is intended for the whole family, with a zero tolerance policy on profanity.