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IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEBRASKA PLANNED PARENTHOOD OF THE HEARTLAND,Plaintiff,
vs
DAVE HEINEMAN, Governor of Nebraska, in his official capacity;
JON BRUNING, Attorney General of Nebraska; in his official capacity;
KERRY WINTERER, Chief Executive Officer, and
DR. JOANN SCHAEFER, Director of the Division of Public Health, Nebraska Department of Health and Services, in
their official capacities; and
CRYSTAL HIGGINS, President, Nebraska Board of Nursing,and
BRENDA BERGMAN-EVANS, President, Nebraska Board of Advanced Practice Registered Nurses, in their official capacities;

Defendants.
AFFIDAVIT OF ANGELA LANFRANCHI, MD, FACS
I, Angela Lanfranchi, M.D., F.A.C.S., working at 30 Redhill Avenue, Suite 3400, Somerville, NJ 08876, being over 18
years of age and fully competent to testify, do hereby swear and affirm based on my personal knowledge that:

1. I am a breast cancer surgeon practising in New Jersey, since 1984. I hold the position of clinical assistant professor of surgery at Robert Wood Johnson Medical School. I am also a Fellow of the American College of Surgeons, and am certified by the American Board of Surgery. My medical degree is from Georgetown School of Medicine, graduating in 1975. A true and accurate copy of my curriculum vitae is attached hereto and incorporated herein.

2. My work includes assessing risk factors of patients presented for evaluation, and induced abortion is one risk factor
I consider routinely.

3. I am a member of the Expert Advisory Panel for the New Jersey Board of Medical Examiners, a member of the Somerset County Cancer Coalition, and am on the Professional Advisory Committee of the Wellness Community of
Central New Jersey.

4. I am a surgical co-director of the sanofi-aventis US Breast Care Center and chair of the Breast Institute at The Steeplechase Cancer Center in Somerville, New Jersey.

5. I am co-founder and president of the Breast Cancer Prevention Institute, a non-profit charitable corporation that has
as its mission to educate lay and professional communities in the methods of risk reduction and prevention of breast
cancer through research, publications and lectures.

6. The Somerset County Commission on the Status of Women in the Field of Medicine and a women’s health center
serving the medically indigent have honored me for my medical contributions.

7. My work was also honored with the 2010 Castle Connelly Medical Ltd. New Jersey “Top Doc” award for Women’s
Health in Breast Surgery.

8. My scholarly work includes authoring articles on the physiology and epidemiology of the abortion-breast cancer link published by the National Catholic Bioethics Center, the Institute for Anthropologic Medicine and Bioethics, Issues in Law and Medicine, and Linacre Quarterly.

9. As a breast cancer surgeon over the last 25 years, I have cared for ever-younger women with breast cancer; my youngest was 25 years old. There has been approximately a 40% increase in incidence in invasive breast cancer over
my career. I have researched the causes of these alarming increases over the past fifteen years and have become knowledgeable about the reasons for these trends, one of which is induced abortion.

10. The vast majority of peer review studies confirm that abortion increases the risk of breast cancer. Many of these studies predate the modern political controversy concerning abortion, and some are conducted in nations where abortion is less politicized than in the United States.

11. Just last year alone, three studies, from the United States, China and Turkey confirmed that abortion is associated with increased risk of breast cancer. Dolle J, et al. Cancer Epidemiol Biomarkers Prev 2009;18(4)1157-1166; Xing P,
Li J, Jin F. A case-control study of reproductive factors associated with subtypes of breast cancer in Northeast China.
Humana Press, e-publication online September 2009; Ozmen V, et al. World J of Surg Oncol 2009;7:37. The Turkish
researchers wrote that “similar to our findings the majority of the studies reported that induced abortion was associated with increased breast cancer risk.” Id.

12. Epidemiological studies have long confirmed that abortion is associated with increased risk of breast cancer, satisfying the Hill criteria for causation. These studies will necessarily continue to be produced because scientists know that in order to conduct valid studies concerning any risk factor all known variables must be controlled for, and induced abortion is one of them.

13. The physiology of why abortion increases the risk of breast cancer is well-understood, as explained below.

14. Briefly, the physiology is as follows. A lobule is a unit of breast tissue consisting of milk glands and ducts which
carry the milk toward the nipple. Before the first full-term pregnancy, the woman’s breast is about 75% Type 1 and
25% Type 2 lobules where ductal and lobular breast cancers form respectively. By the end of the pregnancy, the
breast is about 85% fully matured to cancer-resistant Type 4 lobules and only about 15% immature, cancer-vulnerable
lobules remain, thereby reducing the mother’s future risk of breast cancer. After weaning, Type 4 lobules become Type 3 lobules. There are permanent changes in the up and down regulation of genes in these Type 3 lobules conferring lifelong reduction in breast cancer risk.

15. During a pregnancy the absolute numbers of these lobules also increase as the breast doubles in volume with an
increase in number of lobules and a decrease in stroma (the surrounding connective tissue).Russo J,et al.Mammary gland architecture as a determining factor in the susceptibility of the human breast to cancer. The Breast J 2001;7:278-91.

16. If the woman has an abortion before 32 weeks, she increases her breast cancer risk proportionally to the length of gestation, roughly 3% for each week’s gestation. She increases her breast cancer risk because the breast has already responded to the hormones estrogen and progesterone, which are produced by the ovaries and by the fetal-placental unit in response to fetal-placental secretion of human chorionic gonadotropin (hCG). These hormones cause an increase in breast tissue, Type 1 and 2 lobules, where cancers start. Vatten LJ, et al. Pregnancy related protection against breast cancer depends on length of gestation. Br J Cancer 2002;87:289-90.

17. Only after 32 weeks’ gestation does the fetal-placental hormone human placental lactogen (hPL), in concert with other hormones, fully mature the breast lobules into Type 4, making them cancer-resistant. An abortion before 32 weeks prevents this from occurring.

18. This same physiology accounts for an approximate doubling in breast cancer risk due to premature birth before 32 weeks, as shown by several studies. In addition, it has been well-established by at least 2 meta-analyses that abortion increases the risk of future premature births. A combination of these two effects results in a further increase in breast cancer risk from abortion.

19. First trimester miscarriages (also called “spontaneous abortions”), in contrast, do not carry the same risk as induced abortions because spontaneous abortions are usually associated with low levels of the pregnancy hormones
needed for breast development because there is an abnormality in the fetal-placental unit or the mother’s ovaries, which then results in a spontaneous abortion. Kunz J, Keller PJ, “HCG, HPL, Oestradiol, Progesterone and AFP in serum in patients with threatened abortion, Br J Obstet Gynaecol 83 (1976): 640-44. Women who spontaneously abort often report having “not felt pregnant” due to these low hormonal levels.

20. Even if organizations did not support the independent link between abortion and breast cancer, by virtue of delaying or eliminating a full-term pregnancy in a woman or causing a premature birth before 32 weeks, abortion would increase breast cancer risk.

21. In light of the clear physiology linking abortion to breast cancer, and the numerous studies documenting the increased risk, physicians have a professional duty to disclose that abortion increases the risk of breast cancer.

22. Professional guidelines or consensus or politics cannot override or disprove scientific studies or what is well-accepted in standard texts concerning reproductive risks, breast changes during pregnancy and the pathophysiology of breast disease and cancer.

23. I have reviewed the memorandum submitted by Planned Parenthood of the Heartland in its lawsuit challenging the
Act, focusing on its claims about breast cancer at pages 26- 27.

24. Planned Parenthood states that “[t]he national professional organizations with specialized expertise in cancer and
reproductive health have flatly rejected any association between abortion and breast cancer.” (citing Meadows Declaration).

25. There is a well-documented history of denial by professional organizations of well-established causes of cancer,
such as denying for decades that cigarettes cause cancer. Political or industry influences are known to distort the official positions of professional organizations.

26. Most recently, the journal Cancer Epidemiology published a study conducted by scientists at the University of Colombo in Sri Lanka, which was the fourth study in the past 14 months to implicate that abortion increases the risk of breast cancer although the study did not separate induced from spontaneous abortion. This Sri Lanka study was particularly persuasive because the incidence of breast cancer is relatively low in that country, making it easier to rule out confounding factors.

27. This Sri Lanka study demonstrated that abortion can increase the risk of breast cancer by 240%. This news was then widely publicized in the British press, but did not receive as much publicity in the United States, presumably due to the politicization of the issue here.

28. For political and financial reasons, national organizations may be reluctant to disagree with legislators in Congress
who favor unrestricted abortion, and national organizations are particularly unlikely to contradict their own official statements on the topic. It could be decades before an organization admits it was in error. For instance, under pressure from Senators of tobacco states, the NCI minimized risk of lung cancer for several decades until the US Surgeon General (who is not under the same Federal department as the NCI) issued his 1st report in 1964 warning of
the tobacco/lung cancer risk. The AMA did not support the Surgeon General’s warnings on cigarette packs at the time
of that report.

29. At least one individual belonging to an organization that is in denial about abortion increasing breast cancer risk reported, in her own work, that there is an increased associated risk. Dr. Louise Brinton, Chief of the Hormonal and
Epidemiology Branch at the National Cancer Institute’s Division of Epidemiology and Genetics, reported in a 2009 study that “older age, family history of breast cancer, earlier menarche age, induced abortion, and oral contraceptive
use were associated with an increased risk for breast cancer.” Dolle J, et al. Cancer Epidemiol Biomarkers Prev
2009;18(4)1157-1166.

30. The professional duty to obtain informed consent is not dependent on political views or financial interests.

31. There is no justification for relying on an opinion of a Federal organization under political control, such as the NCI,
that is contrary to peer-reviewed studies and well-understood physiology accounting for the fact that abortion would
increase the risk of breast cancer as acknowledged in standard medical texts. In fact the NCI website as of this date
still contains many errors regarding pregnancy and breast physiology.

32. There is no justification for relying on the opinion of other organizations, such as the American Congress of Obstetricians and Gynecologists (“ACOG”), to the extent they contradict the well-understood physiology and numerous peer-reviewed studies demonstrating why abortion increases the risk of breast cancer. This is especially true when practitioners in ACOG could be subject to malpractice suits resulting from lack of disclosure.

33. In sum, the science is unmistakable that abortion increases the risk of breast cancer, and the medical duty of
informed consent properly includes disclosure of this fact to women considering having an abortion.

I am fully competent to testify at trial to the foregoing matters. I declare under penalty of perjury that the foregoing
is true and correct.
____________________
Angela Lanfranchi, M.D.
SUBSCRIBED AND SWORN to before me this _8th_ day
of July, 2010.
__________________________________________
Notary Public