I'm William Brangham, and this is "Horizons."

We tend to think of cancer as a disease that mainly affects older people, but an increasing number of diagnoses are happening amongst the young.

What is behind this alarming rise, and can anything be done to prevent it?

Coming up next.

♪ Narrator: Support for "Horizons" has been provided by Steve and Marilyn Kerman and the Gordon and Betty Moore Foundation.

Additional support is provided by Friends of the News Hour.

♪ This program was made possible by contributions to your PBS station from viewers like you.

Thank you.

From the David M. Rubenstein Studio at WETA in Washington, here is William Brangham.

Welcome to "Horizons" from PBS News.

Young people today are getting cancer at higher and higher rates.

While researchers have been studying this for a while, it wasn't until a few years ago that this reality hit home for most of us.

Throw down your weapons, and we can handle this another way.

Brangham: That's when Chadwick Boseman, star of Marvel's "Black Panther" series, died of colon cancer at just 43 years old.

You're free.

You can do whatever you want.

Brangham: And then, earlier this year, another jarring loss.

James Van Der Beek, star of the hit TV series "Dawson's Creek," was killed at age 48 by the same kind of cancer that took Boseman.

Just a short time before he died, Van Der Beek spoke publicly about this growing threat.

Colorectal cancers are on the rise in younger and younger and healthier, healthier people.

Colorectal cancer has now become the leading killer of people under the age of 50.

But it's not just that.

More than 10 different types of cancer are on the rise among 20- to 50-year-olds, including breast cancer, kidney cancer, and uterine cancer.

The sharpest rise has been among people in their 20s.

In a few minutes, we're going to talk with some doctors who treat these types of cancers to understand why these rates are going up and what people can do to protect themselves.

But first, we wanted to hear from someone who has successfully navigated this awful journey.

Laura Behnke is a former TV sports anchor who lives in California's Bay Area.

Six years ago, she and her husband began trying in vitro fertilization.

But her successful pregnancy at age 41 at first covered up the warning signs of cancer.

Behnke: Well, my husband and I had gone through three rounds of IVF that were unsuccessful.

And we had done our fourth and final round and finally had one healthy embryo.

And a few days before the transfer, I notices blood in my stool for the first time.

I told myself just to relax, to not strain, and hopefully everything would go away.

And, you know, it did.

It did.

And we had our transfer a few days later.

Thankfully, it was successful.

When I told my OB, I kind of self-diagnosed myself.

I basically told her, "I'm having some bleeding, "so, I assume it's hemorrhoids."

I did have a hemorrhoid flare up in my third trimester, which was unlike anything I'd ever experienced before.

So when my daughter was six months old, that is the only reason that I was sitting in the office of a colorectal surgeon, was because I wanted the hemorrhoid removed.

I'm 42, I'm active.

I felt, you know, I'd been through a year of IVF and then pregnancy and postpartum.

I truly felt good.

I felt strong.

I had just told my husband days before that appointment, like, "I feel like I finally turned a corner.

"After two plus years, I feel like my body is my own again."

She told me I needed a colonoscopy immediately.

As I was waking up, I could hear my surgeon on the other side of the curtain talking to the nurse saying, "I'll come speak to her when she's awake.

"Make sure her husband is with her."

And that's when I knew.

I ended up being stage 3B rectal cancer, which means the tumor had just broken through the rectal wall and was in some of the nearby lymph nodes, but thankfully had not spread to other organs.

The treatment sent me into immediate menopause as well.

So not only was I dealing with cancer and the repercussions of a cancer diagnosis, but I found myself at 42 suddenly in menopause.

So that changes how you view your health and the things that you need to do.

Denial was a very easy place to be given my age, given my health, given my lifestyle.

It just did not seem like something that could possibly happen to me.

Denial is an easy place for many of us.

And so we're going to try and push back on that to understand clearly what is going on here.

Joining us to help with that is Dr.

Veda Giri.

She's an oncologist who specializes in the genetics of cancer at Yale's Cancer Center, where she's also the director of the Early Onset Cancer Program.

And Dr.

Shanthi Sivendran.

She's an oncologist and hematologist at Penn Medicine, and she's also a senior vice president at the American Cancer Society, where she focuses on patient and caregiver support.

Thank you so much to both of you for being here today.

Dr.

Giri, to you first.

We are seeing this sharp rise in cancer among young people and all types of cancer, colorectal being the big one.

Tell us a little bit about the patients that you see.

What kinds of cancers are they coming in with?

How old are they?

What is it you're seeing at your center?

Yes, thank you so much.

This is such an important topic for discussion.

And it's a real pleasure to be here.

We really are seeing a rise in these early onset cancers at Yale Cancer Center and Smilow Cancer Hospital.

What we are noticing is that about 15% of our total cancer patient population is diagnosed with cancers at age 45 or under.

And so this is a substantial proportion of our patient population.

And we really feel that it is important to address the needs of these patients from a clinical perspective, a research perspective, and a psychosocial support perspective as we increase our education of our patients and our communities about early onset cancers.

We're seeing patients with early onset breast cancer, colorectal cancer, gynecologic cancers, and really across the spectrum of cancers.

So it's been quite striking.

Dr.

Sivendran, as I'm hearing Dr.

Giri talking, and I think about cancer patients in their 40s and under, in their 30s and their 20s, that's a very different population than we're used to, than the stereotype.

But I also imagine caring for those people is very different.

Yeah, it is.

I mean, we often think about cancer being a disease of older people, right?

Over the age of 65.

Brangham: What grandpa gets.

Yeah, what grandpa gets.

And so I think what's hard is shifting the mindset of both health care providers and patients and people every day of thinking that cancer can happen to them, no matter the age.

And what we're seeing is that, even though we still see grandpa getting cancer, that 40% of cancers are actually happening to people under the age of 65.

And we heard it today, right?

Like, people are living their lives.

They feel the best that they've ever felt.

They're not thinking about things like, "Am I eligible for screening?"

"Do I have a risk for cancer?"

"How is my lifestyle sort of affecting my risk of cancer?"

And then when a symptom happens, something maybe like bleeding, there are a thousand other reasons, right?

Why that could be.

Brangham: So easy to explain it away.

Sivendran: So easy to explain it away.

And so I think what's really important, all of us as a community, is to really understand that the shift is happening.

That, as we said, 40% of these cancers are happening under the age of 65.

We really need to reframe how we talk to younger people in their medical appointments, through the media, and really getting to people to understand that they have that same cancer risk.

Brangham: Dr.

Giri, the glaring question here is, if we are seeing this rise amongst younger people getting cancer, what is driving this?

There's obviously something that has changed in our world or in ourselves or some combination of it.

What are the leading theories as to what's going on here?

Yes, this is a key question that we are asked quite often.

And it's likely a multifactorial reason or multiple factors coming together to explore and to understand and better define what is contributing to this rise in early onset cancers.

Some of these are, for example, things like environmental factors or dietary changes.

Where this is coming from is that there has been research that's looked at birth cohort effects.

So when we think about generations that were born, for example, Generation X, and more recently, the rates of early onset cancers have gone up from those generations compared to generations before, such as the baby boomer generation.

And so we think what changed in the lifestyle patterns with Gen X and more recently.

And we think about things like ultra-processed foods, potentially more sedentary lifestyle, rising rates of obesity.

And so we think about what are the ways that those types of environmental or lifestyle factors could have influenced the development of early onset cancers.

Many of these things can, for example, influence biological factors, such as the gut microbiome, which are the healthy microbes in our gut that are really there to help develop an immune defense against cancers and really keep this tumor immune defense in check.

And so if the gut microbiome is altered, that can certainly lead to... there's some lines of evidence and research about how that can be influencing cancer development.

There's also these underpinnings of understanding that there might be some genetic basis.

This may not explain the rise of cancers, but there could be genetic underpinnings as well in addition to these lifestyle factors that could be involved in terms of potentially contributing to this rise in early onset cancers.

So, likely there's not going to be one smoking gun, but a mix of factors.

And then we have to think about this individually on a patient by patient basis.

Given that we do have this circumstance of a myriad of factors, as Dr.

Giri is describing, what do you tell people as far as prevention?

I mean, if someone comes to you and says, "I've read about this, "I see that this is going on, "what can I do in my own life "to potentially protect myself?"

What do you tell people?

Yeah, it's a great question.

I think Dr.

Giri brings up really important points, which is that there are what we call modifiable risk factors that can help with prevention against cancer.

So, some of those modifiable risk factors we brought up are we don't need to smoke, right?

We know that smoking is implicated in many different kinds of cancers.

We know that obesity is linked to many different types of cancers, causes inflammation of the body.

So thinking about how can I get moving?

Active lifestyles.

How can I be intentional about my diet?

So we talked about ultra-processed foods, red meats, alcohols that increase the risk of many different types of cancers, including colorectal cancer, which was mentioned today.

And so being thoughtful about what we actually put in our bodies, we only get one, right?

Body.

And so being really thoughtful about our fruits, our vegetables, our lean meats, our whole grains, and then really making sure that we are aware of screening, right?

So that we know, based on our risk, whether that's our genetic risk, or if we have other medical conditions, when is it the right time to get screened?

Brangham: And Dr.

Giri, how do you counsel patients about that with regards to screening?

If someone comes to you and says, "I'm worried, I may have a family history, I may not," what are the types of screenings that are available that might give people a better insight into their risk factor?

Absolutely, it's such an important question because we commonly get asked, "How would I know "that I should be screening at a younger age?"

And so we spend a lot of time talking with not only our patients and our healthcare providers, but our communities about what is the current guidance about who should be getting screened at a younger age.

So some of that information goes back to knowledge of family cancer history.

That's a really powerful tool to think about what age to start screening, but also to potentially consider genetic testing based on family history of cancers.

So for example, if I were to have a mother that had colon cancer, say that was diagnosed at age 45, I would be recommended just by that family history alone to start my colonoscopies starting at age 35, 10 years prior to having a first degree relative diagnosed with colon cancer.

There can be some similar guidance, for example, for breast cancer screening based on usage of risk models, which can factor in family history and other types of risk factors for a woman and calculate a lifetime risk for developing breast cancer.

And if the lifetime risk is over 20% and there's a family history, there can also be recommendations to start breast cancer screening at a younger age, not only with mammograms, but also adding in modalities like breast MRI.

So it really can change the strategy and the age of beginning cancer screening for some of these common cancers to the ones that we've been talking about, colorectal cancer and breast cancer.

But also this information can be brought to a person's doctor and really help to inform whether a person meets guidelines for genetic testing.

If genetic testing is pursued and there's a genetic mutation identified, for example, in a gene such as BRCA, which many people are aware of, linked with hereditary breast cancer and ovarian cancer, prostate cancer for males, for example, breast cancer screening could be recommended to start in a person's 20s.

Similarly for a cancer syndrome like Lynch syndrome, associated with hereditary colorectal cancer and multiple other cancers associated with Lynch syndrome, colonoscopies would be recommended to start in a person's 20s.

So these are some of the ways that we really want to bring education about soliciting family history information and also strategies to do that because that can be a complex conversation, can be difficult to initiate.

And so we're really giving communication strategies for our communities and our patients to initiate those conversations and then empower our communities to bring that information to your doctors.

Dr.

Sivendran, one of my colleagues asked me about this, she said she had done genetic screening and she got the all clear.

She didn't have any markers there.

She thought then, "Does that mean I'm okay, "that I don't really have to worry about this?"

Like how much faith should people put in a possible successful test, quote unquote successful?

Yeah, that's a great question.

So genetic testing is really important.

I think Dr.

Giri really nicely described in these populations or these families that have increased risk, right?

So your mother had colorectal cancer, your sibling had a cancer, but at the end of the day, there are other risk factors other than hereditary risk factors that can cause cancer.

So it's not an all clear, right?

So we know that, for example, in breast cancer, one in eight women are going to get breast cancer regardless of family history, right?

And so it still goes back to... Genetics is one part of it, and especially when we're thinking about young people with cancer, but then there are all those other risk factors that we talked about, nearly half of which are potential causes for cancer, right?

So those lifestyle factors.

And so understanding that cancer can still happen to you and that getting that sort of clean genetic test doesn't mean that you can't get cancer.

Brangham: Got it.

Dr.

Giri, given that colorectal cancer is such a big part of early onset cancers, what are the symptoms that people ought to be looking at?

We heard Laura Behnke before saying, "I was pregnant, I thought it was a hemorrhoid," and she kind of brushed it off.

What are the other things that people ought to be looking out for?

Yes, absolutely.

And this brings this point forward about symptoms that a person can experience and to take seriously and bring them to your doctor.

So for example, some symptoms that could be related to colorectal cancer include things like blood in the stool, abdominal pain that seems to be persistent and unresolved by trying conservative measures like changes in diet or increasing fiber, long-lasting constipation that doesn't seem to be resolving or any change in bowel habits that doesn't seem to be improving over time.

Some other conditions can be things like anemia that could be picked up, let's say from blood work, and that could be related to very slow blood loss in the bowel, and that could be related to a polyp or a tumor, but needs to be evaluated when there is newfound anemia.

And then some other symptoms such as prolonged unexplained fatigue, particularly if it's linked with any of these symptoms, weight loss that's unexplained, symptoms like this really that need to be taken into account and brought to your doctor, particularly if they are new onset for some of them, but also that don't resolve over time.

And that's a big point that we bring up to our patients and our communities, is that it can... that we don't want anyone to feel that this is not taken seriously.

Continue to seek out medical advice from trusted providers until you are able to achieve some solutions, some ways forward with these symptoms and evaluation.

Right, Dr.

Sivendran, when I was talking to Laura Behnke, she kept saying, "Please tell people to look at their poop."

And part of what she was pushing back on is just the stigma around this.

I mean, when you are young, as you were saying before, it's so easy to brush this off, to think "I have a stomach ache, "it's probably going to be nothing."

But there is a sort of a wall of denial and stigma around some of this that we have to push through to get younger people to pay attention to this.

Yeah, I agree with you.

I mean, it is so easy to blame it on something else.

And this is a generation, as we think about Gen X and millennials that probably have kids of their own, are potentially taking care of older adults, older parents, are working.

They feel tired.

I feel tired, right?

We feel tired.

And so it's really easy to blame it on hemorrhoids or blame it on something else.

And I 100% agree, look at your poop, right?

If you feel a lump in your breast, don't ignore that, right?

If something doesn't seem right, you know your body the best, it's really important to bring that up.

And it kind of goes back to, it's really important to regularly see your doctor, to have the kind of relationship where you feel like you can bring that up.

And then to also, just going back to that screening part again, to understand when is the right time for you to screen.

So when we think about colorectal cancer, it always strikes me.

So the average risk person, so we've been talking about kind of special populations, but the average risk person should start their screening at the age of 45.

And that's a change, it used to be 50.

And I think that that's still, that sort of idea that it's 50 still exists out there.

You're 50, you get gray hair, then you get a colonoscopy.

Is the gray hair coming?

Yeah.

So, but it's 45 now, right?

And we, um... And people seem to be surprised about that.

And so we need to continue to push that message, that cancer is happening in younger people.

Get your mammogram, get your cervical cancer screening, think about HPV vaccination, get your colon cancer screening, whether that's a stool-based test or that's a colonoscopy, and pay attention to your body.

Brangham: Dr.

Giri, we have about a minute left.

Let's say someone does test positive for cancer, that lingering suspicion in their mind gets tested, they have it.

Have we gotten better at treating these cancers amongst young people?

Are they different than older people?

Like how worried should people be if they get one of these diagnoses?

Yeah, you know, the key is when these cancers are caught early, for example, colorectal cancer or breast cancer, the cure rates are incredibly high, particularly for early stage cancers.

They are curable.

And so the point is, if we can catch these at a curable point, the outcomes are amazing.

The challenge that can happen is that, because it's a younger population, and to what Dr.

Sivendran talked about, is that they may be not aware that somebody should be getting screened at a younger age, or even getting that colonoscopy at a population level guideline at age 45, the issue becomes that potentially the cancer is caught at a later stage.

And when the cancer is caught at a later stage, it becomes tougher to treat, and there's a higher chance that it could spread.

So as much as we can devote time and energy to currently thinking about public awareness, about who should be getting screened at a younger age, that will be incredibly important to be able to catch these cancers at a curable point.

Great, such an important conversation.

I want to thank you so much, Dr.

Veda Giri, at the Early Onset Cancer Center at Yale, and Dr.

Shanthi Sivendran from Penn Medicine.

Thank you both so much for being here.

Before we leave, we heard earlier from actor James Van Der Beek, who, as he was dying, talked publicly about his cancer, trying to warn his generation of this threat.

And it reminded us of another young actor who did the same thing many years ago, but in a very different environment.

♪ I'm the good champ, lollipop ♪ Brangham: Shirley Temple, later known as Shirley Temple Black, started her acting career at the age of three.

With her iconic ringlet curls, she sang and tapped and charmed her way into Hollywood history.

Pardon me, did I hear you say spinach?

Brangham: After showbiz, Black pivoted to politics, inspired by actor-turned-governor Ronald Reagan.

She ran for Congress, did a stint at the UN, and served as U.S.

ambassador to two different nations.

But in 1972, after performing a breast self-examination, and this was well before that became common practice, she discovered a lump in her left breast.

This was a very different era, both in how the medical establishment treated women, but also in how we talked about breast cancer.

As recounted in Siddhartha Mukherjee's book, in the 1950s, the New York Times refused to print an ad for a breast cancer support group because it had the words "breast" and "cancer" in it.

An editor reportedly suggested it be referred to as "diseases of the chest wall."

Even in the 1970s, amid feminism's second wave, it wasn't uncommon for a woman like Black to be told she was getting a simple biopsy only to wake up and find the surgeon had instead given her a radical mastectomy, removing her entire breast and muscles and lymph nodes without her consent.

Shirley Temple Black was having none of that, famously saying, "The doctor can make the incision, "but I'll make the decision."

Days after her lumpectomy, at the age of 44, Black called reporters to a press conference in her hospital room.

Sitting in her bed, Black broke the taboo, talking openly about her diagnosis, her treatment, and urged other women to pay attention and get medical care if they had symptoms.

She admitted she had to do some soul-searching before talking publicly about what was then still such a fraught topic.

She said, quote, "There was no reason "anyone else should know, "but being open about it just may help other people."

That is it for this episode of "Horizons."

You can find us on YouTube and wherever you get your podcasts.

See you next week.

Narrator: Support for "Horizons" has been provided by Steve and Marilyn Kerman and the Gordon and Betty Moore Foundation.

Additional support is provided by Friends of the News Hour.

♪ This program was made possible by contributions to your PBS station from viewers like you.

Thank you.

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