Kayla Sheehan, MD, listened carefully as her patient, a woman in her thirties with no symptoms or family history of pancreatic cancer, asked about getting screened for the disease. As a primary and palliative care physician for University of Michigan Medicine in Livonia, Michigan, Sheehan helps healthy people navigate cancer prevention and treats patients with late-stage cancer — including young adults who overlooked early symptoms.
“It’s hard for me to not let those cases, which are rare, impact the way that I practice,” she said. “I can really empathize with patients who read stories about the increasing incidence in cancer, especially in young people, and who want to be really diligent about making sure that they don’t have cancer, because I feel that same pressure.”
Cancer rates among adults under age 50 years have been rising since the 1990s, according to recent research. Headlines and awareness campaigns about the risks of early-onset cancers — particular colorectal, anal, and breast — are changing how people in their 30s and 40s think about prevention and are creating new challenges for primary care clinicians.
“Do I want to spend 15 minutes talking about this quote-unquote ‘epidemic’ of early cancer? Not really,” said Ryan Laponis, MD, MS, program director for the primary care residency program at the University of California, San Francisco. “I think there are a lot of other things that are probably more pressing just based on the data. That comes up constantly.”
The increasingly urgent cancer concerns among younger patients could lead to overscreening and distract from other important health threats, according to a study published last month in JAMA Internal Medicine. The researchers suggest rising rates of early-onset cancer may reflect overdiagnosis and earlier detection rather than an increase in “clinically meaningful” disease. They found that aggregate mortality for the eight cancers with the fastest-rising incidence of early-onset disease did not change from 1992 to 2022. However, they found slight increases in mortality for colorectal and endometrial cancers.
Their strong, if controversial, conclusion: “Searching for biological causes for rising incidence in cancers without evidence of a rise in clinically meaningful cancer is bound to be unproductive. Chasing potential exposures is not just a waste of time but also diverts funding, talent, and attention from addressing more important issues affecting young people” in this country.
About 10% of deaths in adults younger than age 50 are from cancer, but four times as many in this age group die from suicides and unintentional deaths, such as car accidents and drug overdoses, according to the study. Other life-threatening conditions, such as uncontrolled high blood pressure and diabetes, can be managed with lifestyle changes, significantly decreasing mortality risk, Sheehan said.
“If someone is perseverating on cancer, which is a terrifying thing to worry about, they don’t always have the brain space to hear us as we’re trying to talk through some of these other things,” she said. “That’s absolutely a challenge.”
Focusing on cancer among young adults may also distract from the need to improve screening uptake among other age groups and populations, said Chyke Doubeni, MD, MPH, chief health equity officer and primary care clinician at The Ohio State University College of Medicine, in Columbus, Ohio. Adults aged 50 years or older face a greater risk for colorectal cancer than young adults, and about 1 in 3 were unscreened in 2023 despite significant efforts by medical groups, such as the American College of Gastroenterology and the American Cancer Society, to expand screening.
“Younger people are asking about colon cancer and cancer in general more,” Doubeni said. “If you screen, you’re going to save some lives, but it does divert attention from a group for whom the risk is higher.”
Every generation of primary care residents faces an unexplained health threat that influences how they approach care, Laponis said. When he was training in the early 2010s, screening for lung cancer was the “issue du jour,” while trainees today may fixate on the incidence of colorectal cancer. The question of how much screening is too much “has been around forever,” he said, eliciting different opinions on frequency of mammograms, colonoscopies, and PSA [prostate-specific antigen] tests to screen for prostate cancer, for instance.
But interactions with patients about early-onset cancer can be particularly fraught, Laponis said. Explaining the potential drawbacks of screening, for instance, demands a high level of trust between doctor and patient — a tall order given 87 million people in the US live in areas with a shortage of primary care clinicians. Not all people are prepared to accept earlier detection of cancer may not extend their life.
“It’s kind of a mature, nuanced conversation,” Laponis said. “Some of my older patients are like, ‘Yeah, I get it.’ Sometimes with younger folks, it’s a little bit harder to cultivate that sensibility. I often need to spend a little bit more time talking through that.”
Sheehan can relate. Her 30-something patient was scared because a family friend had been diagnosed with pancreatic cancer — but she didn’t meet the criteria for screening, which are having genetic risk factors or two direct relatives who have had the disease. Getting a CT screening could involve paying out of pocket, Sheehan explained to the woman. It could find possible abnormalities, leading to additional expensive, invasive tests. Sheehan then discussed screenings that she would recommend based on the patient’s age and health, such as diabetes, cholesterol levels, and cervical cancer. The patient decided against the CT scan.
“Notoriously, we run behind because we want to take that time with people to make sure they feel heard and that they understand why we might recommend the things we recommend,” Sheehan said. “And 20 minutes, it’s really not enough time. That can be even more challenging when you’re seeing someone who has health issues that you really want to get to with them.”
More patients are also asking about multi-cancer early detection (MCD) testing and whole body scans, said John Wuchenich, MD, a primary care physician at Stanford Internal Medicine, in Palo Alto, California. MCD tests (Exact Sciences’ Cancerguard and Galleri) are available by prescription as lab-developed tests but lack FDA approval. The American Academy of Family Physicians (AAFP) discourages the use of whole body scans in asymptomatic people. But some recommended screenings, such as annual mammograms for women aged 40 or older, feel too generalized, Wuchenich said. Patients are looking for more specificity.
“I’m seeing plenty of Silicon Valley techies who look after themselves, and cancer prevention, even in their thirties and forties, is a high priority for them,” Wuchinich said. “I feel like I should have more to offer them than to say, ‘Well, get your mammogram and your cervical and colon cancer screening done, and then let’s do some shared decision making about whether or not you should get a PSA checked.’”
Screenings have been remarkably effective, said Kathleen N. Mueller, MD, system director for integrative medicine and cancer survivorship for Northwell/Nuvance Health in Connecticut and southeastern New York. She points to a 2024 study, which estimated that screening, prevention, and treatment led to 5.9 million fewer deaths from breast, cervical, colorectal, lung, and prostate cancers from 1975 to 2020. Prevention and screening alone averted eight of 10 deaths.
“The juxtaposition of these two articles is completely fascinating,” said Mueller, referring to the new study on early-onset incidence. “We need a ton more research to help us make better informed decisions both as physicians but also as patients.”
As more nuanced data on cancer screening, incidence, and mortality pile up, Laponis said, not only should screening recommendations evolve, but the infrastructure supporting primary care should evolve, too. For example, reimbursement for conversations about cancer screening could help improve screening disparities. The American Medical Association and AAFP promote annual wellness visits, which allow clinicians to bill Medicare for conversations about recommended cancer screenings. There are some efforts to incentivize primary care clinicians to discuss cancer screening with patients, “but they’re not that robust,” Laponis said. In the clinic where he practices, a quality metric encourages primary care physicians to discuss prostate screening with male patients starting at age 50, for instance.
“The problem, from my perspective,” Laponis said, “is there isn’t either societal or healthcare revamp of how we pay for this, or how we adjudicate time for this, or dedicate the resources needed to actually implement these guidelines.”
The sources in this story reported having no relevant financial conflicts of interest.
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