Photograph by Audra Melton
Cari Moskow was 36 years old when a doctor told her quietly that they were going to have to order more tests. Moskow was a busy working actor, juggling film bookings with jobs as a server and a yoga instructor. She ate healthy food and got plenty of exercise, and above all, she was so young—how could she have breast cancer? “Never in a million years did I think I would get cancer,” says Moskow.
She learned her diagnosis in June 2018, and overnight her life turned upside down, as audition tapings and yoga clients were pushed aside for blood draws and oncology appointments. Within months of her diagnosis, she’d had a double mastectomy. She endured grueling chemotherapy treatments in between researching remedies for nail loss and mouth ulcers, and icing her fingers and toes to prevent nerve damage. Testing revealed that her breast cancer was triple negative, an aggressive type that spreads faster and is harder to treat. Doctors squeezed her in for appointments, knowing that time was the best weapon they had against her disease.
Moskow was lucky: Screening had caught her cancer early. By that December, she was in remission, and today she’s past the five-year mark, a key measure of recovery. She got married—she’s Cari Moskow Beegle now—and, though oncologists warned her it probably wasn’t possible, conceived naturally and had a baby. Her son, Ben, turned two in March. “Every year is a celebration,” says Moskow. “I just feel so grateful to be here.”
Every year, there are around 310,000 new cases of breast cancer in American women and people assigned female at birth. Death rates are going down—the five-year survival rate among all breast cancer patients is over 91 percent—but new diagnoses, after falling sharply in the early 2000s, are now climbing slowly. One contributor to that upward trend is cases in younger women: For reasons researchers are still struggling to understand, rates of breast cancer in women 20 to 49 years old have increased over the last 20 years. A study published this year in The Journal of the American Medical Association Network Open found that in 2000, there were 64 cases per 100,000 women in that age group. By 2019, that rate had climbed to 74 per 100,000. “We are hopeful this study will offer clues to prevention strategies that will be effective in younger women,” study coauthor Adetunji T. Toriola said in a press release.
These troubling increases have shifted the medical community’s approach to the disease. In April, the U.S. Preventive Services Task Force lowered the age women should begin regular mammogram screening for breast cancer, from 50 to 40. Researchers are diving into the data to better understand what is causing higher rates of breast cancer in young women, analyzing contributors like genetics, life history, and environmental factors. At the same time, health equity advocates are working to address alarming racial disparities around breast cancer, including higher rates in young Black women than in their non-Black peers, and the fact that Black American women with breast cancer are 40 percent more likely to die of the disease than White women.
The problem is complex, but the answer to many of these questions lies in better screening. Catching breast cancer early can make all the difference: In localized cases where the cancer has not spread beyond the breast (also known as stage 1), the five-year survival rate for most breast cancers is 99 percent. But as researchers learn more about who gets breast cancer, when they get it, and why, it’s becoming clear that a one-size-fits-all approach to screening won’t be enough. It will take more than a general recommendation for regular mammograms to drive down breast cancer rates: We’ll need methods that help women understand their individual risk, access the preventive measures they need, and get the healthcare they deserve—regardless of how old they are, where they get their care, or the color of their skin.
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When the recommended age for mammogram screenings was lowered to 40 this year, it was to return to earlier guidance that had been replaced over a decade ago. In 2009, the task force—a volunteer panel of doctors and disease experts, supported by the federal government, that is considered the leading authority on preventive healthcare in the U.S.—raised the recommended screening age to 50. The research, the task force said at the time, showed that the benefits of screening women in their 40s didn’t outweigh risks like unnecessary biopsies and exposure to low-dose radiation.
For many experts, the task force’s reversal was a long-overdue catch-up to the rest of the breast cancer treatment community. “I’m happy they’ve finally recognized how important this is,” says Lea Gilliland, a radiologist and breast imaging specialist at
Winship Cancer Institute of Emory University.
Gilliland is a member of the American College of Radiology and the Society of Breast Imaging, both of which, along with many other major breast cancer medical associations, have always recommended screenings beginning at age 40. “One in six breast cancers occurs in women in their 40s,” she says.
The task force guidelines have added weight because they help dictate which preventive procedures health insurance must cover; after the group raised the recommended screening age, breast cancer organizations lobbied Congress to intervene, and in 2016, legislators passed a law mandating that insurers cover annual screenings beginning at 40. “Especially for patients with [the government-funded insurance] Medicare and Medicaid, your care is really tied to the government, so we were pleased that that didn’t change,” Gilliland says.
Though insurers must cover annual mammograms, the updated task force guidelines recommend screening only every other year. But many breast cancer experts argue that annual mammograms give women the best chance of catching cancer early. “Going two years between mammograms can be a deal-breaker,” says Gilliland. “Generally, the younger you are diagnosed with breast cancer, the more aggressive your cancer is. So if you get a mammogram every year, you’re going to find a smaller breast cancer.”
But what about women younger than 40? Moskow, diagnosed in her mid-30s, was several years away from beginning annual mammograms: It was genetic testing that led to her diagnosis. Moskow is of Ashkenazi Jewish descent on her father’s side, an ethnic group with a high incidence of a specific gene mutation that increases risk of breast and ovarian cancers. Normally, the breast cancer 1 and breast cancer 2 genes—called BRCA for short and pronounced “braka”—protect against these cancers. But the mutation, which is inherited from parents, eliminates that protection. One in 40 women of Ashkenazi Jewish descent has a BRCA mutation, compared with one in 500 in the general population.
Moskow knew that her aunt, a breast cancer survivor, had tested positive for a BRCA mutation. “But I didn’t know what the mutation was or what it meant,” she says. “No doctor really sat me down and said, ‘This is important.’” Instead, Moskow asked her doctor for the test on something of a whim. “There weren’t any particular symptoms or anything, I just remember having this feeling, almost of darkness. And I heard this little voice in my head that said, get the BRCA test.”
Photograph by Audra Melton
When it came back positive for the mutation, the genetic counselor referred Moskow to an oncologist, who found a lump on her first visit. “It was in a really weird place, closer to my armpit,” Moskow says. “It wasn’t something that would have been easy to find.” Moskow’s sister and two female cousins also tested positive for the mutation; one cousin was diagnosed with breast cancer in her 30s as well. (She’s in remission and doing well.) “Getting tested is definitely the number one importance,” Moskow says.
Having the BRCA mutation isn’t the only factor that increases risk of breast cancer. Other common risk factors include having close relatives who have had breast cancer, being treated with chest radiation for other diseases, and having dense breast tissue. Other genetic mutations can also increase risk for women and men. (While it’s rare, about one percent of all breast cancer diagnoses worldwide are found in men). These risk factors don’t fully explain why more young women are getting breast cancer, but they can help providers pinpoint who should be getting additional screening.
“Someone with a gene mutation, we might start screening as early as age 25,” says Erin Bowman, a breast surgical oncologist and managing partner of Atlanta Breast Care. “But not everyone needs genetic testing—what needs to be talked about more is understanding whether you are high risk or not.” Bowman explains that the first preventive measures begin with primary care providers and OBGYNs, who can help patients understand their risk level.
“Gynecologists [and other primary care providers] are really the gatekeepers for all of this,” says Gilliland of Emory Winship. “Just making sure they take a thorough history and tease out who may be at increased risk.” In 2019, the task force issued a recommendation that primary care providers talk about genetic testing with patients who have a personal or family history of breast or several other cancers, or who have an ancestry associated with the BRCA gene mutations.
The agency hasn’t issued specific recommendations for women with dense breast tissue—a risk factor both in developing cancer and in receiving a late-stage diagnosis—but says more research is needed to determine the best preventive measures for this group, including whether to use more intensive MRI screenings, which can pick up certain cancer indicators missed by traditional mammograms. Whatever the risk factors, medical experts say primary care providers should start the conversation when patients are young and healthy to help them make informed decisions about their care.
“We need to figure out who needs to be in this high-risk pool,” says Gilliland. “And start this conversation before they’re actually of screening age.”
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At the same time researchers are developing precision prevention for high-risk patients, health equity advocates are working to ensure that prevention is accessible to everyone in the first place. Just five decades ago, breast cancer was far deadlier than it is today, killing nearly twice as many women in 1975 as it did in 2019. Improved treatment is keeping more patients alive, but the biggest difference has been from screening: Research shows that mammograms have reduced breast cancer mortality by nearly 40 percent since 1990. Screenings save lives—but that doesn’t mean everyone gets the screening they need.
Over the last few decades, rates of screening have gone up across the board, but low-income women of color and women living in rural communities still face barriers in accessing regular mammograms. An intensive effort to raise screening access and awareness has helped to close racial gaps, especially between Black and White women, and recent data suggests that screening levels in both groups are now roughly equal.
But lurking behind that statistic are lingering disparities, including the number of missed appointments, the time it takes to receive a diagnosis, and access to follow-up treatment. Black women are also more likely to be uninsured than White women—especially in states like Georgia that have refused to expand Medicaid—and for them, finding a free mammogram may not seem worth it if there’s no way to pay for the cancer treatment that might follow.
These inequities don’t fully explain why Black women die of breast cancer at much higher rates than other American women. Research suggests there are multiple contributors to this alarming statistic, including higher rates of more aggressive breast cancer types, more underlying health conditions like diabetes and heart disease, and poorer access to quality health insurance and medical care. But barriers to screening are part of a complex matrix of racism and poverty that, overall, makes low-income Americans of color sicker than their neighbors, and more likely to die of the things that make them sick.
Photograph by Audra Melton
Addressing that matrix is something of a calling for Yolanda Wimberly. A pediatrician by specialty, Wimberly has spent the last few years building an ambitious health equity program for Grady Memorial Hospital. As Grady’s inaugural chief health equity officer, Wimberly’s mission is to close healthcare disparities around metro Atlanta using a community-driven, “whatever-it-takes” approach to get people the care they need.
“Our approach is about bringing the healthcare to the community where they are, versus having them come to us,” says Wimberly.
When it came to improving access to mammogram screenings, that meant putting the machine on wheels. In October 2023, with funding support from the Centers for Medicare and Medicaid Services, Grady launched a mobile mammogram screening service, all housed on a custom-outfitted RV, which rotates to different community health centers throughout the week.
The hospital isn’t the first to do screening on wheels: The first mobile “mammovans” were introduced in the 1970s, and the practice grew popular during the Covid-19 pandemic to continue screenings through shutdowns. But for Grady, it was an opportunity to bring preventive care services directly to places in Atlanta where the inequality matrix is most stubbornly entrenched.
“Our program is really intentional to reach people in zip codes with a life expectancy of 73 or below,” explains Wimberly. Her team analyzed piles of data to build “community profiles” for five low-income zip codes around metro Atlanta, compiling granular information on everything from employment rates to levels of high blood pressure. “We look at all the chronic illness rates so we can say, ‘Okay, there are these specific inequities within this particular zip code,’” Wimberly says. “We’re able to really tailor what we do to what the community actually needs.”
The mobile bus features the same technology as Grady’s permanent screening center downtown; bringing the service directly to community health centers means providers can refer patients for a mammogram down the hall, not across the city. “You don’t have to worry about getting downtown, paying for parking, things that hinder people from going to get screened,” says Stephanie Wilkes, manager of mobile screening services at Grady.
Photograph by Audra Melton
A dedicated staff member manages follow-up for patients with positive screens, ensuring they connect with the care they need next. To prevent cost from being a barrier, Grady partners with the state-funded Breast and Cervical Cancer Program, which covers breast and cervical cancer screenings and follow-ups for eligible uninsured or underinsured women in Georgia. And while the mobile program isn’t specifically targeted to younger women, Grady has always recommended patients begin screening at age 40. “The patients we are privileged to serve are a higher-risk population, so even regardless of specific risk factors, we have always started at 40,” says Wimberly.
Since the mobile mammogram program launched last fall, Wilkes and her team have screened over 1,500 patients. They’ve added cervical cancer screening to their repertoire. “We’re working to be a one-stop shop for women’s cancer screenings,” says Wilkes. In addition to their rotating clinic schedule, the mobile screening team will often partner with churches or sororities in target zip codes to host a screening day for members and nearby residents. The program has been so successful that some community healths centers have mammograms booked out for months; Grady plans to add a second bus for primary care services.
By bringing the service directly to patients’ communities, the mobile program reduces the number of steps required to access preventive care—and the number of opportunities for someone to fall through the cracks en route to treatment. “If I have a job where I work 12 hours a day and only get 30 minutes for lunch, I don’t really have time to sit on the phone making an appointment,” says Wimberly. “We’ve got to make it so easy for people that when they’ve decided they want to do it, it’s real easy-peasy to do.”
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There’s no single explanation for why more young women are getting breast cancer. Changes in hormones may be a factor, as American women on average are having children later and getting their periods earlier. Some research indicates this longer exposure to reproductive hormones could contribute to breast cancer risk.
Smoking, obesity, lack of regular exercise, never giving birth, and not breastfeeding after birth may also contribute to higher rates of breast cancer in women under 45. Black women under 30 seem to be at greater risk than their peers, another complicated statistic that needs deeper study. “We need more research to tease apart what’s biology, what’s lifestyle, and other factors,” says Emory Winship’s Gilliland.
While researchers are working to better understand breast cancer in younger women, medical providers are adapting to the realities of treating young patients. Bowman, of Atlanta Breast Care, has seen the number of younger women with breast cancer go up in the decade she’s been in practice. “The youngest patient I’ve treated was 23,” she says. “Treating someone with breast cancer who’s young is a very different dynamic.”
Fertility, for instance, is an important concern for younger patients. Many opt to freeze their eggs before undergoing chemotherapy, since the treatment can contribute to infertility. Luckily, pregnant women can be safely treated for cancer, though oncologists work closely with the obstetrics team to ensure mother and baby are healthy throughout. Bowman, who has treated at least eight pregnant women with breast cancer, says they are some of her most complicated and emotional cases.
“It’s this duality, where you’re so happy you’re bringing a life into the world,” says Bowman. “But at the same time you’re thinking, What if I’m not here for this child?” Happily, all the women she’s treated during pregnancy have survived and are doing well. Bowman says meeting their kids, and those of other women she’s treated, is one of the biggest rewards of her job. “I love when they come back to the office with their babies, and seeing their families growing and that there is life after cancer,” she says.
For Moskow, life after cancer has been full. She froze her eggs before chemotherapy, but she and her husband conceived their baby naturally, to the happy surprise of her cancer team. Since her treatment, meditation, exercise, and a nourishing diet have all helped her fully recover her health. “I feel great,” she says. “I really think I feel better than I did before I had cancer.”
She recorded informational videos throughout her diagnosis and treatment, which she shares with other women who have breast cancer, and she’s working on creating more resources to help other moms live a healthier life, with or without a cancer diagnosis. “Whether you’re healing from something or preventing it, I think healthy living is something that’s good for all of us,” she says. Most of all, she’s enjoying being a mom, and everything else in life that a breast cancer diagnosis at 36 seemed to put in jeopardy.
Surviving breast cancer will always be a part of her story. Because BRCA gene mutations can also cause ovarian cancer, and make cancer likelier to recur, Moskow still goes in for regular blood tests throughout the year to ensure any changes are caught early. Every time she takes her shirt off and sees her scars, she remembers what she went through. She never expected to get cancer in her 30s. But learning about her individual risk caught her cancer early—something for which she’ll forever be grateful.
“If I had never been tested for BRCA, I would have found my cancer at a later stage,” she says. “Getting tested, getting screened—that’s everything. That saved my life.”
This article appears in our July 2024 issue.
