The Reality of Tumor Growth

A tumor the size of a dime, the kind we call an early cancer, already holds a billion cells. It has been growing for five or six years. By the time you can feel it, you are not at the beginning of anything. You are somewhere in the middle.

Flaws in Traditional Screening

We built our idea of catching cancer early around symptoms and around age. Screen at 45, at 50, when the guidelines say so. The vast majority of cancer diagnoses are found in older adults. But cancer is showing up younger, in people the guidelines miss, and a symptom you can finally feel has usually been years in the making. Balch’s point, made without any drama: age-based, one-size-fits-all screening is missing people.

A Tailored Approach to Prevention

Dr. Balch’s answer isn’t more scans for everyone. It’s first to educate everyone about the lifestyle choices that reduce risk, and then to know your individual risk through extensive family history and privacy-protected genetic screening. That is how you develop a personalized prevention and screening plan. And that starts with a question almost no one gets asked at a routine physical: what are you actually at higher risk for?

• Know your family history, not just your parents but cousins and grandparents.

• Know your lifestyle risk and act on it.

• And if you can, know your inherited genetic risk.

Put those together, and you and your doctor can build a screening plan tailored to you, instead of waiting for a symptom to make the decision for you.

I was screened twice a year for years because I was high-risk, and my care was built around that. Most people never get that conversation.

Topics Discussed with Dr. Charles M. Balch

• Know your risk: family history, lifestyle, genes

• Why “early” cancer isn’t early: the billion-cell dime

• Age-based screening is missing younger patients

• Immunotherapy that treats you, not the tumor

• Stage 3 melanoma cleared without a scalpel

• The cheap FIT test your doctor skips

• New blood tests: promise, and their limits

• Why knowing your risk is a gift, not a sentence

A Roadmap to Get to Know Your Risk

I’m pleased to offer you a place to start taking control of your risk: gettoknowmyrisk.org.

Further Resources

For subscribers: the three things Balch says everyone should know about their own risk, the cheap test your doctor probably never mentioned, the blood tests that didn’t exist five years ago, and why the news you’re most afraid of might be the best news you get.

• Listen to the full episode with Dr. Charles Balch:
  YouTube | Spotify | Apple | Everywhere

• Read the subscriber piece: Know Your Risk. Then Screen for It.
  

  Subscribe now

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She gave me her tennis racket. I was a kid about it. “Grandma, this is your racket. What about when you want to play?” She looked at me like I was sweet and a little slow and said, “Honey, if I can play tennis again, your grandfather is buying me a new one.”

Privately, she turned to him. Fifty years, and she told him he was no good alone. That it wasn’t good for him, and it wasn’t what she wanted for him. She told him he should date. She named the woman he should call. He protested that the woman was already seeing someone. My grandmother, dying, said, “Yeah. She won’t be. Give it time.”

She was right. When my grandfather started dating, months after we lost her, the whole family exhaled instead of bracing. Grandma had already handed us permission. She had done the most loving thing I have ever watched a person do, which was refuse to turn her love into a cage.

I told that story this week to Dr. Monique Nugent, a hospitalist, which means she is the doctor you do not get to choose and only meet when everything is moving fast. She spends her career in the five days that change a family. And she has a phrase for the trap my grandmother stepped around. She calls it “I love you, so I keep you around.”

Hear my story at Prescription for Admission and get Monique’s wisdom on Kicking Cancer’s Ass.

The day before we recorded, Monique had a patient in her nineties, a full code, meaning that if her heart stopped, she would get CPR, shocks, a tube, the ICU, all of it. Monique asked the adult child whether that was really what they wanted. The answer was, “Yes. I love my mother.” Love, here, meant: keep doing the thing that may be hurting her.

Monique wants us to think about love differently. Love does not have to mean prolonging suffering.

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Part of why we get this so wrong is the language we inherited. We talk about cancer as a war. You fight it, you beat it, she’s a warrior, she won’t lose. People hear the name of my show and assume I’m waving the same flag. I’m not, and the research is part of why. When researchers actually tested battle language, they found it backfires. In a set of studies, people shown “war” and “battle” framing of cancer became more fatalistic about prevention and no more vigilant about it. Fighting words made the disease feel more like destiny, not less. Monique put it more bluntly than any study: it is not a competition between your loved one and out-of-control lymphocytes. It is a human being, deciding how they want to live in the body they have.

The war frame does something quieter too. It makes honesty feel like treason. If stopping is “losing,” then nobody at the table can say the true thing out loud. So patients protect us. They hide side effects, they downplay the pain, they nod along, because telling the truth feels like letting everyone down. They may not even realize what the truth is. Among patients with advanced lung or colorectal cancer who were receiving chemotherapy that could not cure them, most did not understand the treatment was not going to cure them. Sixty-nine percent with lung cancer, eighty-one percent with colorectal. The gap between what people are told and what they can bear to hear is enormous, and it is widest with the specialists they love and don’t want to disappoint.

Which is exactly why the interloper gets the truth. Monique walks in as a stranger, and patients tell her everything, precisely because she has no stake in their performance. A husband can ask her to be the villain. A patient can admit they’re done. There is room to be honest with someone who isn’t keeping score of your hope.

I think this is partly a planning problem, and we can change how we plan and discuss our care preferences. The hard conversation is not just kinder. It measurably protects the people left behind. Patients with advanced cancer who had honest end-of-life discussions received less aggressive care at the end and, through that, their caregivers had better bereavement outcomes. And when families actually do the advance care planning, when wishes are known and written down, surviving relatives show less stress, anxiety, and depression. The conversation everyone avoids is the one that spares your family years of second-guessing.

Monique gave me the cleanest frame I’ve heard for why. There’s a difference, she said, between a decision-maker and a proxy. A decision-maker decides what they think is best. A proxy acts as if they are you. If you’ve had the conversation, if you’ve made the words come out of your mouth (“this is my line, I would not want to be tube-fed, I do not want to be intubated”), then your family never has to guess what you’d want. They get to honor you instead. That guilt that gets released, she said, is a gift. A huge one.

None of this requires a lawyer to start. If you want help finding the words, The Conversation Project has free guides built for exactly this kind of talk. When you’re ready to put it in writing, the National Institute on Aging explains living wills and health care proxies in plain language, and CaringInfo, run by the National Hospice and Palliative Care Organization, has free advance directive forms for every state. Print one. Fill it in imperfectly. You can change it right up to the last moment, as long as you’re of sound mind.

That is what my grandmother understood in her bones, decades before I had any research to hang it on. The tennis racket was not surrender. Telling my grandfather to find a new, loving partner wasn’t defeat. It was an instruction. She wasn’t quitting the game. She was telling the people she loved exactly how to keep playing once she couldn’t.

She gave away the racket so nobody would have to wonder. Then she guided my grandfather to enjoy his life with someone else.

Prescription for Admission - https://drmoniquenugent.com/podcast/

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Sources

• Hauser & Schwarz, “The War on Prevention II,” Health Communication (2019): https://dornsife.usc.edu/norbert-schwarz/wp-content/uploads/sites/231/2023/12/20_HC_Hauser_Schwarz_War_on_cancer_II.pdf

• Weeks et al., “Patients’ Expectations about Effects of Chemotherapy for Advanced Cancer,” NEJM (2012): https://www.nejm.org/doi/full/10.1056/NEJMoa1204410

• Wright et al., “Associations Between End-of-Life Discussions and Caregiver Bereavement Adjustment,” JAMA (2008): https://jamanetwork.com/journals/jama/fullarticle/182700

• Detering et al., “The impact of advance care planning on end of life care in elderly patients,” BMJ (2010): https://pubmed.ncbi.nlm.nih.gov/20332506/

• The Conversation Project, free end-of-life conversation guides: https://theconversationproject.org/get-started

• National Institute on Aging, advance care planning: https://www.nia.nih.gov/health/advance-care-planning

• CaringInfo (NHPCO), free state-by-state advance directive forms: https://www.caringinfo.org/planning/advance-directives/

That doctor is Dr. Monique Nugent, a hospitalist, and on this week’s episode she told me she said yes without flinching.

Dr. Monique Nugent understands something most of us are never told: the person who delivers the hardest news in a hospital is almost never your oncologist. It’s a stranger. And there is mercy in that.”

The Burden of Truth

Monique is a kindred spirit (with a lot more education than me). We are both people who have walked into rooms nobody wants to be in and decided to tell the truth there. What surprised me was how often families ask her to carry the unbearable sentence for them.

“A spouse who can’t say it. A patient who can’t tell their kids. They hand it to the interloper, the one who will be gone by tomorrow, because you cannot disappoint someone who isn’t staying.”

Conversations on Medical Time

We talked about why patients confess to strangers what they hide from the people they love. We talked about “medical time,” and the single question to ask before you let a diagnosis stampede you into a decision you didn’t have to make yet. And we both ended up crying, on mic, over the things people say at the very end.

There is a moment when Monique names what families most need to hear after a patient finally says, “I’m done.” They are not giving up. The subscriber article goes there, and somewhere harder. It also goes to my grandmother, and the afternoon she gave away her tennis racket and told my grandfather exactly who to love after she was gone.

That story is for paid subscribers this week, along with the research on why “fight” might be the wrong word for any of this.

Prescription for Admission - https://drmoniquenugent.com/podcast/

Listen to the full episode here: And if you want the rest, you know where the button is.

And if this is the kind of thing you want in your corner, subscribe. It’s free, and the people who need it usually don’t know it exists yet.

Subscribe now

The mammogram is due. You know it means a half day you can’t spare, a drive across town, a paper gown, and two days waiting for a call you’re afraid to answer. So it slides to next month, then next year. And that’s the easy version, the one where a machine exists within reach at all. For millions of women, the nearest one is hours away, booked months in advance, or not there. Screening is the tool we lean on hardest, and the one we’ve made hardest to use.

This week the World Health Organization put a number on that. New cancer cases, around 20 million a year now, are projected to reach nearly 35 million by 2050, and cancer is already the second leading cause of death in the world. The new WHO Global Status Report on Cancer 2026, built with the International Agency for Research on Cancer, lays out a wave we can still get ahead of, if we use the right tools.

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Most of the report’s prevention advice is correct, and you already know every word of it. Don’t smoke. Eat real food. Move your body. Nearly four in ten cancers can be traced back to risks like these. All true, and repeated for decades: warning people off cigarettes for sixty years, nagging them about food and exercise for forty, in so many pamphlets and campaigns that it stopped sounding like information and started sounding like weather. Correct advice nobody hears isn’t a strategy. It’s background noise. The science isn’t the problem. The marketing is.

Leslie Zane has spent thirty years proving this from the other side. Her brand consultancy, Triggers, and her book, The Power of Instinct, rest on one finding: the unconscious mind, not the reasoning one, decides what we trust, buy, and ignore. Winning brands don’t argue with you; they plant themselves in your instinct until choosing them feels automatic. I spoke with her last week, and my mind heard a novel approach to cancer control in everything she said about brands. Prevention runs the opposite play. It feeds the conscious mind statistics, and the conscious mind is barely driving. A cancer number is abstract; it belongs to a population, and the optimist in the back of your skull has already filed it under happens to someone else. It isn’t losing to bad science. It’s losing to a brain that saves its shelf space for what feels like it’s coming for you. The fix isn’t more facts. It’s the discipline Zane sells to the Fortune 100, aimed at the one product nobody markets: your own survival.

Buried in that same bucket are two novel and important things. The HPV vaccine stops the infection behind nearly all cervical cancer and much throat, anal, and other cancer. Not a lifestyle or a habit you white-knuckle for decades. A pair of shots cover you for life. And Helicobacter pylori, a common stomach bacterium, can be caught with a breath test and cleared with antibiotics, cutting the risk of stomach cancer, one of the deadliest in the world. Neither has anything to do with your genes; these prevention interventions work for everyone. Their problem isn’t that people don’t feel at risk. It’s that too few consumers know they prevent cancer at all. That’s the headline, and we keep printing it as fine print.

Genetics is the one thing that beats the optimism. “You could be at risk” is easy to shrug off. “You are at risk, and here is your number” is not.

A small group inherits a single high-impact mutation, for example, the BRCA1, BRCA2, and Lynch syndrome variants that carry heavy risk on their own, the 5 to 10 percent we’ve long called hereditary. The WISDOM study, whose first results were released late last year, found that 30 percent of women carrying one of those BRCA1 or BRCA2 mutations had no family history at all. The old rules, which test only people with a family history, would have missed every one of them.

The rest of us carry a quieter kind of risk: hundreds or thousands of tiny, common variants that mean little alone and a great deal together. A polygenic risk score reads that whole pattern and puts a real number on your susceptibility. WISDOM used those scores to move 12 to 14 percent of women into a different risk category than their age would have assigned. Some higher, some lower.

Two honest caveats, before anyone else raises them. WISDOM is a trial, not yet a guideline, so this is a direction rather than a settled protocol. And today’s risk scores were built mostly on European genomes, so they perform poorly on other ancestries. That is not a reason to wait. It is a reason to build on the science everywhere, which is already happening. At June’s ISOPT Congress, Dr. Ning Liao of Guangdong Province People’s Hospital showed that the inherited-risk map in Chinese breast cancer patients isn’t the Western one: their most common BRCA mutation is BRCA2, not BRCA1, and their tumor genetics diverge from the textbooks written on Western patients. Port a European tool onto them and you get the wrong answer. The fix is population-specific genomics, built group by group.

My mother was 36 when she was diagnosed. My sister was 29. Both are survivors. Both were more than a decade under the age the guidelines say screening should even begin. Their risk was real and early, and no calendar was ever going to catch it. A number would have.

A personal number turns a statistic into a reason to act, and the proof is in the people who already know theirs. In one international study, 64 percent of women who learned they carried a BRCA mutation chose risk-reducing surgery, most within the year, and close to 70 percent of Lynch syndrome carriers did the same within three years. A number gets people to the screening they would otherwise skip, and it fixes the burden we started with: send the intensive screening to the people whose biology says they need it, and spare the ones it was only ever going to frighten. Screen by risk, not by age alone.

Screening is one thing. Daily habits are another matter, and here the number alone is not enough. The same result that gets people screened doesn’t change what they eat or whether they move. The best trials handed people their genetic risk and found no change in diet or activity months later. That isn’t a character flaw. It’s how behavior works.

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Wendy Wood has spent three decades on this. Roughly 43 percent of what we do in a day is on autopilot, driven by context rather than intention, which means the scary statistic and the New Year’s resolve push on the wrong lever. Willpower is not the mechanism. Design is. You change a behavior by changing the cues and the friction around it, not by wanting it more.

So the move isn’t to try harder. It’s to build the behavior into your life so it runs without a daily vote. Here are two examples from my life:

I work out three times a week at 6:30 with my closest friend, same days, in person or on video. It isn’t a fitness plan; it’s our standing date, the way we actually talk. The workout rides along on something I already want, time with her, and neither of us bails when the other is waiting. Behavioral scientists call the pieces of that implementation intentions and temptation bundling. I call it the only reason I’m up at 6:30.

My husband and I turned Sunday into the farmer’s market and a couple of hours of prep together. A date, not a chore. By Sunday night, the good food is washed, cut, cooked, and at eye level in the fridge, so all week the healthy choice is the easy one and the junk takes effort. That’s Wood’s whole point: stop leaning on willpower and rearrange the friction.

None of that needs a genetic test. The test is what makes you commit; the habits are what make it stick.

So treat genetic risk as what it is: a public health catalyst, the thing that turns decades of ignored advice into action people actually take. To work at the scale the WHO is projecting, it has to be three things.

1. Accessible,
   So a risk score isn’t a perk for people who already have good doctors, and never one more thing the wealthiest systems have, and the rest don’t. The report’s own numbers show the stakes: five years after a breast cancer diagnosis, 87 percent of women in high-income countries are alive, against 42 percent in the lowest-income ones. Same disease, opposite odds, mostly a matter of access. A prevention tool that reaches only the countries already winning would widen that gap. The whole point is to close it.

2. Affordable,
   So knowing your risk never depends on the size of your paycheck.

3. And risk-free.
   The biggest reason people refuse a genetic test, if one is even available in their region, isn’t fear of the result. It’s fear of what the result will cost them everywhere else. In the United States, GINA, the Genetic Information Nondiscrimination Act of 2008, barred health insurers and employers from using your genetics against you. Good, as far as it goes, which isn’t far: life, disability, and long-term care insurers are still free, under federal law, to ask, to know, to charge more, and to turn you away. And GINA is only a US law; most of the world has nothing like it. Even nationalized healthcare only takes insurance pricing off the table. It does nothing about an employer who treats your result as a liability, or a community that looks at you differently once your DNA is on the record. Ask people to learn their risk while those doors stand open, and plenty decide they’re safer not knowing. The catalyst never fires.

Cancer cases doubling by 2050 is a projection, not a verdict. We already have a vaccine, a bacterial test, and the power to hand people their own risk as a number they can’t ignore. What we’re missing is the will to make all of it easy to reach, easy to afford, and safe to know.

You don’t pick the pitch. You control your swing. But first you have to see it coming.

I host a show called Kicking Cancer’s Ass. And I think they have a point.

The win-lose version of this is cruel. It turns the sickest people into failures. It tells a woman with metastatic breast cancer that she’s letting everyone down by not being upbeat enough on the days she can’t lift her head off the pillow. I’ve watched people apologize for being tired. For being scared. That framing did that.

So here’s what I actually mean when I say kick cancer’s ass, because it’s almost the opposite of what those critics think.

Redefining Authorship

Cancer reaches for the pen. It wants to be the only author of what happens next: how you spend your time, who you are, what your days feel like, how afraid you’re allowed to be. Kicking cancer’s ass is deciding, as much as you can, what role this thing gets to play in your life, and how you’re going to respond to it. It’s refusing to be nothing but a passenger in something that’s happening to you.

That’s the whole of it. Not the outcome. The authorship. The outcome often isn’t yours to choose. The response always is.

I didn’t arrive at that in the abstract. In January 2023, the day before a surgery meant to lower my odds of ever getting cancer, my surgeon called: the scan had come back malignant. The surgery to prevent cancer was off, because I already had it. I carry a BRCA1 mutation. My mother was diagnosed at thirty-six, my sister Tracey at twenty-nine, nine others in my family as well over time. I’d spent twenty years getting screened every six months, trying to time that surgery around my life, and I timed it wrong by about five years.

At my first oncology appointment, I was vibrating and focused. Not shaking. Vibrating. And in that room I decided this would be a project. I named it, my cancer obliteration project, and by the second round of chemo I had a spreadsheet to track side effects, medication, and mood.

Here’s where I have to be careful, because this is exactly where the toxic version sneaks back in. My spreadsheet did not cure my cancer. Twelve rounds of chemo and a team of doctors at the cutting edge did the medical work. Three weeks before my rescheduled surgery, my scans came back clinically complete. My oncologist said, whatever you’ve been doing, keep doing it. And I’d love to tell you I earned that with my attitude. I didn’t. Plenty of people do everything I did and don’t get that call. If your story turns out different than mine, it’s not because you wanted it less.

What the spreadsheet did was smaller and more important. It kept the pen in my hand. On the days I was frustrated, I still got to decide what would happen in the next 10 minutes. That was mine. Cancer didn’t get it.

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Taking Control of the Tone

Part of chemo is a port in your chest. Mine was a daily reminder of the five years I’d waited too long, so a friend renamed it. VoldaPort. The port that shall not be named. I introduced every new nurse and medical assistant to VoldaPort. They laughed every time. And I thanked them at the start of the appointment rather than at the end. By round six, they were taking care of me before I asked. None of that was fighting. That was me deciding the tone of my own treatment.

I built this show because everything that would have helped me on day one was scattered across a thousand moments that most people, thankfully, only have one or two of, but in a family like mine, you have enough to see patterns. In the first fifty-two conversations we’ve released with Kicking Cancer’s Ass, I close every one with the same question: what’s your advice for someone who wants to kick cancer’s ass? None of them answer with fighting. If the name meant what the critics think, every answer would be about being a warrior. They almost never are.

Hope as Data

This is a genuinely different moment to get cancer than the one my mother walked into at thirty-six. I’m alive in part because I knew I carried BRCA1, information her generation didn’t have. This past year, I’ve sat with scientists working on earlier detection, therapies targeted to the biology of a specific tumor, and immunotherapy that teaches your own body to do the work. Things that were science fiction when my family started losing people are now standard of care. People still die, and my family knows that better than most, but hope isn’t a poster on a hospital wall anymore. Increasingly, it’s data. Even the horrible killer, pancreatic cancer, is having a moment where detection could be much earlier, treatment more effective, and survival more possible. Which raises the stakes on everything else: taking hold of your role, asking the questions, and finding the team at the edge of what’s possible matter more now, not less. There’s more on the other side of it to reach for than there has ever been, at least in countries where cutting-edge screening, detection, and treatment are available. There is a long way to go on access and affordability, but the possibilities are there.

Kicking cancer’s ass was never about winning. It was never about being a warrior, or relentlessly positive, or strong enough to deserve a good scan. It’s about not disappearing inside your own diagnosis. It’s deciding who you’re going to be while this happens to you, what role you’ll let it have, and how you’ll respond. On the good days and the hard ones.

That part is yours. Whatever the scan says. And nobody- not cancer, not your worst day- gets to take the pen out of your hand unless you hand it to them.

That’s the whole show. That’s why I keep doing it.

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I host a show called Kicking Cancer’s Ass and this is our one year anniversary. And I think the critics are right.

The win-lose version of this is cruel. It turns the sickest people into failures. It tells a woman with metastatic breast cancer that she’s letting everyone down by not being upbeat enough on the days she can’t lift her head off the pillow. I’ve watched people apologize for being tired. For being scared. That’s wrong.

So here’s what I mean when I say kick cancer’s ass, because it’s almost the opposite of what those critics think.

It has nothing to do with winning. You can kick cancer’s ass and still die of cancer. I’ve sat across from people who are doing exactly that, living with disease that isn’t going anywhere, and to my eye they are kicking its ass every single day.

“Cancer reaches for the pen. It wants to be the only author of what happens next.”

Kicking cancer’s ass is deciding, as much as you can, what role this thing gets to play in your life, and how you’re going to respond to it. It’s refusing to be nothing but a passenger in something that’s happening to you.

That’s the whole of it. Not the outcome. The authorship. The outcome often isn’t yours to choose. The response always is.

I didn’t arrive at that in the abstract. In January 2023, the day before a surgery meant to lower my odds of ever getting cancer, my surgeon called: the scan had come back malignant. The surgery to prevent cancer was off, because I already had it. I carry a BRCA1 mutation. My mother was diagnosed at thirty-six, my sister Tracey at twenty-nine, nine others in my family before them. I’d spent twenty years getting screened every six months, trying to time that surgery around my life, and I timed it wrong by about one year.

At my first oncology appointment, I was vibrating. Not shaking. Vibrating. And in that room I decided this would be a project. I named it, my cancer obliteration project, and by the second round of chemo I had a spreadsheet.

Here’s where I have to be careful, because this is exactly where the toxic version sneaks back in. My spreadsheet did not cure my cancer. Twelve rounds of chemo and a team of doctors at the cutting edge did the medical work. Three weeks before my rescheduled surgery, my scans came back clinically complete. My oncologist said, whatever you’ve been doing, keep doing it. And I’d love to tell you I earned that with my attitude. I didn’t. Plenty of people do everything I did and don’t get that call. If your story turns out different than mine, it’s not because you wanted it less or did something wrong.

What the spreadsheet did was smaller and more important. It kept the pen in my hand. On the days I was terrified, I still got to decide what happened in the next ten minutes. That was mine. Cancer didn’t get it.

“The outcome often isn’t yours to choose. The response always is.”

I built this show because everything that helped me on day one was scattered across many people, the kind of thing that, in a family like mine, you’d call your sister to ask. Fifty-two conversations now, and I close every one with the same question: what’s your advice for someone who wants to kick cancer’s ass? Almost none of them answer with fighting. If the name meant what the critics think it means, every answer would be about being a warrior. They never are. One guest told me to make sure I was kicking in the right places, that managing a disease is sometimes wiser than trying to destroy it. Another told me the strongest move can be to become the soft person and let people take care of you. Another told me it’s very hard to be afraid while you’re laughing. None of those are war. Everyone is authorship.

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This is a genuinely different moment to get cancer than the one my mother walked into at thirty-six. I’m alive in part because I knew I carried BRCA1, information her generation didn’t have. This past year, I’ve sat with scientists working on earlier detection, therapies targeted to the biology of a specific tumor, and immunotherapy that teaches your own body to do the work. Things that were science fiction when my family started losing people are now standard of care. People still die, and my family knows that better than most, but hope isn’t a poster on a hospital wall anymore. Increasingly, it’s data. Which raises the stakes on everything else: taking hold of your role, asking the questions, and finding the team at the edge of what’s possible matter more now, not less. There’s more on the other side of it to reach for than ever before.

The Shift

If you are currently navigating a diagnosis, or supporting someone who is, consider these shifts in perspective:

• From Warrior to Author: You aren’t obligated to “win” a fight that relies on biology; you are simply tasked with choosing your response to the reality of the situation.

• From “Positivity” to “Presence”: Don’t apologize for being scared or tired. Acknowledging your reality is not a failure—it’s an honest way of taking the pen back.

• From Isolation to Connection: You don’t have to carry the burden of the “spreadsheet” alone. Look for your team, ask the questions, and remember that you get to decide the tone of your own treatment.

Kicking cancer’s ass was never about winning. It was never about being a warrior, or relentlessly positive, or strong enough to deserve a good scan.

“It’s about not disappearing inside your own diagnosis. It’s deciding who you’re going to be while this happens to you.”

On the good days and the ones where you’re vibrating in a chair.

That part is yours. Whatever the scan says. And nobody- not cancer, not your worst day- gets to take the pen out of your hand unless you hand it to them.

That’s the whole show. That’s the lesson my guests have shared, and that is why we keep doing it.

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It’s the advice almost every cancer patient hears when treatment ends. Dr. Jessa Landmann thinks it’s some of the worst advice in medicine.

Jessa is a naturopathic doctor who specializes in integrative oncology, which means she lives in the part of cancer most oncologists wave at on the way out the door. The fatigue that won’t lift. The joints that ache on a drug you’ll take for years. The sleep that fell apart and never came back. Her whole practice runs on one idea, and she said it plainly on the show: “Healing is a proactive process. It’s not a passive process. You can’t just sit around.”

Being proactive is the principle I used to get through my own treatment. Jessa is the one who can explain why it works.

Treating Side Effects as Preemptive

What makes Jessa worth an hour of your time is that she doesn’t treat side effects as the price of admission. She treats them as something you can often get ahead of. There’s a difference, she explained, between walking into chemo with a plan to prevent the nausea and fatigue, and walking in unprepared and spending the next six months playing catch-up. Same chemo. Completely different experience.

We covered a lot:

• Why fatigue is really about inflammation and your mitochondria, not weakness.

• Why she puts food and movement ahead of sleep when she’s untangling someone’s exhaustion.

• What the first 2025 meta-analysis actually found about high-dose IV vitamin C and survival, and why it doesn’t contradict a thing Dr. Lise Alschuler told us in October 2025.

• Why acupuncture for treatment of joint pain isn’t fringe at all.

The Power of Small Changes

One of her patients makes the case better than any study. Three months out of chemo. Joint pain, constipation, terrible sleep, energy at maybe a five out of ten. No new prescription. No supplement stack. Jessa changed one ordinary thing about this woman’s day, and her energy climbed to an eight.

I’m not going to tell you what it was here. It’s almost too simple, and that’s the point.

The full breakdown- the one change, the research behind all of it, and Jessa’s case for why prevention beats recovery- is in this week’s subscriber piece.

And if this is the kind of thing you want in your corner, subscribe. It’s free, and the people who need it usually don’t know it exists yet.

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What nobody tells you is what comes after. Often within the same week, the structure that held your life together for months simply ends. No more infusions on the calendar. No more nurses who know your name. Just a version of “good job, you’re cured, good luck,” and a door that closes behind you.

Then the fatigue doesn’t lift. Your hips ache at night on a pill you’ll take for five years. You sleep badly, or too much. You go back to your oncologist, and the answer, more or less, is to rest and give it time.

Dr. Jessa Landmann has built her career on the conviction that this is precisely the wrong answer.

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A Proactive Approach to Recovery

Jessa is a naturopathic doctor who specializes in integrative oncology, and her work lives in the territory conventional care rushes past: what happens to the body after the cancer is gone.

“Healing is a proactive process. It’s not a passive process. If someone said just rest and just give it time, that’s actually probably not very good advice.”

Understanding Cancer-Related Fatigue

Start with the fatigue, because it follows survivors furthest past the finish line. Most people assume exhaustion means their body is weak or they aren’t trying hard enough. It isn’t, and they are. Cancer-related fatigue is increasingly understood as a problem of inflammation and mitochondrial dysfunction.

Mitochondria are the engines inside your cells; chemotherapy damages them and leaves the body inflamed, and the result is an energy system running at a deficit long after the last infusion. That’s not a character flaw. It’s cell biology. Which means the levers that move it are biological too: what you eat, how you move, how you sleep.

The Power of Movement and Nutrition

This is where Jessa’s head-to-toe approach begins, and the order surprises people. Nutrition comes first, then physical activity, then sleep, though she’s quick to say it isn’t a strict ranking. The movement piece connects to something Dr. Jay Harness walked us through earlier in the series. Exercise is not just good for mood. A landmark 2025 trial called CHALLENGE found a structured exercise program cut the risk of recurrence by 28% and death by 37% in colon cancer survivors. More muscle means more mitochondria, Jessa points out, which means more energy. The thing that feels impossible when you’re exhausted is also one of the most powerful tools you have.

Integrative Tools: Vitamin C and Acupuncture

Some tools start during treatment and continue to work well into recovery. Jessa is precise about high-dose IV vitamin C, and so was Dr. Lise Alschuler when she was on the show. They agree completely, which is worth saying out loud, because the internet is a mess on this. Oral vitamin C and high-dose intravenous vitamin C are not the same drug.

At the very high doses delivered via IV, vitamin C ceases to act as an antioxidant and becomes an oxidant, generating hydrogen peroxide, which is toxic to cancer cells. In 2025, the first meta-analysis of intravenous vitamin C found it associated with significantly longer overall survival. For survivors, the part that matters most is inflammation, which Jessa calls the root of most lingering side effects. Research on people receiving chemotherapy has linked IV vitamin C to less fatigue and nausea, better sleep, and improved quality of life, with relief persisting after treatment. “It’s not vitamin C or bust,” she said. It’s one tool among many.

Acupuncture is another, and it carries an endorsement that surprises skeptics. The Society for Integrative Oncology and the American Society of Clinical Oncology recommend acupuncture for the joint pain caused by aromatase inhibitors, the hormone drugs many breast cancer survivors take for years after treatment ends. This matters beyond comfort. Up to half of women stop taking these drugs early, often because of that pain, and stopping early is linked to higher recurrence. Managing the side effect protects the survivor.

Putting Philosophy into Practice

So what does this look like when it works? Jessa told me about a patient three months out of chemotherapy: joint pain, fatigue, constipation, sleeping badly, energy around a five out of ten. The woman ate almost nothing during the day, then a full dinner at nine at night while driving her teenage boys to baseball. Jessa didn’t add a supplement. She moved the meals to breakfast and lunch and got her off the late dinners. Sleep improved because the body wasn’t digesting at midnight. Digestion normalized. Energy climbed to an eight. Then they added acupuncture for the Tamoxifen joint pain, and that held too. One ordinary change, then another. No heroics.

That’s the whole philosophy in miniature. “If we’re on top of the side effects and trying to prevent them from even happening,” Jessa said, “then by the end you can just move on. Otherwise you’re playing catch-up.”

I got through my own Stage 2A treatment by staying ahead of everything I could, and my doctors kept telling me I was doing it differently. The reason to listen isn’t my story. It’s that Jessa has turned what I reached for by instinct into something teachable, backed by research.

The end of treatment is not a finish line you coast past. It’s the start of the phase you have the most control over. Rest is not a plan. Healing is a verb.

Dr. Jessa Landmann’s book, Beyond Cancer Fatigue: A Path to Reclaiming Energy, was published by Wiley in April 2026.

Sources cited in the full article

• https://www.mdpi.com/2073-4409/8/7/738

• https://pmc.ncbi.nlm.nih.gov/articles/PMC6101225/

• https://www.asco.org/about-asco/press-center/news-releases/movement-medicine-structured-exercise-program-challenge

• https://link.springer.com/article/10.1186/s12967-024-06016-7

• https://pubmed.ncbi.nlm.nih.gov/40613397/

• https://pmc.ncbi.nlm.nih.gov/articles/PMC8177022/

• https://ascopubs.org/doi/10.1200/JCO.22.01357

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Three men. Four time zones between them. Not one of them paused.

Loss of friendships.

Don said it first. Michael said “yep” before Don finished the word. Jay explained it the way only someone who lived it can: when you get diagnosed, the people back home either step up or they disappear.

Nobody hands you that brochure. We talk about scans and ports and the language of fighting. We don’t talk about the friend who stops texting back because your diagnosis scares him and he doesn’t have the words, so he just goes quiet, and one day you realize he’s been quiet for months.

Don, Michael, and Jay are three members of Man Up to Cancer, a nonprofit built on a simple, almost rude idea: men are smarter and stronger as a pack than as lone wolves. Don has beaten cancer three separate times. Michael was told his stage four was inoperable and went and got a second opinion anyway that was much more effective. Jay was diagnosed at 36, in the middle of the pandemic, doing chemo essentially alone while his wife Zoomed into appointments.

What they have now is not a support group. It’s a chat thread that runs all day, men who tell each other when their mental health is slipping, a 200-person retreat in the Poconos every September where grown men throw “I love you” around like it’s nothing. They didn’t get that from the friends who left. They built it. It’s called the Gathering of Wolves and they want every man facing cancer to join the pack. I’m honored to help - and please share this free post so that every man who feels isolated and alone in his effort to be strong facing cancer knows that the Wolf Pack is here for him.

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In the full piece this week, I get into the research says the friends who showed up may have mattered more to these men’s survival than almost anything their doctors did. Not as a feeling. As a measurable predictor of who lives longer and lives better. And what Man Up to Cancer figured out, maybe without naming it, is how to make that support automatic instead of something you have to go beg for at the worst moment of your life. These are Happiness Tripwires (catch me sharing the big idea on Friday, June 26, 2026 at TEDx Ypsilanti).

Listen to the episode here:

The full story and the science behind it are for subscribers:.
Your Old Friends Disappear and the Pack that Won’t

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The Reality of a Quiet Diagnosis

He had not felt at home in a while. Diagnosed at 36, healthy his whole life, physically demanding jobs in the military and the fire service, no family history, no warning. A little blood, some abdominal pain he could have blamed on stress. Then a colonoscopy in the middle of the pandemic, and a year and a half of surgeries and chemo he went through essentially alone; his wife Zoomed in from a parking lot because she wasn’t allowed inside. He had spent his entire life being the person who fixes things. Now he was the thing that couldn’t be fixed by anyone, least of all him.

The Grief Underneath

Here is what nobody warned him about. It wasn’t the chemo. When I asked all three men to name the thing nobody tells you, they answered in unison: the friends who leave. “The people back home either step up or they disappear,” Jay said. Don Helgeson, a three-time survivor, said he wouldn’t share his mental health low points with his regular friend group, only with these two men. Michael Riehle nodded along. This is the grief that lives underneath the diagnosis, and it has a particular cruelty for men, who tend, as Man Up to Cancer puts it, to “check out” when women would “reach out.”

I want to tell you the disappearing friends are just a sad footnote. They aren’t. They may be the most dangerous part of the whole thing.

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The Actuarial Cost of Isolation

In 2010, researchers Martin Pinquart and Paul Duberstein pulled together 87 studies of cancer patients and found that people with high perceived social support had a 25 percent lower risk of dying than those without it. A larger social network, 20 percent. That same year, Julianne Holt-Lunstad’s team published a meta-analysis of 148 studies and more than 300,000 people showing that strong social relationships were associated with a 50 percent greater likelihood of survival, an effect they measured as comparable to quitting smoking and larger than the effect of obesity or physical inactivity. Read that again. The friend who stopped texting back was not a feelings problem. On the actuarial tables, his disappearance sat in the same column as a pack-a-day habit.

So when these men describe what the friends who left took with them, they are describing, without the citations, a withdrawal of one of the strongest predictors we have of who survives cancer and who finds any quality of life inside it. And when they describe what Man Up to Cancer gave back, they are describing the antidote being administered, on purpose, at scale.

The Problem with Support as Medicine

That’s the part I can’t stop turning over. Because the cruel thing about social support as medicine is that it arrives exactly when you are least able to go get it. You are flattened, bald, terrified, ashamed, and someone tells you community is the variable that matters most, so now you also have to summon the energy to build a community from a recliner. It’s like telling a drowning man that swimming lessons would have helped.

The Antidote: Automatic Community

What Don, Michael, and the late Danny Riggs did when they built the first Gathering of Wolves five years ago was take that impossible ask off the individual man. You don’t have to assemble a pack at your lowest moment. The pack already exists, and it comes to find you. There’s a buddy program now that pairs a senior wolf with a newcomer before the retreat, so a first-timer already knows one face when he arrives. One man, who’d never been to anything like it, told Don that knowing he’d be there waiting changed everything. Man Up to Cancer anticipates the needs of men facing cancer and meets them. The chemo backpacks ship to your door. The chapters, more than forty of them, meet whether you’re up to organizing anything or not. Two guys can apply for $100 to go to a baseball game. The support is not something you petition for. It’s the default. It’s automatic.

I have a name for this, from my own cancer years. I used to tell people I had an allergic reaction to pity, please don’t, and then I learned to give them instructions instead, the specific things that actually helped, so the people who loved me didn’t drift away from sheer not-knowing-what-to-do. I started calling them happiness tripwires: little mechanisms you set up in advance so the good thing happens to you without you having to ask for it in the moment you’re least able to ask. (And this Friday, June 26, I’m delivering a TEDx talk on Happiness Tripwires in Ypsilanti, MI - if you are nearby, please come join us, otherwise, look for the video in July). Man Up to Cancer is a happiness tripwire the size of a nonprofit. They wired the social support into the structure so that a frightened man would fall into it rather than climb toward it.

The Pack That Fills the Hole

Which brings me back to the hugging. At that first retreat there was a cornhole tournament, and someone wandered the grounds in a USA-flag speedo to distract the Canadian team. Year two, the toilets backed up and a three-time cancer survivor found himself unclogging a cabin commode an hour before dinner, thinking, I’ve come a long way in the cancer world, and this is where we’re at. They set aside time at the retreat to cry about the men who aren’t there, and then they tell jokes about them, because that’s what those men would want.

The friends who disappear leave a hole shaped exactly like the thing that keeps you alive. The genius of these men is that they stopped waiting for individual friends to be brave enough to fill it, and built a pack that fills it automatically, loudly, in a flag speedo, every September, on purpose.

Sources

• Pinquart, M., & Duberstein, P. R. (2010). Associations of social networking and social support with cancer mortality. https://pmc.ncbi.nlm.nih.gov/articles/PMC2910231/

• Holt-Lunstad, J., Smith, T. B., & Layton, J. B. (2010). Social relationships and mortality risk: a meta-analytic review. https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000316

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She’d been on the recommended dose of her targeted therapy. She’d known for weeks it was unlivable. She hadn’t told her doctor. She thought tolerating it was what a good patient did.

I knew Annabelle’s book before I knew her story. The End of My Life Is Killing Me: The Unexpected Joys of a Cancer Slacker is the funniest, most honest, and most useful thing I have read about living with an incurable diagnosis. Annabelle has been kicking lung cancer’s ass at Stage 4 for five years, on a targeted therapy she was told would stop working in eighteen months. She is alive because she stopped doing what she’d been told a good patient does. She calls herself a cancer slacker, not a cancer warrior. The phrase is funnier than it is, and more serious than it sounds.

What I did not expect, walking into the conversation, was how much of her experience I recognized in mine. I had Stage 2A breast cancer, called my treatment my cancer obliteration project, built a spreadsheet by the second round of chemo to stay ahead of side effects, and still found myself filtering in person. Two different stages. Two different prognoses. Same self-silencing.

In the deep-dive for paid subscribers: what the FDA is finally doing about a fifty-year-old assumption in cancer drug dosing, why the rules that determine who gets lung cancer screened are medical sex discrimination, why lung cancer research is funded at a fraction of its mortality burden, and my spreadsheet to estimate the financial impact of a cancer diagnosis. It’s free at joellekaufman.com.

A few minutes later she tells me about the night her son came home from college and found her unconscious in front of the toilet.

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This was not at diagnosis. She had already started treatment. Annabelle had the rare luck of an oncogene-driven cancer with an actionable mutation. Annabelle was diagnosed with stage IV non-small cell lung cancer with an EGFR (Epidermal Growth Factor Receptor) mutation (specifically, Exon21) in 2020, which meant a targeted therapy existed for her at all. The unlucky part started earlier. Worldwide, more than half of women with lung cancer are never-smokers. The U.S. Preventive Services Task Force requires a smoking history to qualify for lung cancer screening, and the agency has acknowledged its current evidence does not support changing that. The math is medical sex discrimination. Most women with lung cancer cannot get screened for the disease they are most likely to develop without smoking, because the screening criteria were built around a male smoking population. Annabelle, like every never-smoker, found her cancer by accident.

She was lucky a drug existed. She was less lucky about the dose.

The version of her targeted therapy she started on was the standard. The standard was the maximum tolerable dose. For Annabelle, maximum tolerable meant days when she spent more time asleep than awake. Days she couldn’t leave the bathroom. The side effects she now knows were warning her the drug was at a dose she could not survive long-term.

She did not tell her doctor.

She felt, she told me, that she was failing as a patient by not being able to tolerate the dose. She had absorbed the warrior idea before she ever rejected it on the page. So she pushed. So she suffered. So her son found her on the floor.

Annabelle is alive because she stopped.

She talked to her oncologist. She negotiated down. She has been on half the recommended dose for five years. She has stability. She has tolerable side effects. She is still working, still writing, still being kept honest by Shirley.

This is not a fluke. A 2024 retrospective study of first-line patients receiving the most-prescribed EGFR-targeted therapy in lung cancer found that the dose-reduction group had a median progression-free survival of 26 months, compared with 12 months at the standard dose. Half the dose. More than twice the time. The headline-friendly version is that lower can be better. The actual story is that we do not yet reliably know what the right dose is because, for fifty years, cancer drugs were approved at the maximum dose patients could tolerate, on the theory that more was better. That theory is being formally retired by the FDA’s Project Optimus, launched in 2021 by the Oncology Center of Excellence, with final guidance issued in August 2024. The new standard is the optimal biological dose, not the maximum tolerable one. The shift was overdue.

Annabelle calls herself a cancer slacker, not a cancer warrior. The phrase is funnier than it is, and more serious than it sounds. The day she walked herself back from the dose that nearly killed her was the day she gave herself permission to stop performing what a good patient looked like. The reframe runs deeper than the language. She also stopped trying to live like every day was her last, a framework she found exhausting and unworkable. Now she tries to live like it is her first day, led by curiosity. The shift sounds small. It is structural.

The shift only matters if patients tell their care teams what they are experiencing. Clinicians underreport patient toxicities. The research is settled on this. Symptomatic side effects, the ones that wreck quality of life and warn that a dose is wrong, are missed at high rates. Ethan Basch and colleagues at the University of North Carolina built the National Cancer Institute’s patient-reported outcomes version of the toxicity criteria specifically because clinician-only reporting was leaving real symptoms invisible. In phase 1 trials, patient-clinician agreement on symptomatic events has been characterized as moderate to poor.

My experience was different. Stage 2A breast cancer. I called my treatment my cancer obliteration project. My mother beat the same thing. My sister did too. I knew I was going to beat it. By the second round of chemo I had built a spreadsheet of meds, doses, side effects, time of day, what helped. The only way to stay ahead of side effects was to track them. I also knew I would still find myself filtering in person, in the small calculation patients make between not wanting to seem like a baby and not knowing if a symptom is worth a doctor’s time. The spreadsheet did the talking for me. My team spotted patterns. They cut my steroid dose to one-eighth of what I started on, because the higher dose was making me vibrate at four in the afternoon and I did not need it.

Annabelle’s answer was a dose conversation and a refusal of the warrior frame. Mine was a tool. Both are the same act. Both are a refusal to be silent in a system that has counted on our silence to call the trial done.

Lung cancer accounts for about 32% of cancer deaths in the United States and receives roughly 10% of cancer research funding. On a per-death basis, breast cancer research receives more than twenty-five times the federal funding small-cell lung cancer does. The smoker-blame story is part of why. The sex-discrimination story is part of why. Annabelle’s targeted therapy exists because researchers got funded. Most lung cancer patients do not have an actionable driver mutation and do not get her break. Most never-smoking women still do not get screened.

Annabelle named this herself at the end of our conversation. She said the most important thing you can do for your health right now might be how you vote. She meant it about research funding, environmental policy, and which patients are worth screening.

Before any of that catches up, here is what is in your control. Track what is happening in your body. Hand it to your team. Refuse the version of being brave that withholds the data they need to keep you alive.

Annabelle is still laughing at Shirley five years past her eighteen-month prognosis. The spreadsheet I built is free at joellekaufman.com. Annabelle’s book is The End of My Life Is Killing Me: The Unexpected Joys of a Cancer Slacker. Both are tools. Use them.

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Frankly, I cannot imagine facing that news with two young children and a lifetime of dreams ahead of you, and still finding a way to make your spouse’s happiness the rule you live by after he is gone. Heidi did.

A week after donating half her liver to Chad, she was sitting in the basement of a hospital in Seoul on Christmas, eating Domino’s pizza with her sister-in-law, while Chad was upstairs on a respirator learning how to breathe again.

Redefining the “Fight”

We talk about cancer like it is a fight. We talk about winning and losing. Heidi and Chad lost. He died at 46 of acute myeloid leukemia after years of treatment, a liver transplant in Korea that worked, and a bone marrow transplant on the East Coast that didn’t. By any rule the world hands you, Heidi lost.

Heidi does not call it losing.

There is a script we keep getting handed where the only good story is the survival story. After forty years inside cancer caregiving, in my own family and outside of it, I do not believe the script anymore. It is wrong, or at least incomplete, in a way that is costing people their healing.

Inside the Episode

Heidi has a way of putting it that I have not been able to shake. We get into:

• Running the diagnosis like a startup: How she and Chad approached his treatment strategically.

• The day in Gangnam: How she ended up alone on a day she should have been at the ICU, and why she calls it the day she put her oxygen mask on.

• The North Star: How a mantra Chad gave her in his own third person became her guiding light.

Deep Dive for Paid Subscribers

The full piece for paid subscribers goes into the research catching up to what Heidi already knows, the rare disease the world is finally learning to name, and the clinical trials Chad’s death helped make possible. If you have ever loved someone through a fight you didn’t win, this one is for you.

• Watch here on YouTube:

• Read the full piece: [paid Substack link]

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Chad was 46. A startup guy with a PhD in computer science. No smoker, no drinker, fit. He had elevated liver enzymes for fourteen years before anyone could explain why. By the time the picture clarified, in 2017, he had cryptogenic cirrhosis on top of myelodysplastic syndrome with a TP53 mutation, which the biopsy report described in two unmistakable words: poor prognosis. The MDS progressed to acute myeloid leukemia. His marrow needed a transplant. His liver needed a transplant. Either one was risky on its own. Together they were a puzzle most American hospitals would not touch.

Running the Diagnosis Like a Startup

TP53 is known as the guardian of the genome because of its protective role. When it is mutated in MDS, the survival numbers fall off a cliff. Contemporary reviews still frame transplant for TP53-mutated MDS as “utility or futility,” with early relapse rates that gut the curative intent. Heidi and Chad were not delusional about any of this. The first useful piece of advice they got came from Heidi’s sister-in-law: run it like a startup. They were both startup people. They knew most startups don’t make it either.

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Founders cannot make the odds better. They can make the choices. Heidi and Chad got on planes. They flew to a hospital on the East Coast, where they got their first usable plan: come off chemo long enough for a liver, then go back on long enough for a marrow transplant. Then they found out Chad had been removed from the U.S. liver transplant list. His co-morbidity made him a bad bet for a deceased-donor liver. So Heidi offered him half of hers, and they flew to Seoul, where one of Chad’s doctors had connections.

South Korea performs more living-donor liver transplants than almost any other country. The center where Chad was treated was doing close to 400 a year.

Korea performed 1,188 living-donor liver transplants in 2019, about 75% of all liver transplants the country performed that year. The United States, with six times the population, performed fewer than 600.

Putting on the Oxygen Mask

That is the part of the story most caregivers will recognize. Heidi was alone in a country she did not know, recovering from major surgery, with her husband in an ICU bed where the machines were doing his breathing for him. Her sister-in-law came for a stretch. A Domino’s pizza in a hospital basement was the high point of a holiday.

One day, weeks in, Heidi got on the subway and went to Gangnam. She walked K-Pop Road. She ate hummus at a Middle Eastern restaurant because she had eaten too much Korean food. She calls it the day she put her oxygen mask on, and the specifics matter. “Put your oxygen mask on first” gets said to cancer caregivers as if it means something on its own. Heidi made it specific. K-Pop bears. Hummus. A reminder that there was a world she would rejoin.

Chad came home. They were home for four months. The bone marrow transplant happened in July of 2019. It never engrafted. The TP53 mutation, the cobwebs the nurses talked about, the body that had given so much to the liver transplant it could no longer fight a second battle. He died in October, 2019.

Defining Success Beyond the Outcome

Heidi does not call this losing.

There is a version of this story where the lesson is to fight harder, and another where the lesson is to let go sooner, and both are wrong. Heidi told me: I don’t like people to think the outcome defines the success. The research is catching up to her. A 2024 systematic review and meta-analysis in PLOS One found that post-traumatic growth among people bereaved from cancer is real, measurable, and correlated with social support, meaning-making, and the closeness of the relationship the caregiver had to the person they lost. Bereaved caregivers can, in the language of the literature, become genuinely changed for the better. Heidi calls that transformation “also a form of success.”

The Legacy and the Work

The work she is doing now is the proof.

• Advocacy: Heidi sits on the board of Team Telomere, the nonprofit serving families with telomere biology disorders, the umbrella diagnosis underneath Chad’s leukemia and his liver failure.

• Clinical Guidelines: After his death, she helped write a chapter for the second edition of the Telomere Biology Disorders: Diagnosis and Management Guidelines, published in 2022. Since the new edition came out, more families are getting diagnosed earlier.

• Research: She has funded a research grant in Chad’s name. There are two clinical trials in progress now that did not exist when Chad needed them. She calls them shots on goal. The cure, she likes to say, is her favorite four-letter word.

The Windows That Opened

Back to that basement in Seoul. A woman on Christmas. Half her liver gone. A husband upstairs who would die in ten months. What she could not see from there: her sister-in-law’s pizza, her kids learning to do their own laundry, a clinical guideline she helped publish, and the people she will never meet whose diagnoses came faster because of what she wrote.

The door of Chad closed, she told me. But many windows have opened.

That is the win.

Two weeks earlier she had finished chemo for HER2-positive breast cancer. The next morning she hiked Zion National Park. Then she hiked four more trails in Oregon, because resting was never the plan. As she put it, she had been resting through the entire stretch of treatment. By the end she was ready to go.

I did not flinch when she told me because I had done the same thing. E-bike six weeks after my mastectomy. Wakeboarding at three months. Weights all the way through chemo. The people who love us tell us to slow down, and they mean it kindly, and they are usually the reason we hesitate.

The instinct to move is more medical than the instinct to rest.

I never had the science to prove that. I just moved and trusted it. It turns out the research has been sitting there for decades, in journals oncologists were not reading.

In Episode 7, I sat down with Dr. Jay Harness, who spent his whole career cutting out breast cancer before he found it. What he discovered changed how I hear every “take it easy” a patient gets handed.

Behind the Paywall

In the full piece for subscribers, I get into what that research actually says, including:

• The trial that earned a standing ovation at the world’s biggest oncology conference last year.

• The line between brave and reckless that most people put in the wrong place.

Larissa did not ignore her doctor. She did something harder and smarter than that.

If you are in treatment, just out of it, or loving someone who is, this conversation is worth thirty minutes. Larissa is a yoga and mindfulness teacher who walked away from corporate law, and she talks about anger, fear, and the wall of wigs her three sons named like a woman who has decided exactly how to tell her story.

🎧 [Listen to the full episode here.]

Subscribers get the research, the citations, and the one question I think every patient should ask their oncologist.

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His whole voice changed. Vegas? What are you doing there? There are a lot of people there.

Two weeks earlier she had taken her last hard chemo infusion for HER2-positive breast cancer. Now she was about to drive to Zion to, in her words, hug a mountain.

The Instinct to Rest vs. The Science of Movement

His worry was real, and it was not about the hiking. Chemo knocks your immune system flat, and a casino in the middle of cold and flu season is a petri dish. Larissa knew that. She kept to her own suite, stayed outdoors, and went to hug a mountain instead of a blackjack table.

But underneath a doctor’s specific, reasonable caution sits a much older instinct, the one almost everyone aims at people in treatment without thinking: slow down, rest, let me carry that, don’t overdo it.

That instinct is the one that, more and more, the science says is wrong.

See Episode #7 with Dr. Jay Harness - Rest is Killing You - the science of Exercise Oncology

Larissa is a yoga and mindfulness teacher who spent years as a corporate attorney before she pivoted out of law for good. She talks about her body the way you talk about an instrument you have played for decades. When cancer arrived she was furious at it, and then she did the thing she teaches: she got underneath the anger, found the fear sitting under it, and got up and moved. By her own account she had been resting through the entire stretch of treatment. By the time the worst of the chemo was behind her, she was not looking for a sofa. She was looking for a trailhead.

Overcoming the Invisible Research

I should say up front that I am biased. A month before my own surgery, because I had to book the flights, I asked my plastic surgeon whether I could e-bike through vineyards in France. She looked at me and asked, “Will you use the e-bike part?” Yes. I had no interest in undoing fourteen hours of her beautiful work.

Six weeks after my bilateral mastectomy and reconstruction, I was “pedaling” through those vineyards. Three months out and cleared, I was wakeboarding. I lifted and did interval training the whole way through chemo. So when Larissa told me about Zion, I did not gasp. I recognized her.

Here is what neither of us could have explained at the time, even as we both did it on instinct, and what a surgeon named Dr. Jay Harness spent thirty-five years of operating without knowing. He told me on the show that he built some of the first integrated breast cancer centers in the country and performed mastectomies for three and a half decades before he stumbled onto exercise oncology, about eight years ago, when someone suggested he meet a woman named Andrea Leonard.

The science she described made his jaw drop. As he put it to me, “Why in the world did I not know about this?”

The answer was almost absurd. The research had been sitting in sports medicine and kinesiology journals since the 1990s, invisible to the oncologists treating the very patients it was about.

What the Guidelines Say Now

The old instruction was simple: rest, avoid activity, get on the sofa.

• The National Cancer Institute now says plainly that early exercise research contradicted that advice (NCI Cancer Currents Blog) and that the field of exercise oncology now includes more than 1,000 randomized trials.

• The American Cancer Society’s current guidance is close to the opposite of rest: survivors should build up to 150 to 300 minutes a week of moderate movement (ACS Nutrition and Physical Activity Guideline), plus strength work a couple of days a week, which eases the fatigue and treatment side effects most patients are told to simply endure.

Then last June the evidence stopped being suggestive and got loud.

The CHALLENGE trial, published in the New England Journal of Medicine, followed 889 colon cancer patients for nearly eight years (NEJM CHALLENGE Trial).

These results sit in the same neighborhood as chemotherapy. It earned a standing ovation at ASCO, and the journal ran an editorial telling oncology it was time to act (NEJM Editorial).

That trial was in colon cancer, so I will not pretend it proves the same numbers for Larissa’s breast cancer or my triple negative. The breast cancer evidence runs the same direction, though: physical activity after diagnosis is associated with a lower risk of dying from the disease (NCI Guidelines). Jay’s read was that my years of lifting had given me a real head start before I took a single drug. I’m sure Larissa’s yoga practice did the same for her.

Defiance with Discernment

Larissa did not ignore her oncologist. She heard the worry, mitigated the real part, and made her own informed call. I asked my surgeon before I touched that e-bike. The guidelines build in caution: get cleared, let surgical sites heal, protect an immune system that chemo has knocked down.

The point is not to overrule your care team. The point is to stop treating your body like glass, as research keeps insisting that movement may be part of what saves it.

Which brings me back to the elevator. Her oncologist heard Vegas and pictured crowds, germs, a body with its defenses down. Fair enough. So she stayed outside and pointed herself at a mountain, which is about the safest place a person with a flattened immune system can be, and which also happened to be doing her more good than a sofa ever would.

She hiked Zion the next morning. Then four more trails in Oregon, building her tolerance as she went, because that is how she does everything. Her oncologist wanted her safe. What she handed him was better than safe. She handed him a patient who was already doing the one thing the science keeps begging the rest of us to try.

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He looked at her chart, told her thyroid cancer wasn’t really “cancer-cancer,” and walked out.

She broke down crying. Alone in the room. Until his PA came back in and hugged her.

The Unseen Weight of a Second Cancer

This was the part that confused her. She’d done this before. Way harder the first time. Triple negative breast cancer, BRCA2, double mastectomy, chemo, hysterectomy, the works. This was supposed to be the smaller one. The easier one. It wasn’t.

She said it out loud while we were recording:

Why am I having this with thyroid cancer when I didn’t have it with chemo?

Most patients have felt some version of this and never had the language for it. The recurrence that hits harder than the original. The second time around that breaks you in a way the first time didn’t.

• Doctors call it: Anxiety.

• Survivors (and some therapists) call it: PTSD.

Both might be partly right. Erin’s experience pointed somewhere else, though. Somewhere specific. Somewhere that wasn’t about the cancer at all.

It was about a person she had the first time and lost the second time.

What We Are Exploring This Week

The deep piece this week is about what she had, what she lost, what the research says about the difference it makes, and what this means if you’re carrying a known mutation, navigating a recurrence, or staring down a fresh diagnosis from a system that hands you a list of doctors and a phone number.

If you’ve ever felt like the cancer itself was the easier part of cancer, this one is for you.

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Erin’s full episode is live now: Kicking Cancer’s Ass: Erin Gray

The deep article on what she lost (and how to ask for it back) drops to paid subscribers this week.

→ Subscribe for the longer article, transcript, and more ways to Kick Cancer’s Ass.

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Connect with Erin:

• Erin’s counseling website: www.bewellwithincounseling.com

• Erin’s podcast website: www.wickedpsychotherapists.com

What the surgeon said next mattered more than the diagnosis. Not the news. The choreography. Here is your oncologist. Here is when you’ll meet her. Here is the doctor who will do your hysterectomy. Here is your plastic surgeon. Here is the order of things. Erin had been carrying a BRCA2 mutation for over a year. She’d known this was coming. The surgeon didn’t hand her a packet. She handed her a map.

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Eight years later, Erin sat in the same doctor’s office with a different diagnosis: papillary thyroid cancer. Not BRCA-related. Unrelated to the first. By every clinical measure, smaller. Less aggressive. Less surgery ahead. She should have been the most prepared patient on the schedule. She fell apart. The oncologist she’d known for years told her thyroid cancer wasn’t really “cancer-cancer,” shrugged, and walked out. The PA came back in and hugged her while she cried. Erin’s reaction surprised her: I didn’t have this with chemo. I didn’t have this with the mastectomy. Why now?

The Power of a Guide

The first time, Erin had a guide, and the second time, she didn’t. A guide is the person who, after the diagnosis, says these words: here is what happens next, and next, and next.

For Erin, the guide was her breast surgeon. When the second diagnosis fell outside that surgeon’s territory, the guide didn’t transfer. Erin had to assemble a team from scratch. The cancer wasn’t the destabilizing thing. Not having a map was.

What I’m describing might sound like emotional support. It isn’t. It’s a documented clinical intervention with thirty-five years of outcomes data.

• The Harlem Hospital Pilot (1990): The first patient navigation program in the United States started at Harlem Hospital in 1990, led by surgical oncologist Harold Freeman. His patients had been arriving with late-stage breast cancer at survival rates that were a national scandal. After he built a navigation program that walked patients from suspicious finding to resolution, five-year survival in that population went from 39% to 70%.

What the Data Shows

The intervening decades have produced more evidence than most oncologists know how to act on:

Study / SourceKey Finding

2023 Systematic Review

(CA: A Cancer Journal for Clinicians)

Patients with a navigator were two-and-a-half times more likely to adhere to treatment. (Source)

2024 Systematic Review

(Current Oncology Reports)

Navigation improved treatment initiation in 70% of studies and treatment adherence in 71%. (Source)

What Erin lost between cancer #1 and cancer #2 was not soft. It was the thing the data says moves outcomes.

A Systemic Gap

Erin had a guide the first time because her breast surgeon happened to be the kind of doctor who conducts. There is no system that requires it.

The American Cancer Society funded Freeman’s pilot in 1990, and there are still only about 2,500 certified genetic counselors in the entire United States (Source), roughly eight per million people. If you find out you carry BRCA1 or BRCA2 today, you are stepping into the same gap Erin stepped into before her first diagnosis.

Erika Stallings, whose mother had BRCA2 breast cancer, called for a genetic counseling appointment and was told the next opening was five months out. (Source)

That is not anomalous. That is the system working as designed.

I had a guide on my own genetic diagnosis without realizing how lucky I was. I was the third person in my immediate family to learn I was BRCA1 positive - and I had assumed it for years prior. My mother and sister were already on the map. The route was drawn in pencil before I was born. I had a geneticist talk with me before and after the DNA test and she share the map of my choices.

But when I was diagnosed with cancer, my hospital did not have (and still doesn’t have for breast cancer) a patient navigation team to guide me through the process. I was lucky because I’d been a caregiver so many times before that I knew the map. Most people don’t.

Finding Your Map

If you’re newly diagnosed, or carrying a known mutation, or supporting someone who is: who is your guide?

Not the doctor with the most letters after their name. The person who tells you the next three appointments, the next three weeks, the next three decisions. If your team has not named that person, name them yourself.

• Ask the oncology nurse navigator at your hospital.

• Ask the genetic counselor’s office.

• Ask one of your doctors which person on the team to call first when you don’t know what to do.

The PA who hugged Erin in the exam room wasn’t supposed to be the guide for the second cancer. Nothing in the system told her to be. She just was. Sometimes guides appear. The rest of the time, you have to ask.

Matthew Zachary (episode 37) is leading a national movement for a Cancer Patient’s Bill of Rights that would include a patient navigator for EVERY person diagnosed in the US. It’s called WethePatients.org and worth a look.

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[00:00:00] Hello. Welcome to Back to Kicking Cancer’s Ass. The podcast for people who’ve been recently diagnosed or suspect they’re about to be and want information, they want, hope, they wanna know, how do I do this? How do I kick cancer’s ass? And I am so lucky today to have my guest, Dr. Erin Gray. Erin is not just a psychotherapist.

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Abraham Williams, 37 years old, was just diagnosed with an extremely rare form of bone cancer. She didn’t share the type, and I’m not going to guess at it. What she did share is that he’s facing the fight of his life, and she needed to focus her time and energy on supporting him - something incompatible with her job as Director of National Intelligence.

Anyone who has loved someone through cancer understands how she felt.

Abraham, to Tulsi, to their family, we are all pulling for you.

But one number triggers me.

Thirty-seven.

The curveball is getting younger

I never got to believe the comforting story — that cancer is something that happens later, to older bodies, with more warning. My family didn’t let me. My mother was diagnosed at 36. My sister was 29. I grew up knowing in my bones that cancer comes for people in the prime of their working lives, and that it does not wait for a convenient decade.

So I did the thing the comforting story lets most people skip: I assumed the worst about my own odds and acted on it years before I had any proof. I changed how I lived. I nursed each of my kids for a full year, partly because I knew it lowered my risk. I didn’t get genetic confirmation until my early 30s after two of my three kids were born, but by then I’d been pushing back for years. I did nearly everything in my power short of a preventive mastectomy. When I finally decided to do that…I was in my 50s, and that’s when I was diagnosed. In my family, that made me the late one. The exception.

I can’t prove that acting early bought me those years. There’s no clean experiment for the cancer you didn’t get in your 30s. But I believe it did. The difference between my timeline and my mother’s and my sister’s wasn’t that I was healthier; it was luck. But the fact that my cancer was found very early and highly treatable - that wasn’t luck. That was vigilance informed by risk assessment.

That’s why a 37-year-old with bone cancer doesn’t land on me as rare bad luck. It lands as a pattern I’ve watched my whole life. Early-onset cancer — diagnosed in adults under 50 — is rising across many cancer types, not just one. People in their thirties and forties are getting diagnoses their grandparents wouldn’t have seen until their seventies, if at all. Abraham is 37. He is not the exception we want him to be.

And for some of those people, the risk was knowable. Not the diagnosis — the risk. The loaded dice they were carrying without ever being told.

What “knowing” actually buys you

I talk about agency constantly in coaching, in this podcast, and in my own treatment. It’s finding the levers that are yours and pulling them hard.

Genetic risk assessment is one of those levers, and most people don’t know it’s sitting right there.

A small but real number of cancers — including some of the rare and aggressive ones — trace back to inherited risk you can identify with a test combined with family history (if known) and a lifestyle inventory. Not a maybe. A known syndrome, a known gene, a known elevated risk.

Take the most studied example in bone cancer. People with a particular inherited syndrome that raises their risk of sarcomas and several other cancers can enroll in a surveillance protocol built specifically for them — annual whole-body MRI, regular imaging, bloodwork, the works. No radiation, because their bodies can’t tolerate it, which the protocol accounts for. And it works. In one analysis, that kind of imaging caught 41 of 46 of this type of bone cancer at an early, treatable stage. Survival improves when you screen the people who need screening.

This is the whole reason I do this work

I don’t know whether anything could have changed Abraham’s path. Neither do you. That’s not the point. The point is the thousands of people walking around right now carrying a risk they’ve never been told about, who could be in a surveillance program tomorrow, whose stage-1 catch is sitting in a test they’ve never taken.

I had that warning. Most people don’t. The WISDOM study tested 46,000 women and found that 30% of those carrying a high-risk gene had no family history of breast cancer at all. A third. Under today’s rules, no one would have offered them the test. They’d have found out the way too many of us did — after they already had cancer.

That’s what makes me want to change the whole system. Knowing your risk shouldn’t depend on having the “right” family history, or the money, or a doctor who happens to think to ask. Every adult should be able to get a genetic risk assessment — comprehensive, private, and free — and everyone who comes back high-risk should be walked straight into the screening and the support that catches things early.

So don’t wait to be told you qualify. Ask about genetic counseling. Ask what risk assessment is available to you. Ask while you’re healthy — that’s when the answer is worth the most.

We can’t stop every curveball. But we are getting better, every year, at seeing them coming. And seeing them coming is how you get to swing.

To Tulsi and Abraham: I wish you the best of luck. I hope the cancer responds to treatment and that you are surrounded by people who bring you joy.

I always ask: What’s your advice for someone who wants to kick cancer’s ass? Mine, today, is this — find out what your risk is, and if you have high risk, be vigilant about the right screening protocol, lifestyle changes, and staying up to date on prevention and detection research.