Doctors first identified cases of unexplained muscle weakness and limb paralysis in children, which they called acute flaccid myelitis, or AFM, in 2014 — though in retrospect, sporadic cases showed up as early as 2009, said Dr. Kevin Messacar, an infectious disease specialist at Children’s Hospital Colorado. The hospital was one of the first to raise alarms that something unusual was going on.

Nationwide, cases spiked again in 2016 and 2018, with only a handful recorded in odd-numbered years, according to data from the Centers for Disease Control and Prevention.

But the pattern broke in 2020, possibly because measures to combat COVID-19 kept kids from getting other viruses, and while the most likely culprit virus returned in 2022, the expected cases of paralysis didn’t.

Last year, the CDC recorded 18 confirmed cases of AFM, down from a high of 238 in 2018. Colorado has ranged from zero to four cases each year since 2018, when the state recorded 17.

The evidence linking the syndrome to infection by the common respiratory bug enterovirus D68 has only grown, raising questions about whether the virus itself changed, kids’ immune systems are responding differently, or some other environmental factor tipped the balance, Messacar said.

Typically, EV-D68 causes colds, but for unknown reasons, it infected the spinal cord and caused muscle weakness and paralysis in a small percentage of kids.

“It may not be as straightforward as one of those three factors,” with multiple changes contributing, he said.

No cure exists for AFM, and children who had it vary in how much they’ve recovered.

Lydia Pilarowski, a 16-year-old who lives in Denver, had one of the earlier known cases in August 2014.

She and her brother both had what seemed like ordinary colds, but Lydia remained lethargic after her brother recovered. Then their mother, pediatrician Dr. Sarah Lacey, started noticing Lydia couldn’t do things she did before, like turning while riding her bike or playing the piano with her left hand.

“That’s suddenly when it dawned on me that something was wrong,” Lacey said.

Certain muscles in her upper arm no longer obeyed her brain’s commands to move, so Lydia has worked with occupational therapists over the years to strengthen the other muscles and find creative ways to do the things she wants to.

For example, when she was skiing competitively, Lydia noticed her left arm was dragging in the wind and slowing her down. She initially wasn’t sure how people would react to her skiing with her arm in a sling — a clear marker of an otherwise invisible disability — but it improved her times and was freeing in its own way, she said.

“Instead of trying to work through something I can never work through, I work around it and work with it to do the things I love,” Lydia said.

The process of learning how to live with the after-effects of AFM never really ends, Lacey said.

As Lydia tries more things, they confront new challenges, such as how to put a suitcase in a plane’s overhead bin when one arm won’t go over her head. They also recently learned that the syndrome had subtle effects on Lydia’s diaphragm, contributing to shortness of breath that Lacey initially thought more cardiovascular training would resolve.

“There are so many things we don’t know,” Lydia said.

While AFM seems to have gone away as an immediate public health concern for the moment, researchers are still trying to understand it, said Dr. Carlos Pardo, a professor of neurology and pathology at John Hopkins University’s School of Medicine.

Right now, one of the top theories is that a different variant of EV-D68 emerged in the early 2010s, causing paralysis in rare cases, he said.

A research lab on the University of Colorado’s Anschutz Medical Campus is working on comparing samples of EV-D68 that cause paralysis in at least some cases and others that don’t, Messacar said.

They’ve found only a small number of mutations between the two variants, and are studying whether any of those could have made the critical difference. If they do prove important, that information could help detect if more-dangerous variants return or even lead to new vaccines, he said.

Another possibility is that EV-D68 could always cause paralysis in rare cases. Other syndromes cause the same symptoms, so it could be that doctors simply didn’t pick up that a virus might be the root cause, Pardo said.

The syndrome’s seeming disappearance also could have at least two possible explanations, Pardo said. Maybe it couldn’t hang on during the early years of the pandemic, when people weren’t spreading it, and different variants replaced it. Or, maybe enough people now have immunity from a large wave of EV-D68 that the number who are susceptible to that variant dropped dramatically, he said.

While scientists still don’t know everything they would like to about AFM, they’ve made significant progress since 2014, when they didn’t even have a test that could detect whether the virus had gotten into someone’s spinal fluid, Messacar said. An antibody-based treatment for EV-D68 is going through trials, and more than one possible vaccine is approaching human testing, he said.

Lydia said she hopes researchers can learn more about what caused the wave of AFM cases, both for her own understanding and to prevent something similar from happening again. But that the uncertainty is something she’s had to “make peace” with, using the same skills that help her adapt to each new challenge that arises from her disability.

“I think growing up, you have these preconceived notions about what your life will look like,” she said. “For me, it’s been about embracing the unknown.”

The Centers for Disease Control and Prevention recommend that everyone 6 months and older get an annual flu shot and the newly approved and updated vaccines for COVID-19.

The guidance is more complicated for respiratory syncytial virus, with vaccination recommended for people over 75; those between 60 and 74 who have chronic conditions; and women between 32 and 36 weeks of pregnancy who will deliver during RSV season. Anyone who got the RSV shot last year doesn’t need another one, unless they became pregnant again and need to pass protection to a new baby.

People get the best immune response if they space out their flu and COVID-19 shots, but they need to consider if they will return to get another vaccine, or if they’re likely to forget or get busy, said Jenna Guthmiller, an assistant professor of immunology and microbiology at the University of Colorado School of Medicine. She didn’t specify how far to space them out.

The shots are safe to get together.

“If it’s convenient for you to get them all at the same time, just do it,” she said. “Some protection is better than no protection.”

Ideally, people would get their shots around late October, since the flu typically takes off in the state near the end of the year, Guthmiller said.

Not everyone agrees that waiting is the best plan.

While some people like to time their shots closer to the holidays, getting them early ensures people won’t get sick or pass the viruses to others during the early weeks of respiratory season, said Dr. Amy Duckro, an infectious disease specialist at Kaiser Permanente Colorado. She personally likes to get the flu and COVID-19 shots together, so as to only have side effects once a year.

“I’d recommend getting them as soon as you can. It does take some time for immunity to develop,” she said.

Given the high amount of COVID-19 circulating right now, the best thing is to get that shot as soon as possible, said Beth Carlton, chair of environmental and occupational health at the Colorado School of Public Health. For flu, people should get adequate protection as long as they get the shot before Halloween, she said.

Last year, flu shot uptake held steady, while the number of people getting COVID-19 vaccines dropped. Relatively few people got a new shot for RSV, which typically causes colds but can be deadly in infants and older people.

So far, uptake of the new flu and COVID-19 shots has been relatively strong, said Jessica Chenoweth, who oversees 17 CVS pharmacy locations along the Front Range. She isn’t sure what changed to revitalize people’s interest.

“It feels on-pace to what I’ve seen in previous years,” she said.

People who got a COVID-19 booster during the summer wave should wait two months before getting their next dose, though they could get the flu shot earlier if they want, Chenoweth said. Generally, though, she recommends getting all seasonal vaccines at once, to avoid forgetting one.

Some people who got the COVID-19 vaccine for free last year will have to pay out of pocket this fall. The Bridge Access program, which paid for COVID-19 vaccines for uninsured people, ended this year, but the CDC said it would allocate $62 million for state and local health departments to buy vaccines they can give out for free.

Chenoweth said the shot costs about $200 if an uninsured person pays cash. Nearly all insurance plans cover them.

The flu and COVID-19 vaccines change each year, to try to match the dominant variants. RSV doesn’t evolve as quickly, so the vaccine is the same one that rolled out last year.

For the first time in a decade, the flu vaccine will include three strains, rather than four. The influenza B Yamagata strain hasn’t shown up in testing since March 2020, and flu manufacturers dropped it from the vaccine this year. Unlike influenza A strains, flu B only circulates in people, so when respiratory virus transmission plummeted early in the pandemic, the Yamagata strain apparently couldn’t survive, said Guthmiller, the CU researcher.

“There’s a strong belief that it’s gone extinct,” she said.

The updated Pfizer and Moderna COVID-19 vaccines teach the body to make the spike protein from the KP.2 variant of the virus, which is a cousin of the currently dominant KP.3.1.1. When the body sees the spike, it develops antibodies against it, reducing the risk a person will get sick if they encounter the actual virus. The disembodied spike proteins produced after vaccination can’t give anyone the virus, though some people feel tired or achy because of their immune response.

The updated Novavax shot, which injects the spike protein directly, is based on the JN.1 variant, which dominated last winter.

In addition to getting vaccinated, people can protect themselves and others by staying home if they feel sick, washing their hands frequently, practicing general healthy habits and wearing masks in crowded spaces if they feel comfortable doing that, Duckro said.

“We certainly wouldn’t want to rely on vaccines entirely,” she said.

As a health reporter, I have more experience with hospital prices than many people, so I thought I’d use my own situation of choosing where to have my baby as a demonstration of how to figure out what you might pay when you know you’ll need care.

For years, people who study the economics of health care have debated whether giving people more transparent information about prices will result in savings for the patient and the system as a whole.

Studies haven’t found significant changes in consumer behavior — a January poll found only about 17% of people feel they know what their care will cost before they get it — but the federal government and the state of Colorado have continued to pass laws to make it easier to find and compare prices.

While I’m searching for information about a birth, you can use these same basic steps for any planned hospital visit. This guidance doesn’t apply in emergency situations, though.

If you’re having severe chest pain, feel weak on one side of your body or are bleeding profusely, skip all this and get to the nearest emergency room. Federal and state laws should protect you from surprise bills, and as painful as fighting your insurance company after the fact may be, you don’t want to risk death by delaying care.

Step 1: Find out which hospitals are in-network

In my case, this was pretty easy. My workplace insurance is through Kaiser Permanente Colorado, which also owns the medical practice where I receive prenatal care, so my doctor knew which hospitals are in-network.

If your situation is different, you’ll most likely need to call your insurance company for this one. Asking the hospital if they take your plan won’t get you the answer you need — they might say they accept your insurance, but if you’ve gone out-of-network, you could be stuck with a significant bill.

Even if the hospital is in-network with your insurance, you might get a provider who isn’t. Unless you’re having a planned cesarean or induction, you have no way of knowing which obstetrician or anesthesiologist will be on call when labor starts. Colorado state law and the federal No Surprises Act both forbid billing patients at the higher out-of-network rate in those situations, provided they’ve gone to an in-network hospital. (They also don’t allow those higher bills for emergencies.)

Step 2: Find out likely costs

Basically every hospital is required to either display a list of prices for common “shoppable” services or to offer a price-estimating tool. The tools vary in how much personal information they ask for, and those that demand more tend to produce more accurate estimates.

In my case, the tools estimated a roughly $1,100 cost at Sky Ridge Medical Center in Lone Tree, or $1,700 at either Good Samaritan Hospital in Lafayette or Saint Joseph Hospital in Denver. The estimates were based on my insurance requiring me to pay one-fifth of my hospitalization cost.

You may be sick of calling your insurance company, but you should probably double-check your costs, because the estimate tools don’t make any promises.

You might also want to look up a few scenarios. Most people plan on an uncomplicated vaginal birth, but you might want to know what you could pay if you need a cesarean or have complications. Speaking of which…

Step 3: Figure out your worst-case scenario

If you’re the kind of person who wants to know the full range of what you could face, you’ll want to be familiar with your out-of-pocket maximum, which is what it sounds like: the ceiling of what you could spend on medical care in a given year. Most plans have a separate, higher out-of-pocket max if you go to an out-of-network hospital, though.

Most insurance companies will have a feature on their websites that allows you to see how much you’ve spent so far this year, and how that compares to your maximum spending. If yours doesn’t, you’ll have to call your insurer again to answer this one. (Sorry to be the bearer of bad news.)

In my case, I’m getting close to the out-of-pocket maximum because of some medical expenses at the start of the year, so the cost difference between my three options is minimal. If you have many thousands of dollars left to go until your max, though, you could have significantly different bills, particularly if you have complications.

Step 4: Consider non-financial priorities

You don’t have to complete this step, but not everything important translates into dollar amounts.

In my case, two of the three in-network hospitals would require a highway drive, which made them less appealing to me. I don’t relish time spent on Interstate 25 under any circumstances, and sitting in traffic while in labor sounds like an experience I’d rather avoid.

Your priorities may be different, though. Maybe you had a great previous experience, or a terrible one, at one of your hospital options. Maybe you place great value on the closest possible location. Maybe you want a religious hospital, or prefer to avoid one. Ultimately, only you can decide what matters most to you.

A final thought

Things can go wrong even if you’ve done everything right. Your best bet is to get any prices you were quoted or promises that all providers are in-network in writing. It doesn’t eliminate the chance of a billing error, but it would give you some ammunition to fight back.

Two Colorado researchers looked at 205 pairs of mothers and children from non-white ethnic groups living in Massachusetts, in cooperation with scientists elsewhere. When mothers reported they’d experienced more types of racial discrimination, such as mistreatment at work or when looking for housing, their children appeared to be biologically “younger” than their chronological ages of between 3 and 7. Children of mothers who didn’t report discrimination had about the expected biological age. (The study didn’t quantify how distressing the mothers found the discrimination.)

As people age, the way DNA expresses itself changes predictably, giving each person a biological age that might not be the same as the number of years they’ve lived. A sector of the anti-aging industry has keyed into this phenomenon with products that promise to reduce someone’s biological age, theoretically holding off both visible aging and diseases associated with late life, such as dementia and most cancers.

Prior studies have found an association between accelerated biological aging and health problems in adults, and established that adverse conditions in utero are linked to faster aging in adulthood, said Dr. Zachary Laubach, a research associate in evolutionary biology at University of Colorado Boulder and one of the researchers involved in the study.

For example, another recent study found that people who were fetuses during a famine in the Netherlands in winter 1944-1945 had faster biological aging than people who weren’t exposed, he said, and other studies found they had more midlife health problems. The science isn’t settled on whether the accelerated DNA aging caused those health problems, or if they both resulted from some other underlying mechanism.

Intuitively, then, slower biological aging might seem like a good thing, but that isn’t necessarily the case, said Dr. Wei Perng, an associate professor of epidemiology at Colorado School of Public Health and one of the researchers. The study didn’t look at whether the children were smaller than expected or met their developmental milestones later, so it can’t rule out immediate effects, and not much other information exists on aging in children, she said.

“A deviation we see from the population level (of aging speed) is probably not good,” she said.

The children’s aging might accelerate as they grow up, or they could hit puberty later, which would possibly shorten their fertile years, Laubach said. Alternatively, they might not see any clear differences.

For now, all they can say is that mothers’ experiences of racism have a noticeable effect on how children age, but not what that will mean for their health over time, Perng said.

“We weren’t trying to say, ‘This is good,’ or ‘This is bad,’” she said.

The study, published in the International Journal of Environmental Research and Public Health, examined lung tissue from 65 people with unexplained shortness of breath and other respiratory symptoms after deploying to Afghanistan or Iraq. Deployed veterans were more likely to have silica in their lungs than people who weren’t in the armed forces, with combat veterans showing more damage than service members who worked in other jobs.

People with combat roles tended to have a variety of unhealthy respiratory exposures, including burn pits, sandstorms, diesel exhaust, tiny particles generated by explosions, dust from heavy equipment on dry soil, and pollution from local industries or trash burning, said Dr. Cecile Rose, an occupational and environmental pulmonologist at National Jewish Health.

She and the other researchers didn’t think silica would be the primary contaminant they’d find in veterans’ lungs.

“That was unexpected, but not surprising” when considering their exposure to dust and sandstorms, she said.

People who inhale large amounts of silica over a prolonged period can develop silicosis, a disease in which inflammation in the lungs causes scarring and difficulty breathing, Rose said. Silica inhalation is one factor in the increase in cases of black lung disease among coal miners in recent decades, because the miners have to cut through other rock types to reach narrow coal seams, she said.

“Silica dust is a powerful stimulant of lung inflammation,” she said.

Lung samples taken from people who died in accidents and hadn’t deployed overseas during their lifetimes showed small amounts of silica, but not comparable to what the combat veterans had, Rose said. Because the veterans were younger and less likely to have smoked, if anything, their lungs should have looked healthier, she said.

People who inhale significant amounts of silica can reduce their likelihood of disease by limiting further exposures, but that may not be feasible for career soldiers, Rose said. They also would want to avoid civilian jobs that would increase their risks, like mining, stone cutting and certain construction trades, she said.

Not everyone who served in combat experienced the same hazards, and the country needs more research to determine who needs careful lung monitoring, Rose said. Combat veterans shouldn’t ignore lung symptoms, though, and might consider joining the Airborne Hazards and Open Burn Pit Registry to help with research, she said.

“We don’t really know how many people are at risk,” she said.

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GID BIO is conducting a phase 3 trial of a process that extracts fat from the patient, uses a chemical reaction to isolate cells believed to have regenerative properties and injects them into the patient’s knee.

Phase 3 trials typically follow hundreds or thousands of volunteers over at least one year to determine whether a treatment is effective and clarify what side effects it can cause, according to the U.S. Food and Drug Administration.

The trial isn’t enrolling patients in Colorado, but if the therapy gets FDA approval, doctors offices could easily adopt it here and around the country, said William Cimino, CEO of GID BIO.

While fat tissue may not appear interesting at first sight, it includes several types of cells, including ones that help rebuild connective tissue and blood vessels, Cimino said. Those same cell types are available elsewhere in the body, but they are highly concentrated in fat, and most people don’t mind giving up a bit of that particular tissue, he said.

Studying cell-based therapies in arthritis is difficult because people tend to report significant relief from placebos, creating a challenge in sorting out whether they experienced relief from the treatment because they thought they would, said Dr. Cato Laurencin, CEO of the Cato T. Laurencin Institute at the University of Connecticut, who studies fat-derived therapies but isn’t affiliated with the GID BIO trial.

That said, studies taking different approaches have shown indications that some of the chemicals produced in fat can help with tissue regeneration, he said.

“There is absolutely tremendous potential,” he said.

People think of the breakdown of cartilage — the cushion between bones — as what’s causing their arthritis, but often that’s not the most important factor, since bone and connective tissue also break down, Cimino said. Cartilage can’t regenerate, but the bones themselves and the tendons holding them together can, he said.

Patients wouldn’t see any difference in images of their knees after the injections, but have reported reduced pain and better functioning in the smaller studies before the current trial, Cimino said.

“This is unquestionably a cellular-level repair,” he said.

Chimeric antigen receptor T cell therapy, known as CAR-T, is a type of immunotherapy that involves taking cells from the patient’s body and altering them to attack cancerous cells that have specific proteins on their surfaces. The patient then gets the altered cells by infusion.

A study at University of Colorado’s Gates Institute on the Anschutz Medical Campus is looking at CAR-T in adult patients with acute lymphocytic leukemia, a cancer of the blood and bone marrow, whose first round of chemotherapy either failed or gave a disappointing response that suggests it won’t work for long, executive director Dr. Terry Fry said. (The institute is named for rubber manufacturer Charles C. Gates.)

This specific study is looking for safety and will have preliminary results next year. Assuming it doesn’t find any problems, a larger study would test if patients do better when receiving CAR-T rather than another round of chemotherapy, Fry said.

When a cancer therapy is new and carries unknown risks, typically the first patients who receive it are those who are out of other options, Fry said. If it works well and doesn’t cause unacceptable side effects for patients whose cancer resisted treatment, then researchers start looking into whether offering it earlier could make sense, he said.

“When we see something is successful, we forget that someone had to be that first patient” and take risks, he said.

Generally, people with the type of leukemia CU is studying have two options: chemotherapy or a bone marrow transplant, both of which can be grueling, Fry said. The advantage of CAR-T, when it works, is that the patient only has to take it once, he said.

“It can be advantageous to take a single treatment, get on with their life and have done with it,” he said.

While nothing is certain, people who don’t go into remission after being treated with chemotherapy often don’t do much better with another round, so if studies find that giving them CAR-T earlier is effective, that could spare them another round of ineffective treatment, he said.

“The current (drug) label requires us to force that patient to get another line of treatment so they can relapse, and then we can give them a CAR,” he said.

Immunotherapy carries its own risks, including secondary cancers, and a small number of patients have developed lymphoma after treatment with CAR-T for another blood cancer. Right now, it appears that developing lymphoma after CAR-T is “extremely rare,” and no one is sure if the CAR-T caused it or if the patients’ previous chemotherapy did, Fry said. Roughly 3% of patients who had one type of blood cancer develop a secondary cancer regardless of whether they received CAR-T, he said.

“It’s very rare that a cancer treatment is a free lunch,” he said. “So far, (secondary lymphoma) looks to be extremely, extremely rare.”

T cells are the part of the immune system that kills infected cells. In CAR-T, they’re altered to recognize and attack cells with selected proteins on their surfaces. Certain types of leukemia and lymphoma are relatively easy targets for CAR-T, because the type of white blood cell that has become cancerous has a protein that isn’t located elsewhere in the body, Fry said.

And since people can live without those cells for a time, so long as they receive antibody drugs to protect them from disease, wiping out healthy cells along with the cancerous ones doesn’t cause much collateral damage.

Developing CAR-T therapies for other cancers has been more difficult, Fry said. To develop a CAR-T that worked for solid tumors, they would have to find a protein on the surface of the cancerous cells that wasn’t widely present in the healthy organ around it, and solve other challenges that aren’t a factor with blood cancers, he said.

“I think we’ll eventually figure it out,” he said.

The U.S. Dietary Guidelines are based on reducing the risk of long-term health problems, like an increased risk of multiple cancers, diabetes and liver disease. They offer you a relatively simple answer, with a daily maximum allowance for cisgender men and women. (The guidelines don’t specify what transgender people should do.)

The question of whether alcohol is playing an unhealthy role in your life isn’t as straightforward, though, and is based on how well you’re functioning, rather than a drink threshold.

One rule of thumb is that alcohol is a problem if a person has injured themselves or someone else while drinking, or if family or friends have expressed concern about the person’s alcohol use, said Dr. Joseph Schacht, who studies alcohol use disorder at the University of Colorado’s Anschutz Medical Campus.

“If you are questioning how much you’re drinking, you probably should cut back,” he said.

No more than one or two a day

The U.S. Dietary Guidelines recommend no more than one standard drink on any day for women and no more than two drinks for men.

On average, women produce less of an enzyme needed to break down alcohol, and have less water in their bodies to dilute it. That means that women tend to develop health problems at lower levels of drinking than men do.

The guidelines are supposed to be a ceiling for each day, not an average; they don’t equate to having seven drinks on Saturday and then abstaining for the rest of the week. Also, a drink as the guidelines define it isn’t necessarily a typical serving, with the following counting as a standard drink:

• 12 ounces of beer that’s 5% alcohol
• Eight to 10 ounces of hard seltzer
• Five ounces of table wine
• Three to four ounces of stronger wines, such as sherry or port
• Two to three ounces of liqueurs or cordials
• 1.5 ounces of brandy, cognac or distilled spirits, such as whiskey or rum

If you’re not sure how much alcohol might be in your favorite cocktail, you can find out by trying the National Institute of Alcohol Abuse and Alcoholism’s online calculator.

What are you giving up?

When drinking is causing a problem in someone’s life now, rather than just setting them up for potential health problems later, that’s what’s known as an alcohol use disorder.

The disorder can be mild, if someone has two or three symptoms; moderate; or severe, if they have at least six symptoms.

Those symptoms are:

• Drinking more than intended
• Inability to cut down on drinking
• Spending significant time drinking or recovering after drinking
• Strong cravings to use alcohol
• Drinking interferes with life at work, home or school
• Alcohol use causes problems with friends or family
• Giving up other activities because of drinking
• Using alcohol in dangerous situations, or doing something unsafe while intoxicated
• Continuing to use alcohol even though it causes or worsens other health problems, or drinking until you black out
• Needing more alcohol to get the same effect
• Experiencing withdrawal symptoms (such as difficulty sleeping, shakiness or nausea) or drinking to avoid withdrawal

If some of those symptoms sound familiar, you’re not alone: The Substance Abuse and Mental Health Services Administration estimated about 12% of Coloradans who are 12 or older had an alcohol use disorder as of 2021. While the survey question changed somewhat, meaning the numbers don’t exactly compare to pre-pandemic data, it appears the prevalence of unhealthy alcohol use has gone up since 2019.

If you’re concerned about your drinking, the first step is to talk to your doctor about what options might work for you. Those range from visiting a counselor to talk about better coping strategies, to taking medication to reduce cravings, to short inpatient stays to make sure withdrawal doesn’t become dangerous.

The National Institute on Alcohol Abuse and Alcoholism has a resource where you can look up addiction treatment programs, as well as doctors and therapists specializing in addiction care. The state of Colorado also has a search tool called Own Path, where you can find providers offering care for mental health and substance use disorders.

If your first attempt to cut back isn’t successful, don’t get discouraged. A national survey found about half of people are able to stop or significantly reduce drinking in two or fewer tries, though the average is five tries because people with greater mental health needs tend to require more attempts. The journey isn’t always linear, though, and many people return to drinking more than they wanted to at least once.

Marc Condojani, director of adult treatment and recovery at the Colorado Behavioral Health Administration, said most people will recover from alcohol use disorder, and that in some ways, the odds are better than they ever have been. People looking for help have more options for peer support and sober housing, whether as part of a program or run democratically by people in recovery, he said.

“There are probably more people living in recovery… than who are struggling with active addiction,” he said. “Recovery is not just possible, it’s the expected outcome.”

The Denver Post is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center, The Center for Public Integrity and newsrooms in select states across the country.

The popularity of Dry January and Sober October brings certain advantages: bars are more likely to have a mocktail selection than they were a decade ago, and your friends will have heard of the concept of a dry month, even if they aren’t interested in trying one themselves.

But changing habits around alcohol is still challenging, and the odds of success are higher if you go in with a plan, said Dr. Jeremy Kidd, a member of the American Psychiatric Association’s addiction council.

While many people can stop or curtail drinking on their own, others need support from a doctor or mental health professional, he said.

Dry January presents an opportunity for people to reconsider the role alcohol plays in their lives, he noted, but the same strategies work regardless of the season.

Kidd recommended the following 10 tips for a successful Dry January:

1. 1. If one month seems daunting, try going without alcohol for a week, and then reassess.
   2. Set a specific goal, either to stop drinking altogether or not to exceed a certain number of drinks per day or week. Most of us don’t do well at keeping vague resolutions, such as that we want to “get healthy.”
   3. If you’ve noticed alcohol is primarily affecting one area of your life — say, that you argue more with your partner when you’ve been drinking — you might set your goal based on that. For example, in that situation, you can decide not to drink in situations that tend to be stressful.
   4. If you aren’t sure how much you drink, consider keeping track for a week. Keep in mind that drinks you buy at restaurants and bars may include more than one serving of alcohol.
   5. Ask your partner or a friend to support you in reducing your drinking.
   6. Come up with a plan to refuse if someone offers you a drink. You don’t have to give an explanation for why you aren’t drinking if you don’t want to. If you expect serious pressure, you could keep a nonalcoholic drink in your hand to deter offers.
   7. Consider how you’ll handle people, places and emotions that might tempt you to drink. Avoiding them may be the easiest approach in the short term.
   8. If you can’t avoid a triggering situation, remind yourself why you aren’t drinking, and that cravings fade.
   9. Remove alcohol from your home, and come up with alternative activities when you normally would drink.
   10. If you slip up, start again and don’t beat yourself up. Try again, and consider asking for more support.

People who have been drinking heavily every day for an extended time shouldn’t try to quit drinking on their own, because they risk dangerous withdrawal symptoms such as seizures and hallucinations, Kidd said. Medication can ease the withdrawal process.

Some people who don’t experience withdrawal nonetheless report the first few days can be rough, with more difficulty falling asleep and increased irritability. (Alcohol slows down the central nervous system, so when you take that away, the brain needs time to adjust.) Over time, though, most people report better sleep and more energy, and some have reduced anxiety or depression after a few months without drinking.

Even if a person doesn’t have physical symptoms, giving up drinking can bring up uncomfortable feelings that the alcohol temporarily soothed, Kidd said. If that happens, working with a mental health professional can help you learn healthier coping skills when anxiety or depression appear, he said.

“That gives them a chance to have a conversation with someone about how to manage that anxiety,” he said.

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The Denver Post is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering stories on mental health care access and inequities in the U.S. The partners on this project include The Carter Center, The Center for Public Integrity and newsrooms in select states across the country.

“It felt very round and hard, so that was pretty abnormal,” she said.

A biopsy confirmed she was right to worry: the lump was cancerous. And so Brown, a 22-year-old Loveland resident, joined the unenviable, growing group of young people fighting cancers that generally had been considered diseases of later life.

Nationwide, the rate of cancers before age 50 increased about 4.4% in women from 2010 to 2019, but decreased about 4.9% in men. Breast cancer accounted for the largest share of early diagnoses, though rates increased faster for cancers of the digestive system. Most of the increase came from people in their 30s, with rates holding steady for other groups.

It’s not just an American phenomenon, either: cancer diagnoses worldwide in people between 14 and 49 increased 79% between 1990 and 2019, according to a study in the British Medical Journal of Oncology. Some of the increase may reflect that more people are being screened for cancers before age 50 — meaning more tumors are likely to be found — but the study’s authors suggested other factors also are involved.

Dr. Virginia Borges, director of the Young Women’s Breast Cancer Program at UCHealth, said that while breast cancer is most common in older women, about 27,000 patients under 45 are diagnosed each year nationwide. It is significantly rarer in women in their 20s, and those who develop breast cancer that young usually have a clear genetic predisposition, she said.

That was the case for Brown. She knew she had a family history of cancer and was planning to get genetic testing, even before her diagnosis. When she did get tested later, she found out she had a variant of the BRCA1 gene that increases the risk of breast and ovarian cancers. She opted to get a double mastectomy, and might have surgery to prevent ovarian cancer in the future.

“It scares me more to possibly have to go through this again than to just do that,” she said.

BRCA1 and BRCA2 are the best-known genes linked to breast cancer, but there are seven others that appear to increase risk, Borges said. That’s why it’s important to know your family history, since tests that only look for a few genes may miss others that raise risk, she said.

Family history includes not only parents and grandparents, but any aunts, uncles or cousins who had any type of cancer, Borges said. While breast cancer is extremely rare in men, some of the same genes increase the risk of other cancers, so having multiple male relatives with cancer may be a warning sign, she said. Cancers that were diagnosed before age 50 are especially important to note, as are ovarian cancers.

If genetic testing uncovers a reason to be concerned about cancer risk, people can start their screening earlier, Borges said. Some women consider mastectomies or removing their ovaries or fallopian tubes, if they’ve given birth to any children they intend to have, she said. (Research suggests ovarian cancer may often start in the fallopian tubes, and removing them would give patients another preventive option without pushing them into sudden menopause, as removing the ovaries does.)

“These screening tests don’t prevent the cancer, but they can help catch the cancer early,” she said.

Earlier this year, the U.S. Preventive Services Task Force issued a draft recommendation that women at average risk start receiving mammograms at 40, down from the previous recommendation that they wait until they turn 50. High-risk women have the option to start even earlier, if they and their doctors believe it’s appropriate.

While genetics are a strong clue to whether a person may experience cancer early in life, not everyone who gets breast cancer at a young age has one of the clear risky genes, Borges said. There could be risk factors that stretch back generations, but right now, no one’s sure what they are, she said.

“There’s no clear pattern,” she said.

Dr. Mary Beth Terry, a professor of epidemiology at Columbia University, said it’s still not entirely clear why early-onset breast cancer is rising, but research has been able to rule out some simple explanations. While rising obesity may be a factor in the increase in gastrointestinal cancers and increase the risk of breast cancer late in life, women who have obesity are at no higher risk of early breast cancer than those who are leaner, she said.

Likewise, decisions about childbearing don’t appear to be the main factor, Terry said. The earliest American cancer registry, which covers Connecticut, shows early-onset breast cancer has been rising since the 1930s — before hormonal contraceptives came on the market, and through relative booms and busts in fertility. And today, breast cancer is rising in younger women both in societies where women are more likely to delay or forgo having kids and in those where the average family has half a dozen children, she said.

For a long time, the assumption was that early-onset cancers were genetic and later ones were caused by people’s environments and behaviors, Terry said, but research has shown that’s a false dichotomy. The exact mix of factors varies from person to person, though.

“Every cancer is because of your genes and your environment,” she said.

The most likely environmental factors contributing to the risk are increasing rates of heavy drinking among young women; changes in the average person’s diet; differences in childhood infections, which shape the community of bacteria living inside us; and chemical exposures during puberty, pregnancy, lactation and menopause, Terry said. Those periods are particularly significant because the breast tissue is changing, she said.

There is a link between an increased risk of breast cancer and even moderate drinking, but if women don’t want to entirely stop, they can reduce the risk by not binge drinking, Terry said. The Centers for Disease Control and Prevention define binge drinking as four or more drinks in quick succession for women, and five or more for men.

“If you take something in fast, and it’s a carcinogen like alcohol, your body can’t clear it and repair the damage,” she said.

One factor that temporarily increases breast cancer risk for young women is having a child, Borges said. Giving birth and breastfeeding decrease the risk of developing breast cancer after menopause — when most diagnoses happen — but for reasons that aren’t clear, the risk goes up for the 10 years after having children. That said, even women who have genetic risk factors for breast cancer should be able to have children, if they choose, she said.

“We want women who want to have a child to have a child,” she said.

People who develop cancer earlier in life have more time to live with potential adverse effects from both the tumor itself and the treatment. While breast cancer can be more aggressive in young women, especially young mothers, there’s a good chance of curing those patients if they discover the cancer early, Borges said.

That means it’s particularly important to keep young patients’ goals in mind, particularly whether they want to preserve the option to have biological children, she said. That can involve either harvesting eggs before beginning chemotherapy, or giving a drug that basically puts the ovaries into a dormant state, limiting damage to the eggs.

“It’s kind of like turning them into Sleeping Beauty under the glass,” she said.

While breast cancer is still far less common in younger women than in those who’ve been through menopause, it’s important to be aware of your body and get screened if something seems wrong, Terry said. Female firefighters and military members have a somewhat elevated risk because of exposures on the job, and new mothers need to know that pregnancy hormones can feed any small tumors that might have been present in their breasts, she said.

“Women know their own bodies, and doctors shouldn’t say, ‘You’re too young for breast cancer,’” she said.

Brown urged other young women to find out their family history, and to get genetic testing and early screening if they find something that concerns them.

In her case, the tumor was at stage two, meaning it hadn’t spread outside the breast and is likely to respond well to treatment.

“My cancer is not only treatable, it’s curable. If I hadn’t found it as early, it might not have been,” she said.