Ann Young wasn’t sure whether she would ever be a mother. She was 32 years old, married and completing a fellowship in paediatric emergency medicine at Boston Children’s Hospital – the final step in her 15 years of medical training. She was devoted to her work, and looking forward to becoming a doctor. In her free time, she loved rock climbing; she enjoyed the focus she felt while scaling rock faces. Young valued her autonomy, and wasn’t sure she was ready to give it up to have a child. “I don’t necessarily want control of everything in the world around me; I just want control of myself,” she told me.
But once Young, a devout Christian, started praying, she began questioning her resistance to motherhood. She came to believe that becoming a parent could, in part, help her deepen her relationship with God by helping her learn about service and sacrifice. She and her husband Alex started trying to conceive and, in August 2022, she became pregnant.
Up to that point, Young had believed that as long as she worked hard enough, she could achieve almost anything she wanted: “I want to be a doctor. All right. These are the 1,000 steps you have to do. And I will do all of them.” But that idea began to dissolve when she had a miscarriage at 11 weeks. Some things were out of her control after all. Then, in January 2023, she found a lump in her left breast.
Like many young women in her position, she initially didn’t think much of it. Young was slim, muscular and healthy; she didn’t drink or smoke, and she had no family history of cancer. But in April, Alex noticed the lump and told her to feel it again. This time, the lymph nodes near her armpit were rock hard. “As a physician, I already knew what it was as soon as I felt it,” she said. Two days later, Young had a biopsy. The results confirmed that she had breast cancer.
Breast cancer mainly affects middle-aged and older women – the median age of someone diagnosed with the disease is 62. But its prevalence, like that of many other cancers, is increasing in young people. Globally, the incidence of early-onset cancers – typically defined as ones that appear in people younger than 50 – rose by 79% between 1990 and 2019, with breast cancer accounting for the largest number of cases. Between 2012 and 2021, the diagnosis of breast cancer in women under 50 increased by almost 1.5% each year. Although breast-cancer survival rates are high – in America, 86% of women are alive ten years later, compared with 62% of women for all cancers generally – outcomes tend to be worse for young women, whose cancers are typically more aggressive.
A diagnosis of breast cancer is devastating at any age, but in young people it can precipitate a unique set of crises. Treatment can induce early menopause and ravage fertility. Mastectomies can trigger body dysmorphia, which can be particularly harmful for young women, who often already suffer from insecurity about their appearance (especially if they are dating or looking for a partner). Many young patients are mothers, who somehow have to balance the needs of their children with the demands of their own care. And survivors have to live for decades with the side effects of treatment – which can include pain from nerve damage, extreme swelling and reduced lung capacity – and the fear of recurrence.
The uptick in breast-cancer cases among young women has also had unexpected social consequences. Young patients’ partners have become their carers decades sooner than they might have imagined; parents are taking in their adult children; and a new infrastructure of medical and mental-health care has developed to support this growing patient group.
Ann Young was diagnosed with an early stage of an aggressive breast cancer known as Her2+ – which occurs when breast-cancer cells have high levels of a protein that makes them divide and grow more rapidly. The cancer was also hormone receptor positive, meaning that oestrogen and progesterone had caused additional cell growth. The cancer was treatable but would require a programme of surgery, chemotherapy and radiotherapy over the course of a year. Young asked herself: “Will everything I worked for just disappear?”
One of her most urgent questions was whether she could still get pregnant after treatment. A colleague’s wife recommended that she contact Ann Partridge, an oncologist at Boston’s Dana-Farber Cancer Institute who studies young women with breast cancer, particularly their fertility. On Partridge’s advice, Young took the drug Lupron during chemo. Lupron, which was originally developed for prostate cancer, can suppress the ovaries’ production of oestrogen, helping to stop the growth of cancer cells and preserve fertility (Young also decided to freeze her eggs). But without oestrogen, she was thrust into early menopause. In most women, levels of the hormone gradually drop over decades; to lose it all at once, Young said, was “horrific”. It became hard to sleep at night because of the hot flushes. Her vaginal tissue became dry and thin, and she lost her sex drive.
After chemotherapy, Young also lost her hair; after surgery, her left breast. (A surgeon recommended she keep her right one in case she wanted to breastfeed someday, though any remaining breast tissue carried the risk of becoming malignant.) Her whole body hurt from treatment. She could no longer climb because her hands were so dry; if she worked out at all, it took three or four days to recover. She could sleep for 15 hours at a time, and didn’t even get out of bed for her own birthday party. “I was 33 and felt like a 60-year-old,” she told me. It was particularly excruciating when she developed an abscess on her labia and could feel every painful sensation when she had it removed (the local anaesthesia didn’t work).
In order to focus on treatment, Young delayed plans to move to Honolulu, where she’d been due to start a job in the late summer of 2023. The abrupt change of plans was destabilising. She had already felt in limbo, about to quit one position and begin another; now she was anxious that her new employer might perceive her as too sick to ever do her job well. She also worried about whether she would retain her knowledge and skills. “It was my whole identity,” Young said of being a doctor. “I hadn’t seen the fragility of it, that it really can be taken away from you in an instant.”
All of this took a toll on Young’s mental health. That summer, she would often get together with a friend whose father was dying, to cry in public – get-togethers that they called their “cave of sadness”. On a blog where she shared updates with her friends and family, Young wrote that, “It’s hard not to feel as if a vital part of me has gone into hibernation, a quiet and distant memory from my daily personhood.”
Even though she knew her independence had been curtailed by her treatment, she still sometimes had trouble asking for help. When Alex couldn’t make one of her appointments, he would arrange for friends to join her; at other times, Young would send her friends the details without explicitly asking them to come. (They always did.) She needed people for practical reasons – to give her water, hot packs and massages during infusions. But more importantly, she didn’t want to be by herself; it was lonely being the youngest breast-cancer patient at the clinic. “You show up at the cancer centre, and everyone looks like your grandparents,” Young said. She felt different from the other women, who no longer had to think about their fertility or careers. Sometimes, they would notice her youth and tell her, “Oh, you must have a family history.” “But it’s just me,” she said. “I’m the family history now.”
Our risk for cancer is known to increase as we age. Unhealthy habits compound over time; the effects of carcinogens build up in the body; ageing tissues and cells can facilitate cancer cell growth. So why are cancers on the rise in young people?
Shuji Ogino, a molecular epidemiologist at Brigham and Women’s Hospital in Boston and a professor at Harvard University, believes that the uptick is caused by changes to what researchers call our exposome – the environmental factors that influence human health. People are, on the whole, more obese and more sedentary than their ancestors; they are also more likely to drink alcohol and smoke too much, to eat ultra-processed foods, and to get too little sleep. All these trends are linked to an increased risk of cancer. From the time people are very young they are also more exposed than previous generations were to pollutants, carcinogens and microplastics, which can cause genetic mutations and even accelerate the growth of tumours.
In a study published in Nature in 2022, Ogino and his colleagues observed that the global rise in early-onset-cancer cases kicked off in the 1990s, with patients in their 30s and 40s. That would seem to indicate that human lifestyles profoundly shifted during the 1950s and 1960s, just as those people were born. It’s not difficult for doctors or even casual students of history to guess what changed: in the mid-century, many people gained greater access to cars and pre-packaged foods, and increasing numbers gravitated towards office jobs that kept them desk-bound all day. “We don’t know the whole picture yet,” Ogino cautioned. But one thing seems clear: our bodies are growing up in different environments from those of previous generations.
Scientists trying to understand the rise in early-onset breast cancer in particular believe another social shift may be relevant: since the 1950s more women have opted to have babies later in life, or not at all. Studies have shown that while pregnancy increases the short-term incidence of breast cancer, in the longer term it lowers the risk of disease. That’s because pregnancies reduce the number of menstrual cycles a woman undergoes – meaning that she is exposed to less oestrogen and other hormones over her lifetime, explained Adetunji Toriola, a professor of surgery at Washington University in St Louis. (The same is true of breastfeeding.)
This is important because oestrogen activates cell division in breast tissue, which increases the risk of cancer-causing mutations. According to a study published by Toriola and four co-authors last year, hormones are driving the rise in breast-cancer cases among young people: at least 70% of new breast cancers are fuelled by oestrogen or progesterone, and they tend to be more aggressive than other types.
Many modern women have become accustomed to the idea that they can build families (should they wish to have them) on their own terms and timeline. Yet having a child later in life does bring health risks, as well as compound those arising from long-term exposure to oestrogen (for example, women on average start their menstrual cycles earlier in life and stop them later than previous generations). For many young women, this reality can trigger a sense of helplessness – as well as the feeling that a breast-cancer diagnosis is a form of punishment for her choices.
The incidence of breast cancer in women under 40 is still low: as of 2021, one out of 4,000 women in this age group in America had a diagnosis, compared with around one out of 200 in women aged 65 to 74. But there is growing awareness that the medical establishment needs to better cater to younger patients. Because society is not, on the whole, primed to believe that women in their 20s and 30s can get breast cancer, women and doctors alike often ignore a lump in a breast – causing the disease to be caught only after it has spread. This tendency is exacerbated by the fact that most women do not receive regular breast-cancer screening until they are well into middle age, though that may soon change, at least in America: last April, the US Preventive Services Task Force, a national panel of doctors who make recommendations to primary-care physicians, announced that women should start getting mammograms at 40 rather than 50.
Last year I visited Ann Partridge, the expert on breast cancer in young women, at Dana-Farber’s medical campus in Boston. It is a massive, sleek complex with a ground-floor gift shop selling wigs, mastectomy bras and a large array of hats and head scarves; Partridge occupies a sunny corner office on the 16th floor. A rapid speaker with piercing blue eyes, Partridge, who is 55, has been trying to untangle the science behind breast cancer in young women longer than most. She started specialising in breast cancer in 1999; later that year, a close friend was diagnosed at the age of 30. The friend would call Partridge to talk about her concerns, and about the more subtle ways that the diagnosis pervaded her life. How would she look in a post-mastectomy camisole top? When should she tell her new boyfriend about her diagnosis?
These conversations made Partridge realise that young breast-cancer patients had a specific set of concerns. “I was watching these women wanting to be pregnant, and I was myself trying to be pregnant,” she said. “I was relating to the young women and thinking, emotionally, wow, that’s got to be really hard.” In 2005 she co-founded Dana-Farber’s Programme for Young Women with Breast Cancer, now known as the Young and Strong Programme for Young Adults with Breast Cancer, one of America’s first centres devoted to this group. “It became my crusade to try to unravel what we do and don’t know, and how we can better support these patients psychologically and socially,” Partridge told me.
Today, the programme is one of a handful of institutions across America offering support tailored to the needs of young women with breast cancer. In addition to providing clinical care, these centres offer targeted therapies to address side effects that particularly hurt younger patients. Interventions might include family-planning meetings to determine whether to put patients on fertility-preserving drugs; topical oestrogen to help women with menopausal symptoms fight vaginal dryness; and medications to alleviate hot flushes and increase libido.
These programmes also provide various forms of pastoral care, including access to peer-support groups and counselling. Because many young women are in the early stages of their careers, social workers are sometimes on hand to offer advice about the patient’s finances and professional stability. Mental-health care, meanwhile, often focuses on the aspects of having cancer that younger women may find especially difficult: distorted body image, the effects on their sexuality and the sense that their “normal” lives are being put on pause. “It is a time of major developmental milestones,” Cristina Pozo-Kaderman, the director of mental-health services for young adults with cancer at Dana-Farber, told me. “It’s a time period where you’re forming your identity. Cancer really disrupts and delays all that’s happening.” The experience is particularly hard on those who have only recently become independent from their families. “All of a sudden you go back to needing people,” Pozo-Kaderman said. “You always need them, of course, but now in a very real way, with basic activities of daily living, you’re going to need people to be much more involved.”
One of the women to have benefited from Dana-Farber’s specialised treatment programme is Meghan, a 29-year-old physical therapist living in Boston. Meghan was diagnosed with stage-four metastatic Her2+ breast cancer in 2022. In Partridge’s words, she was “cool as a cucumber” as they began planning for her treatment. But the prognosis was hard for Meghan to wrap her head around. “I had a ten-year plan of where I wanted to be professionally,” she explained. She had been planning to work as a personal trainer for Major League Baseball players – a strenuous job, with long hours on one’s feet. “I was like, well shit. I can’t do this anymore.”
Because women with metastatic breast cancer are unlikely to go into remission, the question becomes how to help them live as well as possible, as long as possible. Meghan decided she wanted to run, ride her bike and play softball as long as she could. She also didn’t want to be readily identified as a sick person – “I’m still so independent I don’t want to be labelled as someone who’s needing extra help, because I don’t,” she told me – so she initially opted for a less aggressive treatment that would let her keep her hair. Partridge prescribed Meghan a hormone therapy aimed at young women with late-stage breast cancers called Kisqali Plus, which has been shown to have fewer side effects compared with chemotherapy infusions; it’s also shown to help pre-menopausal women with cancer live longer.
On a Sunday morning last spring, I visited Meghan at her trim, clapboard South Boston condo. She cheerfully showed me around, her rescue dogs, Rex and Murphy, trailing behind her. Normally on a Sunday she’d go to Mass, play basketball with friends and stop for cheap beers at a neighbourhood bar. But because she was getting over a cold and not feeling very energetic, she had decided to stay at home.
Now three years into her treatment, Meghan is feeling relatively healthy and normal. She still plays in the weekly adult softball league she has been a member of for seven years; with her athletic build and long blonde hair, she also looks remarkably well. When I spoke to her again in December, she told me that she only felt ill during those weeks when she was undergoing infusions; sitting out weekends with her friends so that she could recover at her parents’ house would trigger a “severe case of FOMO”.
Cancer treatment has also shaped her dating life. Every once in a while, a friend checks in with her: “Have you been dating a boy long enough to have that conversation with him?” The answer is always no; she’s never liked anyone enough. She dislikes dating apps and prefers to meet guys at bars and in parks, though most of the men she’s met have proved disappointing. She had recently dated “a classic finance bro” for two months. “He was very into himself, and worked [only] for money,” she said.
Her frustrations sounded typical for a woman in her late 20s – except, of course, for the fact that she has to weigh up if and when to broach the topic of cancer. The finance bro, for example, did not seem as though he had the emotional capacity to support her through the inevitable challenges of her disease. A potential partner “has to really reflect upon, and understand the consequences of me living with that diagnosis,” Meghan explained. “I already know I can’t have kids” – she chose to forgo fertility treatment – “so that’s something they would have to be aware of. And know that every day something new could happen. I might not feel good.”
Last summer, Meghan travelled to a Taylor Swift concert in Scotland, and to Medjugorje, a holy site in Bosnia and Herzegovina for people with incurable ailments. There, she and her mother visited a copper statue of Christ, whose knee occasionally “weeps” holy water. Meghan rubbed the water over her breast, where the cancer started, and on the skin over her liver, where tumours were growing. She wasn’t expecting a miracle. Still, it was a jolt to get her scans back in August and see that the tumours had grown.
Over the past few months, she’s been testing out a number of more aggressive chemo regimens, all of which carry a higher risk of hair loss. (To preserve her hair, Meghan now wears a “cold cap” in treatment, a device that cools the scalp to constrict blood flow to hair follicles.) The period when she started a new treatment was always the darkest; she hated facing the uncertainty of how her body would respond. Her life, Meghan told me matter-of-factly, would be “treatment until failure” – that is, until she dies.
For now, these new treatments seem to be working. Her hair is still there. And she’s still able to make light of her diagnosis. During the pandemic, she and her friends, as a joke, made playlists for their own funerals. “I have to revisit it,” Meghan told me. “I’m Irish, so our funerals are parties.” Any time she sees patients in the late stages of the disease at Dana-Farber, she sees her own future. But that future hasn’t arrived yet.
When Christine Danielson started treatment for stage 3 Her2+ breast cancer in 2021 at the age of 34, she was anxious about how to share the news of her diagnosis with her three children, who were six, four and 11 months at the time. Although she “was on the verge of throwing up all the time”, she didn’t want her kids to know how terrible she felt; sometimes, when she was in pain, she’d hide herself away in her bedroom and cry.
Danielson took a leave of absence from her job as a behavioural analyst; her husband, who at the time worked remotely for the government, was able to help with school runs and child care. Even so, she tried to stick to her typical routine as a mother: getting her kids up in the morning, making breakfast, cleaning the house, going grocery shopping, driving them to sports. She lived in Norton, a town roughly 60km from Boston, and it was usually only when she went into the city for treatment that she’d leave them with her husband. “He’s a phenomenal dad,” Danielson told me. “But he’d take them out to eat instead of having cooked meals when he was on duty. Did he wash the clothes? No, and that’s not anything against him at all, it’s just different when you’re a mom. You just instinctively know.”
Today, after a double mastectomy, chemotherapy and radiation, Danielson is finished with active treatment. But the trauma of that process has left its mark on her family. Her eldest daughter had become so worried that Danielson would die that she suffered intense night terrors; she began going to therapy. And her youngest daughter seems to have absorbed more from her mother’s treatment than Danielson initially realised. Recently, when she watched a commercial for a hospital that specialises in paediatric cancers, she asked Danielson, “Mommy, am I going to get cancer like you someday?” Danielson didn’t know how to respond. “I think Mommy had it so that none of my babies are ever going to have it,” she ended up saying. Her daughter persisted: “Will you get it again?” “Some of these things are coming up in a very young little girl that shouldn’t,” Danielson said. “That also weighs on me.”
Danielson’s physical recovery has been difficult, too. The suture material between her first breast implant and her skin broke apart. Her doctors performed surgery to fix it, but her wound became infected. Danielson switched out her implant; that incision didn’t heal either. Doctors gave her the option of having another operation, or keeping her chest flat. “Mentally, I don’t think I could deal with not having breasts,” Danielson told me. She then received what’s called a lateral-flap procedure, in which surgeons took some muscle from her back and placed it above the implant to make a new breast. Now, she said, “I have less range of motion, and it’s not very pretty, but the outside world can’t tell the difference.” She has to be careful not to strain herself, but last autumn, when one of her daughters got so ill that she needed to go to hospital, Danielson insisted on carrying her from the car: “I’m like, you know what? I don’t care. I’m a mom. I’m going to bring my daughter to the hospital.”
Surgeons are pioneering new, less invasive forms of reconstruction that are proving particularly appealing to younger patients. Dhivya Srinivasa, a reconstructive surgeon at a private practice in Los Angeles, offers microvascular surgery, which takes tissue from other parts of the body – often, from the patient’s abdomen – to make a breast. The resulting breast has blood flow and is warm to the touch; it also requires less maintenance than implants, which require replacement every ten or 15 years. “The beauty of using their own tissue”, Srinivasa said, “is that the operation lasts a lifetime. It will last until your heart stops beating.”
Srinivasa has noticed that among the growing numbers of young women with breast cancer coming to her clinic, there is a preference for double mastectomies – even if only one breast is cancerous – because her patients are worried about getting cancer again. She generally performs the breast reconstruction immediately after the mastectomy to minimise the trauma that a woman might endure when her breasts are gone. She also does what she can to save the woman’s nipple (rarely, she told me, do you actually have to remove a nipple to treat the cancer). “It’s very hard to prepare a woman for what her chest will look like, the scar straight across her chest and the nipple missing,” Srinivasa said. “You can show someone a million pictures, but until it’s your body and you look in the mirror and you don’t recognise the person looking back at you, it’s hard to prepare someone for that.”
Danielson received nipple tattoos after her first reconstructive surgery. “Once I got the nipples, I realised how much I missed not having them, as a woman,” she told me. The tattoo artist who did them, Audrey Moschella, remembers how sensitive Danielson was to the zing of the needle. When Moschella offered to stop, Danielson said, “No, this is amazing. I didn’t think I had any sensation there.” She wept after the session.
Srinivasa noted that even the most flawless breast reconstruction “doesn’t always equate to self-satisfaction and sexual satisfaction. There’s a piece of that that I think is hard to restore once it’s lost.” Indeed, despite the reconstruction and cosmetic adjustments, Danielson is still self-conscious about her appearance. “I lost my hair. I had no eyelashes. No eyebrows for a really long time. No hair anywhere. You don’t feel really beautiful.” She never wanted the outside world to perceive her anxiety about her body, which is why she opted for the implants. But she still finds her scars frustrating to look at. “I’m angry,” she told me. “My body doesn’t feel like mine anymore.”
In March last year Ann Young finally moved from Boston to Honolulu to begin her new job. In her first week, a hospital staffer put an IV in her arm for a chemotherapy infusion; within a few days, Young was working with her in the emergency room. The staffer was confused, until it hit her that Young could be a doctor as well as a patient. “Turns out we’re human too,” Young said.
After having taken a year off to pursue treatment, returning to her job was jarring at first. But work now felt less essential to her identity – “I did come to realise my job can’t save me,” she told me. She made sure to take better care of herself than she had before cancer, eating full meals while on shift and preparing for overnights by exercising and napping.
Young and her husband Alex slipped easily into the slower pace of Hawaii; they enjoy walking the five minutes to their new church every Sunday and hiking up the steep hill at Koko Head. I visited them at their spacious new apartment in a high rise; half a mile away the Pacific was glistening. Although she still had hot flushes and was usually exhausted, Young seemed in a lighter mood than when I first started talking to her in October 2023. She had been prescribed a topical vaginal oestrogen, and she and Alex were able to have sex again, though it sometimes elicited complex feelings: her scars made her feel less desirable. But the intensity of her treatment had led them into a more sexually and emotionally intimate marriage – no small feat after 15 years together. “I don’t have to hide in my own marriage,” Young told me.
Alex, for his part, has felt changed by cancer. A friend of his had recently died of colon cancer at 34. That loss, as well as Young’s treatment, had forced him to confront deep-seated fears about his own mortality, and to re-examine what it meant to be a good partner and a good friend. “I feel like we’ve aged a lot, in our hearts, and in the things we want to talk and think about,” he told me. “How to love people. How to contribute.” He also had to come to terms with the ways in which Young’s treatment has affected his own dreams of becoming a parent. In Hawaii, they’ve found that friendships with childless people were simpler for them. “She would be an incredible mom,” Alex said about Young. “But we hold it sort of loosely.”
Young finished her chemotherapy infusions last August. This summer, she plans to take a year-long break from ovarian suppressants and aromatase inhibitors, which reduce oestrogen, in order to try once again to have a baby. (She is meant to be on these hormone-suppressing drugs for up to a decade because they can reduce the risk of cancer recurrence; a temporary break of a couple of years, however, is safe to do, according to research by Partridge and several dozen others.)
Both Young and Alex accept that they may never become biological parents. Still, Young can’t help but feel sad about that fact, and confused about the different paths her life could take. “Suddenly depriving a young woman of oestrogen for two years then handing it all back and saying ‘now go and have a baby!’ feels intimidating, highly pressurised, and anxiety-inducing,” she wrote on her blog. “Every day I am off my therapy means cancer cells can take root. And yet every day I do not get pregnant means I may never be a biological mother. The complete lack of control is maddening. How do you live in that tension without losing your mind?” ■
Meg Bernhard is a journalist based in Las Vegas
ILLUSTRATIONS PETRA ZEHNER
Source Images: Science photo library
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