Rachel Abrams: From the New York Times, I'm Rachel Abrams and this is the Daily. You go into the chemotherapy room and I remember sitting in a circle with like 60 to 80 year olds and I was there as a 25-year-old. For years now, cancer's been seen as a disease that people mostly get when they're older. But apparently that's changing.

Young Cancer Patients: When I was diagnosed, I was 28. —— Yeah, I was 32. —— When I was 37.

Rachel Abrams: More young people are getting cancer than they ever have before. I wasn't able to be the kind of husband that I wanted to be, the kind of father that I wanted to be. Dating was like a new challenge for sure. I mean, I had to file for bankruptcy. I ended up having to do chemo while I was pregnant. At a time when you really feel like you have so much in control in your life, you're just like you completely lose control of everything. And so today, health reporter Nina Agarwal explains what scientists are starting to learn about what's driving this rise and what it means for a generation of young cancer survivors. It's Monday, August 10th. Nina Agarwal, welcome to the Daily.

Nina Agarwal: Hi, thanks for having me.

Rachel Abrams: Nina, your beat is chronic disease and you recently published a series on the growing rates of cancer among young people and we're going to talk about what you found in your reporting. But before we do that, I just want to define what we're talking about here. Exactly, like who and what are we referring to when we talk about growing rates of cancer among young people?

Nina Agarwal: So early onset cancer generally means cancer in adults under 50. So not super young, but young for cancer. Cancer has historically been a disease of aging, but researchers have started to document in a pretty systematic way that cancer diagnoses are increasing in younger adults. And this is something, you know, we've been hearing about kind of in trickles, but you know, in the last couple of years, there have been some comprehensive papers showing that this isn't just an isolated phenomenon. This is a pattern happening across cancers over decades. And it's been happening every year since 1990.

Rachel Abrams: And you know the rates vary from cancer to cancer. So for some it's annual increases of 1 to 2% a year and for others and in certain age groups the increase could be as much as like 6% per year.

Nina Agarwal: Yes. And for younger people it's very unexpected. I mean, I think a cancer diagnosis is unexpected and undesired at any time, but it comes out of left field for so many of these younger adults. And it totally upends their lives in a way that is different from the way it upends the lives of older people because this is happening at a really vital moment in their life when they're still kind of putting down the roots and becoming the adults that they're going to be. And I spent a good part of the last year trying to understand exactly what the experience is like. Not only what's happening and why, but what that means for the people who are getting diagnosed. We had hundreds of people write into us to share their experience of early onset cancer. And I spoke to dozens over months to just get a picture of all of the ways that getting a cancer diagnosis in that time of life, your 20s, your 30s, your 40s, how it changes a trajectory of everything that comes after.

Rachel Abrams: I wonder out of all the people that you spoke with who are dealing with these issues at such a young age, is there somebody who stands out to you specifically that maybe illustrates some of what you're describing?

Nina Agarwal: Yeah, I mean there were so many whose stories were really moving and there were some common themes among many of the stories in terms of disruptions to their finances, disruptions to their family planning, disruptions to their careers, disruptions to their relationships. But one young woman I spoke with, Whitney Johnson, her experience and her story really stuck with me.

Rachel Abrams: Tell me a little bit about yourself, what your life was like before you got cancer.

Whitney Johnson: Yeah, so I, I'm Whitney Johnson and...

Nina Agarwal: She was 36 and living in Portland, Oregon. And she was just, you know, at a stage where a lot of people are in their 30s.

Whitney Johnson: Trying to focus on my career, trying to focus on like redoing my house, trying to figure out if my boyfriend and I should stay together.

Nina Agarwal: Like she was in a relationship that was relatively new and trying to figure out where she was with her boyfriend and kind of where it was going. And one night about two and a half years ago, they were making out.

Whitney Johnson: We started kissing and kind of stopped at one point and he's like, "I don't want to be weird, but I think I feel something in your boob."

Nina Agarwal: And that's how she found the lump.

Rachel Abrams: Oh my god, that must have been so jarring to have him say that in the middle of this like very intimate moment. What was your diagnosis?

Whitney Johnson: Triple negative breast cancer, stage 2 B. And so that means that this, the tumor was I want to say around 2 to 3 cm. And also...

Nina Agarwal: She was diagnosed with triple negative breast cancer which was a pretty serious and aggressive type. And when she got the diagnosis she not only had the tumor in her breast but also some signs of cancer in one of her lymph nodes. At that time she had just gotten back from a family trip and vacation and she ended up not going back to work because she needed to go into treatment immediately.

Rachel Abrams: What did that treatment look like?

Nina Agarwal: So, she was going to need chemotherapy and then also at least one surgery. But before she could even start, doctors asked her if she wanted to freeze her eggs.

Whitney Johnson: And so, first things first, like my brain wasn't even on the cancer. My brain was like all the things that go into freezing your eggs and what that meant for like my future and what that meant. Like my boyfriend and I at that time like we weren't talking about having kids...

Nina Agarwal: You know she and her boyfriend had been dating a couple of years at that point and all of a sudden she had to think about you know is this something that I'm going to want that we're going to want and she's over the course of a few weeks having to inject herself with hormones and he trying to be supportive but they were not in a place in their relationship where they were both trying to do this of their own volition.

Rachel Abrams: That feels like so much pressure at the sort of newer end of a relationship when, as you said, they're not even talking about having kids. Kids aren't even on the radar. And just to say, egg freezing is a really intense process. It's intense emotionally and it's also intense physically.

Nina Agarwal: Yeah, absolutely. And the whole experience of having cancer and having then to go through treatment was upending her notions of what it was to be a woman in this relationship. One of the reasons I was really moved and struck by Whitney's story was she talked very articulately about being a woman in this phase of life.

Whitney Johnson: As women, like we spend our whole lives trying to figure out like how can I show up in a way that feels right for me and I can feel confident and like I can love who I am.

Nina Agarwal: Like she talked about how it had taken a long time, you know, to grow into herself and she loved her hair. That was one of her defining features. It was like long and blonde and beautiful and she had come to like her breasts. That hadn't always been the case, but at this point, she was really comfortable with herself and then here she is and she's going to get chemo and it's going to make her lose all her hair and she's going to have a bilateral mastectomy and she's going to lose her boobs.

Whitney Johnson: And then even if I do get through this, you're telling me that I want to try to date someone when I don't have hair and don't have boobs and don't have estrogen.

Nina Agarwal: And it just totally shook her notions of being like a sexy, confident woman when she was also kind of early in this relationship where that's how she wanted to show up in that relationship. Like it's just like this perfect storm of stealing your femininity when you're supposed to be feeling kind of like at your height of womanhood in some ways.

Rachel Abrams: I'm curious how her boyfriend navigated all of this because this is just so much pressure obviously to put on a relationship that is relatively new where you have two people who are still trying to figure out what they want. They're still trying to get to know each other. So to have this giant tragedy dropped in the middle of that, I can imagine why that is a different dynamic than when this happens to a couple that is established for many many years and just has a different familiarity with each other.

Nina Agarwal: Yeah. I mean, one of the things that she said was like we had no practice, you know, like we didn't have peers and friends who were in this situation and his friends didn't really know how to support him and all of a sudden he's thrust into this role of being caretaker. He was like 29, I think, when she was diagnosed.

Whitney Johnson: And then I remember there was this one weekend that he was out with his friends. And that was the weekend I realized I might die.

Nina Agarwal: She told me one story about how...

Young Cancer Patients: ...some family coming in.

Nina Agarwal: She was at a really low point in her treatment when she was really sick and she sort of had this realization like, "Oh, I might die."

Whitney Johnson: Cuz like, you know, you always kind of know, but you don't ask directly. And then I'm like, "Oh, this might be 5050 that I'm here in five years." And I think it was the first time that I had let myself think about it. Like, "This might be it." I'm literally like, "Right."

Nina Agarwal: She was kind of just spiraling. And her boyfriend was out at a cabin that weekend with friends.

Whitney Johnson: I remember like I was trying to process this and then like, you know, texting, but he's like at a cabin partying with his friends, but I'm like, "I need to I need to talk." And I'm like, I might die. Like, talk to me about that. But like, he couldn't. He's like, I'm here with my friends. I need a break. I don't have it in me. And that was terrible. Cuz they're like, I'm at my darkest and I want my partner to to see me through this time and and he just couldn't.

Nina Agarwal: And she needed him in a way that their relationship kind of hadn't experienced before and maybe wasn't ready for.

Rachel Abrams: God, that sounds so tough for both of them.

Nina Agarwal: Yeah, definitely for both of them. I mean, she told me I don't think it's easy to get cancer at any age, but that she was jealous of people who got it when they're older...

Whitney Johnson: ...because maybe where they are in their relationship can withstand it a little better. Everything was one-sided for a long time and we weren't there and it didn't go well.

Rachel Abrams: Did they consider breaking up, Nina?

Nina Agarwal: I asked her...

Whitney Johnson: ...and she said, you know, at that time you're like...

Nina Agarwal: ...she was really just like in survival mode, like trying to deal with cancer and it felt like thinking about her relationship ending was just like too much to think about taking on...

Whitney Johnson: ...that would make my head explode.

Nina Agarwal: ...when that was the sort of support and she was just trying to get through the day-to-day of fighting the cancer.

Rachel Abrams: What about her friends? Did she have friends that were part of a support system, not just her boyfriend?

Nina Agarwal: She did, but her family didn't live in Oregon. And her friends were in a similar stage of life as she was before the cancer. Some of them were getting married and having babies. And you know, it was hard to be around people whose lives were moving forward. And this is something many people told me. It was really hard to watch their friends and their peers and their colleagues move forward in their lives, and you're just sort of stuck or maybe even moving backward.

Whitney Johnson: I remember the walk I went with on a friend with...

Nina Agarwal: ...she told me about how she had gone for a walk with a friend and her friend told her that she had just gotten pregnant and she could see that the friend was having a hard time sharing this with her.

Whitney Johnson: And it was one of those moments that like I feel so bad cuz she was she was sad to tell me because she knew it would be hard. But, you know, it was sad to see her friend moving forward in this way. And she was having to put this pause on everything.

Nina Agarwal: And so, you know, your your friends are who you who you spend your time with, you kind of compare yourself against. And so, they're like able to be taking these next steps in their lives. And as I'm like taking a step back into nothingness and the unknown.

Rachel Abrams: So how did Whitney's treatment go?

Nina Agarwal: So it was grueling. She completed her chemotherapy, you know, lost all her hair. She had a double mastectomy. For now, the cancer's gone, but that doesn't necessarily mean it's gone forever. And a fear of recurrence is real. And I think Whitney is still dealing with how unexpected this cancer diagnosis was at this time in her life and kind of grappling with why it happened at such a young age, you know, and that's something I've also been really interested in. I've been reporting on what scientists are learning about what's driving these rates of early onset cancer and scientists are starting to find some answers. We'll be right back.

Rachel Abrams: Nina, I want to better understand what we understand about what's driving this increase in cancers. So maybe just to start can you lay out when we say that cancer diagnoses in young people are rising which cancer specifically are we talking about?

Nina Agarwal: So there are a number of cancers that appear to be increasing in the earlier age group. One paper from last year showed that 14 different types of cancer were increasing in the early onset age group and that includes some common ones like breast and colorectal cancer as well as uterine cancer, testicular cancer, pancreatic cancer and several others.

Rachel Abrams: And just to ask a question that I'm sure is on a lot of people's minds listening to this. These increases cannot just be attributed to increased screening.

Nina Agarwal: No, I mean depending on the cancer, some might be attributable to increased screening. Like thyroid cancer is one that comes to mind, but for a number of reasons, a lot of experts I talked to said they don't think it's all screening or incidental diagnosis. For one, most of these cancers, when we're talking about people under 40 or under 50, these are not populations that are regularly screened. For another, you know, some of the cancers certainly are showing not just increased incidence, which could be they're just finding them, but also increased mortality. And that's particularly true for colon cancer and uterine cancer. And something else that we're seeing is that people born in more recent generations are at greater risk of having cancer, which suggests that there might be environmental or lifestyle exposures, things that have collectively happened to us as a society over time that could be affecting our cancer risk.

Rachel Abrams: Well, let's talk about that a little bit more because I'd like to understand what we do know about what is driving these upticks. So talk to us a little bit about those environmental factors and how they're interacting with our biology in a way that may be contributing to these trends.

Nina Agarwal: Sure. So I will say because the phenomenon has really pretty recently been identified, researchers don't know for sure what's driving it, but they have some hypotheses and you know they're building off of what we know about what causes cancer generally.

Rachel Abrams: Mhm.

Nina Agarwal: So there's a fair amount of evidence linking obesity, alcohol use, and poor diet, particularly red meat and ultraprocessed foods to some early onset cancers. And then there are other questions that researchers have about potential other exposures like plastics or forever chemicals. But it's really hard to tell at this stage because it's very hard to link things in our environment directly to a cancer outcome. One of the most classic examples of this is smoking. It took researchers a long time to link smoking to lung cancer, but eventually there was such a large body of evidence that they could make that causal link.

Rachel Abrams: Right. Cancer is notoriously difficult to prove causal links to, whether it's, you know, where you live or what you're eating.

Nina Agarwal: Yeah. But some of the more emerging evidence is showing some surprising things as well that suggests the drivers of earlier onset cancer are different from some of the things we've historically thought about.

Rachel Abrams: Tell us about some of those surprising findings.

Nina Agarwal: One of the things that researchers are really trying to look into is how our environment or things in our lifestyle might be affecting our genes. So, it's unlikely that as a population, our genome has changed dramatically in the last 50 years to make us as a population more susceptible to cancer.

Rachel Abrams: Right?

Nina Agarwal: So one area that researchers are looking into is how things in our environment might be affecting our genes once we're already alive to maybe make us more predisposed to cancer. So one example is in colorectal cancer. You know I spoke to a researcher who's been doing some work analyzing the pattern of mutations in patients who had early onset colorectal cancer.

Rachel Abrams: ...mutations in their genome.

Nina Agarwal: ...right exactly changes to their genes and he's able to see a sign of an E.coli infection with a particular kind of E.coli in the pattern of mutations in the patients who had early onset cancer and he also was able to say that the E.coli infection had likely happened pretty early in life like within the first few years...

Rachel Abrams: ...meaning what that these patients showed signs that they had gotten infected with E.coli when they were that young and so he's now making some sort of connection between E.coli and colorectal cancer.

Nina Agarwal: I mean, it's a that's a big leap because you can't infer causality, but because you're getting this hit to your gene within the first few years of life and then that mutation is going to be compounded by other mutations or by factors maybe like inflammation, you're sort of getting put on the fast track to cancer and that might be one explanation for earlier onset cancer. But that being said, we don't necessarily know and I asked, you know, have we been as a society having more ecoli infections over time?

Rachel Abrams: That would be my question. Are we getting exposed to E. coli more and more?

Nina Agarwal: So I think some researchers are trying to look at samples that were biobanked decades ago and see if they can track E.coli in the samples over time. I don't think that research has been done yet. But the researcher I spoke to did tell me something interesting which was that there are some suggestions that the particular type of ecoli that may be creating this set of mutations has come with industrialization. So it's kind of like a handwavy way to say maybe it's something in the food that we now eat or the antibiotics we use. They don't really know but they are seeing this link.

Rachel Abrams: Even if we don't fully understand it, there's some connective tissue there is what you're saying.

Nina Agarwal: Yes.

Rachel Abrams: What about some of the other cancers you mentioned, Nina? Do we know more about what is driving those? What's contributing to the uptick there?

Nina Agarwal: Yeah, so researchers have also done a fair amount of work on breast cancer and are also looking at this interplay between our environment and lifestyle and how that might be increasing our predisposition to cancer. And so one of the things that they found is the role that the menstrual cycle and how many menstrual cycles we have might be playing here because some research has shown that girls now get their periods a little bit earlier than they did in the 1950s. And women are having their first pregnancy later than they did in the 1950s.

Rachel Abrams: M.

Nina Agarwal: And the menstrual cycle is this time where your cells are expanding and proliferating and your hormone levels rise and fall. And as the cells are dividing, they're more susceptible to mutations. And so during that time, if you're exposed to something that's harmful, like alcohol or something that can increase your risk of a DNA mutation, the effects of that can accumulate the longer you have this time period where you're kind of going through these monthly cycles of cell proliferation, expansion, and then dying off. And pregnancy kind of stops that prolonged period of increased risk because there's something protective about a first pregnancy particularly at a younger age and breastfeeding. After that in the long run your breast cells they spend more time doing DNA repair and they've sort of changed in a way that is protective against breast cancer. So basically this combination of women getting their periods earlier in life and also having children later in life is expanding that in between period where they are most vulnerable to breast cancer. Is that right?

Rachel Abrams: Yeah. Or most vulnerable to the changes that can lead to breast cancer. I'm also hearing by implication, I think, something that feels a little shocking, which is that women who don't have kids, whether because they can't or they don't want to or whatever the reason, they are more vulnerable to breast cancer. Is that the right inference to be drawing from this?

Nina Agarwal: Yeah, it's totally crazy and unfair. And I know that that can just sound like we're blaming women for their own cancers, which is not at all what researchers say. You know, they're saying these are societal shifts and it's totally reasonable in this day and age that women want to have a career or not have a baby at age 20. But at the population level, when they look at kind of what are the factors that are linked, they do find that pregnancy, particularly a first pregnancy at a younger age between kind of the ages of 20 to 25 and breastfeeding are protective against breast cancer in the long run.

Rachel Abrams: ...what you have laid out. Some of these findings are really genuinely surprising. I think a lot of people know by now that toxins like alcohol and smoking may contribute, but the thing you said about pregnancy, the idea that there's bacteria hanging out in your gut from when you're a kid that could cause cancer or could lead to cancer some way, I don't think that those are factors that are really on people's minds.

Nina Agarwal: Yeah. And I think people want to know if there's a reason for their cancer, but I talked to so many people who were diagnosed with early onset cancer and it's so out of their control. Like there are lots of people who ate their vegetables and had a good diet and exercised and had babies pretty young and still got breast cancer. You know, I've talked to patients in that situation. It feels like it's worth saying that even if we start understanding more and more about why younger people are getting cancer, getting that kind of clarity is not necessarily going to be total comfort for people who are sick, they're not going to know exactly for sure what caused their cancer. That's just not how science works. And that's probably going to just be very unsatisfying, even if we are more educated.

Rachel Abrams: Yeah. I think for most people, they'll never know exactly why they got cancer. Nina, I want to go back to Whitney for a second because you said her initial cancer diagnosis was two years ago. How is she doing now?

Nina Agarwal: The last time I spoke with her, she was doing pretty well. She had gone back to work and she and her boyfriend were moving in together, but she was still kind of dealing with the emotional and physical scars of this experience that I think that's going to take a lot longer to do. For example, after her double mastectomy, she did eventually have a reconstruction.

Whitney Johnson: ...like having this reconstruction like it's been one of the hardest like lasting parts.

Nina Agarwal: She's had people say to her like, "Oh, you know, you got your boobs done." And she's like...

Whitney Johnson: ...totally just incensed by that comment cuz she's like...

Whitney Johnson: "Do you understand that a mastectomy reconstru...?"

Nina Agarwal: This is not a walk in the park. This is not something I wanted. And even though her reconstruction was successful by standards of the surgery...

Whitney Johnson: I hate them. I hate them a lot.

Nina Agarwal: She kind of hates her new breasts and they don't feel like hers and it's a hard line for her to tow, much less her boyfriend...

Whitney Johnson: ...because like you're not supposed to like these better than the old ones.

Nina Agarwal: You're supposed to like the old ones better, but yet you're supposed to support the new ones and love the new ones and think they're beautiful. So she, you know, on her good days can be sort of accepting of what she looks like and who she is now. And on her bad days, there's a mix of trying to move forward and also grieving what was or what could have been. And she's trying to figure out what's next for her in her life. She's wondering whether she wants to have children and if so, you know, maybe soon. She's of course worried about the cancer coming back. But really the thing that sticks with me the most about her was just how lonely the experience was and also how unprepared she felt for it because it's not something that typically happens in this stage of life. And I think that was true for most of the people I talked to. One of the things they wanted people to understand was this isn't just like a temporary derailment and then you go back to your normal life. And because this phenomenon is relatively new in the sense that researchers are able to see bigger picture trends and document it and talk about it, people who have been diagnosed at a younger age don't really feel like the public or even their friends and family get what they're going through.

Whitney Johnson: People want to help you, but also they might be really bad at it. you're so totally alone and really are in charge of yourself.

Nina Agarwal: And I think a lot of the people I spoke to really wanted to speak to me and tell their story because they wanted other people like them to feel seen.

Rachel Abrams: Nina Agarwal, thank you so much.

Nina Agarwal: Thanks for having me.

Rachel Abrams: We'll be right back. Here's what else you need to know today. On Sunday, the Israeli government rejected President Trump's plan for rebuilding Gaza. The 15-point proposal included the gradual disarming of Hamas and the withdrawal of the Israeli army from more than half of the area that it still controls. But Prime Minister Benjamin Netanyahu dismissed the phased approach, saying that Israel won't leave Gaza until Hamas is completely disarmed. Today's episode was produced by Alex Stern and Claire Tennis Getter. It was edited by MJ Davis Lin and contains music by Dan Powell, Marian Lozano, Sophia Lanman, and Chelsea Daniel. Our theme music is by Wonderly. And this episode was engineered by Alyssa Moxley. That's it for the Daily. I'm Rachel Abrams. See you tomorrow.