Early-onset cancers, found in people under 50, are on the rise in Canada and worldwide

Jay Abramovitch still thinks of the medical resident who told him he was too young to have cancer.

Mr. Abramovitch was 36 at the time. He was feeling some abdominal discomfort in the weeks before his appointment with the resident, who was training in the office of Mr. Abramovitch’s family doctor. The pain was manageable, like an aggressive case of butterflies before a big test. But there was also a small amount of blood in his stool, a symptom that scared him.

Mr. Abramovitch saw his family doctor after his meeting with the dismissive resident, and his doctor was more receptive to his concerns. She referred him for a colonoscopy, but also told him that if he was too nervous to wait, he could go to the emergency department and try for a faster exam.

That’s how Mr. Abramovitch wound up in the ER of a small community hospital outside Ottawa on Nov. 16, 2020, clutching a paper copy of a CT scan with the words “possible malignancy” stamped in bold letters across the top. He was alone. His wife, who had been banished to the parking lot because of COVID protocols, wasn’t able to hold him until later in the day, when a sympathetic nurse snuck her into the hospital through a back door.

“I definitely went into a little bit of shock,” Mr. Abramovitch said. “I could feel my stomach basically right up into my throat and the room started to kind of shrink.”

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He was stunned because even though he went to the ER with anxiety about cancer in the dark recesses of his mind, most of him believed the medical resident. Surely, at 36, he was too young to have cancer.

What Mr. Abramovitch knows now is that he is part of a global increase in cancer rates among people younger than 50.

The steady rise in early-onset cancer, usually defined as cases diagnosed in people 18 to 49, has been especially pronounced in colorectal cancer, the type Mr. Abramovitch had. But an international team of epidemiologists, drawing on data from the World Health Organization’s Global Cancer Observatory, also noted similar trends for 13 other types of cancer. Their 2022 study was headlined, “Is early-onset cancer an emerging global epidemic?”

The global incidence, or rate of new cases, of early-onset cancer increased by 79 per cent between 1990 and 2019, according to a separate study of 29 types of cancer in 204 countries and regions published in 2023 in the journal BMJ Oncology. Early-onset cancer deaths increased by nearly 28 per cent in the same period. Just last week, the American Cancer Society highlighted the growing burden of cancer in middle-aged and young adults, especially women, in its annual report on the disease in the United States.

“This is something that I have been shouting from the rooftops for years: I think that we are in somewhat of an emergency,” said Michael Raphael, medical oncology lead for the Young Adult Colorectal Cancer Clinic at Toronto’s Sunnybrook Health Sciences Centre. “The frustrating thing is that a lot of people just don’t have any idea that this is coming or any idea this is happening, and so they can’t take preventative measures to stop it.”

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Dr. Raphael’s frustration is heightened by the fact that the Canadian cancer system is not designed to meet the unique needs of patients in their 20s, 30s and 40s. Younger adults usually have fulltime jobs, mortgages and children at home. Their financial needs are different from those of the retirees who still account for the vast majority of cancer patients. So are their mental-health needs. Facing death at 40 is not the same as staring it down at 85.

Early-onset patients also tend to have a more aggressive disease, and their cancers are often discovered at later stages. This is partly because they’re too young to qualify for organized screening programs that generally start at age 50. But it’s also because doctors, who are accustomed to seeing cancer in older patients, sometimes brush them off. Other times it’s because patients themselves don’t know the signs of cancer and put off seeking care.

Enhancing services for younger cancer patients and attracting research dollars to solving the medical mystery of early-onset cancer can be challenging because, despite rising rates in the young and early middle-aged, cancer remains overwhelmingly an affliction of the old.

As Dr. Raphael himself acknowledges, 92 per cent of colorectal cancer cases in Canada are found in people older than 50. The statistics are similar for other cancers. As people get older, carcinogenic exposures pile up, immune systems weaken, and aging cells accumulate random mutations that increase the risk for most cancers.

One clue about the increase in cancer rates among younger adults is that the shift appears to be generational: Members of Generation X and millennials are developing some types of cancer at about twice the rates that earlier generations did at the same ages. Scientists and epidemiologists are now racing to understand how changes in the lifestyle and environment of people who grew up in developed countries in the 1970s, 80s and 90s might be contributing to their elevated cancer risk.

While researchers seek answers upstream, physicians like Petra Wildgoose, a GP-oncologist and lead of the Young Adult Colorectal Cancer Clinic at Sunnybrook, do their best to help young cancer patients in the here and now. “We’re trying to raise awareness about the downstream implications of having a diagnosis at such a young age,” Dr. Wildgoose said, “because the downstream implications are huge.”

The screening gap

Stephanie Florian was at her wit’s end when she marched her husband, Rod McInnes, then 42, down to an urgent care centre in North Vancouver to demand a scan for him. Mr. McInnes’s family doctor had told him his crippling abdominal pain and frequent trips to the bathroom were likely due to diverticulitis, a condition that develops when pouches on the colon wall become inflamed. The antibiotics Mr. McInnes was prescribed didn’t help. Instead, his pain intensified and he shed 20 pounds from his 240-pound frame in a week.

At urgent care, a doctor speculated that Mr. McInnes probably had kidney stones before relenting and sending him to Lions Gate Hospital for a scan. “If it hadn’t been for me yelling my face off in the office,” Ms. Florian said, “they would not have done it.”

The CT scan revealed that Mr. McInnes was beyond saving. He had a mass the size of a baseball in his colon. There appeared to be more than 200 nodules on his lungs. His bones were riddled with cancer. He would die 14 months later, on March 6, 2022, at the age of 44, leaving Ms. Florian and their two sons behind.

The late Mr. McInnes was far from alone in having a primary-care provider wave away his cancer symptoms as something benign. One of the chief ways health systems in Canada and abroad may fail young adults with cancer is by diagnosing them at later stages of illness, when their disease is generally harder to treat. One Canadian-led meta-analysis – a review of 39 international studies – found that when colorectal cancer patients younger than 50 experience delays in cancer care, those delays usually occur before they’re diagnosed. Younger patients were at higher risk of presenting with advanced cancer than their peers over 50, the study found.

An online survey conducted by Colorectal Cancer Canada in 2022-2023 as part of a program called Never Too Young found that 72.8 per cent of adults under 50 weren’t diagnosed until their disease had reached stage 3 or 4. Two-thirds of early-onset cancer patients surveyed last fall by another Canadian patient advocacy organization, the Colorectal Cancer Resource & Action Network (CCRAN), said their symptoms were initially dismissed by health-care providers, and 78 per cent of those patients felt it was because of their age.

CCRAN began hosting an annual symposium for early-onset colorectal cancer patients in 2021, but in 2023 it broadened the event to welcome younger adults with malignancies of all types, a reflection of the changing demographics of cancer.

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Canada’s approach to screening shares some of the blame, too, according to advocates for lowering the ages at which Canadians are routinely checked for common cancers.

“It is a shocking travesty,” Dr. Raphael of Sunnybrook said, “that any person who wants a colonoscopy could not get a colonoscopy.” He concedes he’s biased by the number of young colorectal cancer patients he sees in his clinic, which is dedicated to that demographic, but he argues every Canadian should have access to regular colonoscopies beginning at age 35 – even though there isn’t clinical trial evidence to support starting so young.

“I practice it personally, and I recommend it to every trainee and every person who comes through my clinic,” he added.

Supporters of Canada’s current approach to screening warn there are costs and potential harms to indiscriminate screening. The Canadian Task Force on Preventive Health Care, a federally funded independent panel that advises primary-care doctors and nurses, recommends that stool tests and mammograms for screening purposes don’t begin until age 50.

In the United States, a similar expert panel recently reduced the starting age to 45 for colorectal cancer screening and to 40 for breast cancer screening, largely in response to evidence of rising rates of those cancers in 40-somethings.

Members of the Canadian task force have said they are trying to balance the possible benefits of early diagnosis with the risks of widespread screening, which can include unnecessary biopsies and the stress of an abnormal finding on a scan that turns out to be harmless. In the case of breast-cancer screening, the Canadian panel updated its advice last year to say that women in their 40s should be able to get a mammogram if they want one, but it stopped short of recommending that everyone do it.

That position provoked sufficient outcry from women and cancer advocacy groups that federal Health Minister Mark Holland promised to expedite an external review of the task force’s mandate and scientific processes.

In the meantime, most provinces have either lowered the starting age for mammograms or promised to do so. They haven’t done the same for stool tests or colonoscopies to detect colorectal cancer, despite their success in reducing cancer rates among Canadians older than 50.

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When all ages are taken into account, “colorectal cancer is actually the fastest declining cancer over the past five years in Canada,” said Darren Brenner, a University of Calgary epidemiologist and co-chair of the Canadian Cancer Statistics Advisory Committee.

Widespread use of stool screening tests, followed by colonoscopies during which precancerous polyps are spotted and removed, is preventing cancer. “It’s a pretty amazing advancement,” Dr. Brenner said. But not for those too young to qualify. Colorectal cancer incidence rates rose for every age group of adults under 50 in Canada between 1971 and 2021.

The late Rod McInnes’s case was part of that distressing trend.

His son Cash, then 14, remembers his parents calling him and his younger brother into a family meeting to tell them their father had cancer. Months passed before Cash understood that his dad was dying. Now, as a University of Guelph student living thousands of kilometres from his family’s home in North Vancouver, he is doing his best to manage the guilt he sometimes feels for behaving like a typical teen when Mr. McInnes was ill. He’s considering becoming a grief counsellor.

“I regret any time I didn’t spend with him that I could have or should have,” Cash said. “He would come to my room and I’d be sitting at my computer and he’d be using his cane, or, like, pushing whatever assist he had, and I wouldn’t even get up to give him a hug good night. Just small moments like that, where he had to be alone, is where I think I find the most guilt.”

‘Not the full picture’

Jean Seely, the head of breast imaging at The Ottawa Hospital, says she “felt an overwhelming sense that something was afoot.” More and more often she found herself delivering the gut punch of a breast-cancer diagnosis to women in their 40s or 30s or even 20s, a rarity early in her career.

Dr. Seely and her colleague Anna Wilkinson, a GP-oncologist at The Ottawa Hospital who noticed the same phenomenon in her practice, worked with analysts at Statistics Canada to see if national cancer registry data matched their experience.

Their study, published in 2023, found that Canadian women in their 20s, 30s and 40s are more likely to get breast cancer now than women in the same age groups did in the 1980s.

Canadians born between 1967 and 1982 also have higher rates of new cases of colorectal cancer than those born earlier, studies show. The oldest Millennials, born in 1980, are just approaching their mid-40s, so the full picture for their birth cohort isn’t yet clear, but Dr. Brenner said early data point to a continuing increase.

A similar pattern is evident in several other types of cancer, including thyroid, kidney, endometrial and prostate, according to a study of 3.8 million American patients. It found members of Generation X have been experiencing larger per-capita increases in new cases of leading cancers among younger adults than members of any other generation born between 1908 and 1964.

A leading hypothesis for this demographic turning point is that late Generation Xers and Millennials were the first to partake from childhood in unhealthy habits that are now staples of modern life, including sitting most of the day, sleeping poorly, and eating meals laden with ultra-processed food, refined sugar and cured meat. The Western-style diet may be changing the gut microbiome – the composition of bacteria, fungi and viruses living in the human belly – in ways that have already been tied to colorectal cancer.

Other possible culprits include stress, increased use of antibiotics in childhood, and exposure to air pollution and pesticides. Obesity, which is more common today in young adults than it was two generations ago, is also a well-established risk factor for some cancers.

“But that’s not the full picture,” said Andrew Chan, a gastroenterologist and research scientist at Massachusetts General Hospital and Harvard University. “I think there’s also probably other risk factors that have yet to be identified. I think we can all point to examples in our clinic of people who don’t seem to have any of the traditional risk factors for colorectal cancer, yet still get cancer at a young age.”

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Dr. Chan is co-leading an international team of researchers seeking more nuanced answers to the question of why colorectal cancer rates are rising in people younger than 50. The group garnered a grant of up to US$25-million from Cancer Grand Challenges, a project led by Cancer Research UK and the U.S. National Institutes of Health that aims to solve complex problems in cancer.

Obesity and drinking alcohol are linked to breast cancer, as is the trend toward delaying or forgoing childbirth. Earlier this month, the U.S. Surgeon General called for labels on alcohol warning that drinking can increase the risk of at least seven types of cancer. Women who don’t have biological children or have them later in life don’t benefit from hormonal changes during pregnancy and breastfeeding thought to reduce long-term breast cancer risk.

In the case of breast cancer, ethnicity is a factor as well, Drs. Seely and Wilkinson found in a separate study. Working again with Statistics Canada, they married data from the Canadian Cancer Registry and the census to discover that while the peak age of breast cancer diagnosis for white women in Canada is 65, it’s in the late 40s or early 50s for women of most other ethnicities.

Black women are particularly susceptible. They experience twice the rate of triple-negative breast cancer – an aggressive and difficult-to-treat subtype – compared to white women. The peak age of death from breast cancer in Canada is 79 for white women and 56 for Black women.

Genetics and lifestyle aren’t the primary factors in all types of cancer in which there has been an increase among younger adults. Cervical cancer rates, for instance, have been rising nearly 4 per cent per year since 2015 in Canada for reasons that appear linked to declining access to Pap smears. Most cervical cancer cases occur in women younger than 50.

Cervical cancer is almost always caused by the sexually-transmitted human papillomavirus, or HPV. It’s preventable with an effective vaccine administered in middle school, but the women of Generation X and most Millennials graduated before it became available. Regular Pap smears, which can spot precancerous cells in the cervix before they become dangerous, might not be top of mind for younger women, and they can be difficult to access for the millions of Canadians who don’t have a family doctor, Dr. Brenner explained.

The bottom line, Dr. Seely added, is that research scientists are still trying to understand how the complex interplay of lifestyle, social determinants of health, genetics and the environment influence cancer rates in people under 50. “I think there’s probably environmental factors we aren’t even are aware of,” Dr. Seely said – factors that could, for instance, be causing other population-level biological changes such as girls starting their periods earlier, which may raise their risk for breast cancer.

For patients in their 20s, 30s and 40s, answering the question of why they got cancer often takes a backseat to something more pressing: Accepting a life that could be cut short. And, for parents, despair at the thought of their young children growing up without them.

The personal toll

The day Kat Hum learned she had cancer was also the day she stopped breastfeeding her second child. Ms. Hum had little choice. Doctors ordered her to spend 11 days in the hospital after an MRI revealed her spine was studded with tumours.

“My first and only immediate thought was: Who’s going to look after my kids?’” Ms. Hum said.

Ms. Hum was 40 when she went to the ER at Toronto’s Michael Garron Hospital on Nov. 30, 2021, because her back was so sore she could barely walk. She’d been in agony for months. The pain hadn’t dissipated after the birth of her daughter four months earlier, as Ms. Hum’s obstetrician-gynecologist had promised it would.

Further testing would later confirm Ms. Hum had stage 4 cancer that had spread to her spine and brain from a mass in her breast. Her son, Kayden, was just three at the time. Her daughter, Kaia, was an infant.

During her first stint in the hospital, Ms. Hum began typing messages for her children into her phone in case she didn’t live to raise them. “I wish I could have guided you through life’s obstacles to build resilience,” she wrote. “I wish I could have loved you unconditionally and protected you from being hurt by life’s injustices only as a mama bear will do.”

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One of the defining characteristics of the early-onset cancer experience is that patients often have young children at home. They need practical help such as childcare, and emotional support for navigating the minefield of explaining a cancer diagnosis to kids.

Since helping to found the Young Adult Colorectal Cancer Clinic at Sunnybrook in 2019, Dr. Wildgoose has heard other common concerns from her patients. Taking time off work for cancer treatment hurts their post-secondary education, careers and bank accounts. Like patients of all ages, they often require care for anxiety and depression that cropped up with their cancers. Unlike older cancer patients, they may live for decades with the emotional and physical fallout of cancer. They also struggle to find peers.

“It is a very lonely experience for young people,” said Jennifer Catsburg, a clinical nurse specialist with the Adolescent and Young Adult (AYA) oncology program at Princess Margaret Cancer Centre, part of Toronto’s University Health Network. “Their siblings, their cousins, their friends, their peers, their colleagues at work – not many, if any, of them are facing a cancer experience.”

Ms. Catsburg said it’s clear more resources are needed to support younger patients with cancer and their families.

The clinic she works for is one of just a handful of dedicated AYA oncology programs in the country, although she said several other cancer programs are trying to beef up AYA offerings, such as peer meetups and seminars on navigating postsecondary education, work and child-rearing while battling the disease. One of her fellow Princess Margaret clinical nurse specialists now spends half her time running a new AYA program at Southlake Health in Newmarket, north of Toronto.

Sunnybrook also has programs for young adults with breast, gynecological and hematological cancers, but Dr. Wildgoose said that level of support for younger adults with cancer is rare in Canada. “There is a huge gap in care,” she emphasized.

Hoping to remedy that, a working group of Canadian doctors, nurses, social workers and other health professionals who work with AYA patients (usually defined as those aged 18 to 39) has begun meeting virtually every two months to share the latest research and best practices for helping their patients. The ad hoc group, which includes Dr. Wildgoose and Ms. Catsburg, calls itself the AYA Canada Collective.

Fertility comes up regularly when the collective meets, Ms. Catsburg said. In fact, ensuring that young cancer patients are given options to preserve their fertility is what spurred the creation of the AYA clinic at Princess Margaret in 2014 in the first place.

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For women like Nicole McRonney-Apaw, who was single when she developed breast cancer at the age of 33, a cancer diagnosis can force sudden family-planning decisions at a moment of immense stress. Ms. McRonney-Apaw chose to freeze her eggs before starting chemotherapy. That required injecting herself with ovarian-stimulating hormones to produce multiple eggs that could be harvested and put on ice.

“With fertility treatment,” she said, “your hormones are all over the place. To be mentally in a state where you’ve just found out you have cancer, plus you’re introducing a bunch of medications that can exacerbate an already stressful situation, just made it very, very dire.”

Ms. McRonney-Apaw, now 35, is finished with cancer treatment, save for a regular dose of the hormone therapy tamoxifen. Her prognosis is good. But being a cancer survivor complicates her life in ways that sets her apart from other women in their mid-30s.

Consider dating. She wonders about when and how to bring up her fertility status. She won’t know unless she tries to conceive whether her treatment made her sterile. She has those back-up eggs in the freezer, but she doesn’t know how that information would land with a new man. “It feels like you’re damaged goods a little bit – even though I know I’m not.”

Parenthood was also on Mr. Abramovitch’s mind when he was diagnosed. At the time, he and his wife, Leslie, were starting the process of adopting a baby through the Children’s Aid Society (CAS). Cancer put that dream on hold, prompting the couple to set aside their adoption plans while they waited to see how Mr. Abramovitch would respond to treatment. He’s doing well. In September, he ran a half marathon.

Being diagnosed with cancer as a young man also gave Mr. Abramovitch a perspective on life that he considers a gift. “It’s not normal at this age to face your mortality,” he said. “You don’t want to wait anymore, right? If you really want to do something, you just you have to do it.”

That’s why, when the CAS offered Mr. Abramovitch and his wife a baby girl two weeks after he finished his chemotherapy, they said yes.

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