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Here is what Dr. Sacha Howell told me at the Rise Up conference in San Francisco that I want every person with a daughter, niece, sister, wife, or female friend to know: the first genetic abnormalities that eventually lead to breast cancer appear in late adolescence. Not when the tumor shows up on a mammogram. Not in her thirties, when she finds the lump. In her teens. Quietly. Invisibly. Driven by the hormones that flood a young woman’s body every month from the time she gets her first period.

The cancer we diagnose at forty has, in a real sense, been twenty years in the making.

That changes what prevention has to mean. Prevention isn’t a middle-aged woman’s problem. It’s a life-course problem. And until very recently, the medicine for it has been stuck.

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For forty years, the answer has been narrow. If you are at risk for estrogren receptive cancers - tamoxifen or aromatase inhibitors. For triple-negative - Prophylactic surgery. And for women at risk of triple-negative breast cancer — the most aggressive form, and the one BRCA1 carriers are most likely to develop young — there has been no pharmacological prevention option at all. Just surgery, or active screening and hope.

Dr. Howell’s team found another possibility.

In November, they published a study in Nature — yes, that Nature — showing that a drug called ulipristal acetate, taken for 12 weeks by 24 premenopausal women with a family history of breast cancer, produced measurable changes in their breast tissue that look a lot like cancer prevention working at the cellular level.

The drug reduced the proliferation of luminal progenitor cells — the cells that turn into aggressive triple-negative breast cancer. It reduced breast tissue density on MRI. It restructured the collagen architecture. It made the tissue less stiff. Every one of those measurements is a known marker of reduced cancer risk.

And here’s where it gets complicated.

Ulipristal acetate is the same active ingredient in Ella, which, as Dr. Abigail Liberty explained on the show last week, has been on U.S. pharmacy shelves for twenty years as emergency contraception.

Your OB/GYN has prescribed it. European regulators paused it two years ago after five women out of nearly a million on the drug developed liver failure.

Five in a million. That’s 0.0005%.

At the same age, the rate of women dying from breast cancer is thirty times higher.

Statins and hormonal contraceptives carry higher complication rates than ulipristal acetate does. Both remain widely prescribed. Nobody is pulling them. Ella is available in the USA.

When I asked Dr. Howell why European regulators applied a stricter standard to a drug that prevents cancer than they do to the drugs millions of women take every day, he didn’t dodge: “We don’t know. We all agree it doesn’t really make sense.”

Two things you can do this week:

1. Listen to the full episode with Dr. Sacha Howell. If you have a family history, if you’re BRCA-positive, or if you’re one of the two-thirds of women who develop breast cancer with no family history at all, this conversation is for you.

2. Bring the Nature paper to your OB/GYN (DOI: 10.1038/s41586-025-09684-7). High-risk women don’t have oncologists yet — that’s the whole point. Prevention lives in your gynecologist’s office, and most gynecologists haven’t seen this study.

The full subscriber article goes deeper — into why progesterone, not estrogen, may be the real driver of triple-negative breast cancer risk, and why anti-progestins may be the first real pharmacological prevention option for the women who have, until now, had none.

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An American oncologist stood up. “Why aren’t we doing this everywhere?”

Dr. Howell, politely, said: “Well, you don’t have this drug in America.”

Dr. Abigail Liberty, an OB/GYN at OHSU who had flown to Manchester from Portland, stood up next.

That moment — one specialist knowing something another specialist didn’t, across a gap that has nothing to do with science and everything to do with how we’ve sorted women’s health into acceptable and unacceptable categories — is what this episode is about.

The Gap Between Two Worlds

Ella is ulipristal acetate, 30mg. It’s been in U.S. pharmacies for twenty years. It works by blocking the progesterone receptor — the same mechanism Dr. Howell found protective against pre-cancerous breast changes in his research.

OB/GYNs know it well. Most oncologists have never encountered it, because it lives in a corner of medicine — emergency contraception, abortion-adjacent — that oncology doesn’t visit.

The reason it hasn’t crossed into breast cancer prevention isn’t safety. The data on liver risk pulled from European fibroid markets show the same statistical rate as common antibiotics that nobody has pulled.

The reason is that we hold medicines associated with women’s reproductive choices to a different standard than medicines associated with conditions we’ve decided are serious.

Fibroids are serious. Breast cancer risk is serious. The drug sitting in the pharmacy is serious.

What You Can Do Today

Ask your doctor — or your daughter’s doctor, or your sister’s doctor — for advanced provision of Ella. A prescription you have on hand before you need it. Studies show it doesn’t change how often people use condoms. It doesn’t change sexual behavior. The only thing it changes is the time between identifying a risk and taking action.

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The full episode with Dr. Abigail Liberty is on Spotify, Apple Podcasts, and YouTube. Search Kicking Cancer’s Ass.

Subscribers: This week’s article goes into the biology — why progesterone may matter more than estrogen in breast cancer risk, what the luteal phase has to do with it, and the full three-layer case for why this drug hasn’t reached the women who need it.

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The science behind why progesterone — not estrogen — may be the overlooked driver of breast cancer risk. The research. The politics. And why the standard applied to this drug was different from the start. This week for subscribers.

A few years after my cancer treatment, a hormone specialist prescribed estrogen replacement. She was managing the full picture—cardiac health, bone density, and libido. These are legitimate concerns, and she was doing exactly what she was trained to do.

Four weeks later, my radiologist called me:

“Joelle, what did you do? Your breasts have been calm for years and now they’re lit up and I don’t like it one bit.”

The hormone doctor didn’t know what estrogen would do on a breast MRI. The radiologist didn’t know what the hormone doctor had prescribed. I was the only person in all three rooms, and I didn’t know enough to connect the dots.

This isn’t a story about doctors who failed; it’s a story about how women’s bodies are divided among specialists operating without awareness of one another. Oncology, Gynecology, and Radiology live in different worlds.

The Manchester Revelation: Progesterone vs. Estrogen

Two years ago, Dr. Abigail Liberty (OB/GYN at OHSU) attended a conference where Dr. Sasha Howell presented research on anti-progestins.

For forty years, breast cancer prevention has been organized around estrogen (Tamoxifen, Aromatase inhibitors). However, the science points to a different driver:

• The Luteal Phase: During the two weeks after ovulation, progesterone surges. Breast cells swell, immune cells flood in, and tissue remodels. Dr. Liberty describes it as the breast “preparing for battle.”

• The Risk: This monthly high-activity window has a high error rate.

• The Solution: Anti-progestins interrupt this cycle, keeping the breast in the quieter, lower-risk follicular phase.

The Invisible Medication

When an oncologist asked why this wasn’t being used in America, the answer was startling. The drug already exists—it’s called Ella (ulipristal acetate). It has been in U.S. pharmacies for twenty years as emergency contraception. The oncologists in the room had never even heard of it.

Three Barriers to Progress

The reason Ella hasn’t crossed into cancer prevention isn’t due to science, but three structural barriers:

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1. Stigma: Because it is used as emergency contraception, it faces social hurdles that make it harder to study for secondary uses.

2. Regulatory Entanglement: Because it is in the same class as medications used in abortion, it faces political scrutiny and artificial barriers.

3. Double Standard. In Europe, a higher daily dose of UPA was approved for fibroid treatment after showing a significant reduction in bleeding and pain in the PEARL clinical trials. When post-market data showed cases of drug-induced liver injury, it was pulled from the market. The liver injury rate was statistically equivalent to common antibiotics like Augmentin, antibiotics that remain on pharmacy shelves without question. The difference in treatment wasn’t a difference in risk. It was a difference in how seriously we take women’s pain. Fibroids are disabling. The standard applied to the drug that treated them was not the same as the standard applied to a drug treating a UTI. The drug was pulled because it treated “women’s pain” (fibroids), which is often taken less seriously than other conditions.

   The full episode with Dr. Abigail Liberty is on Spotify, Apple Podcasts, and YouTube.

Looking Ahead

Dr. Liberty’s goal is to study whether the current 30mg dose of Ella can replicate the tissue-protective effects seen in European studies. This coordination failure isn’t just a communication problem; it’s a policy and patient safety problem.

Dr. Sasha Howell — the researcher behind the Manchester findings — joins Kicking Cancer’s Ass next week. His work is the scientific foundation for everything Dr. Liberty is trying to build clinically. Together, these two episodes make the case that the coordination failure between specialties isn’t just a communication problem. It’s a research problem, a policy problem, and a patient safety problem.

The fix starts with the question your doctor isn’t asking yet.

💡 What to Ask For Today

• For Prevention: Ask your doctor for advanced provision of Ella (ulipristal acetate, 30mg). Having a prescription on hand reduces the time between identifying a risk and acting on it.

• For Hormone Therapy: If you are on HRT, ask your hormone specialist and your radiologist if they have compared notes. If they haven’t, you must be the one to connect them.

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Tim Baker, living the dream. He’s a surf writer with a beautiful family, walks to the waves when out of the blue, a stage four prostate cancer changed everything. And he’s gonna tell us a little bit about what happened about his book, Petting the Shark, and dating in your 50s as a cancer survivor.

Daniel Garza has been navigating health, identity, and intimacy, including AIDS, anal cancer, and ostomy, agoraphobia, sobriety with his partner Christian besides him. He’s lived the compounding effect of diagnosis after diagnosis on a relationship.

Mike Prescott and his beautiful wife Shirley join us. Mike overheard nurses casually discussing male castration and then found out it was for his case before anyone talked to him about what treatment might do to his sex life, after.

Three weeks after his prostatectomy, did I say that right guys? Three weeks after his prostatectomy, he found himself having suicidal thoughts, but now three, four years later, he and Shirley, who’s gone through her own cancer treatment are having more sex than before his surgery. So if you or someone you love has gone through cancer and is wondering if they’ll ever feel desire again, whether their partner sees them in the same ways or how to start the conversation,

Mike & Shirley (01:31.432)
You got it.

Tim Baker (01:32.258)
Mm-hmm.

Joelle Kaufman (01:56.876)
This is the guy’s version of sex and cancer. So welcome back. Welcome back to Kicking Cancer’s Ass, the podcast rewriting cancer story, putting you in control. I’m Joelle Kaufman, and today we tackle sex and cancer from the men’s perspective, what nobody tells you, what changes, and what you can do about it, with Daniel Garza, Tim Baker, and Mike and Shirley Prescott. Hi, guys. Thank you for being here.

Mike & Shirley (02:02.435)
to ask the public to rewrite the cancer story.

Mike & Shirley (02:21.705)
Thanks for having us.

Tim Baker (02:22.124)
Thanks, Joel.

Daniel G Garza (02:23.644)
Good to be here.

Joelle Kaufman (02:25.198)
So let’s just jump into it and let’s talk about, know, when the women were on, they said nobody brought it up. Nobody talked about what cancer treatment, what surgery was going to do to their sex life. How about for you guys? What did you not know about how cancer treatment was going to change your sex life? And what do you wish someone had said to you before it started?

Who wants to go first?

Tim Baker (02:56.642)
I could say I was given very little information about the nature of hormone therapy when I was prescribed it. I think there’s the kind of obligatory fact sheet that you’re given when you’re prescribed any medication. But it was pretty blunt. I think there was just a kind of statement that it would affect sexual function and libido, but there was no offer of any ways to manage those effects.

And I think it was more or less implied that that element of your life was over and behind you and you should just kind of get used to it, which was pretty disheartening.

Joelle Kaufman (03:37.994)
I would think so. On top of a cancer diagnosis, you’re told, and Tim and Daniel, I know you were both pretty young, and Mike, your story is you were not going to tolerate not having a sex life with your wife. And so how did that feel to hear such a thing? what did you do with that, Tim?

Mike & Shirley (03:58.25)
Well, it was the first office that I visited when I was diagnosed and I subsequently changed offices, changed practitioners after that, but I didn’t know anything at all about prostate cancer, I guess as most people know it just sneaks up on you. And so when I was in the room and the physician had given me the digital exam and

Joelle Kaufman (04:08.183)
No.

Mike & Shirley (04:28.125)
told me about the tumor size and things like that. That’s when he walked out and I could hear the nurses talking outside the door and they were talking about male castration. And I had no idea. It’s a lack of education on my part, what they were talking about. And so when they came back in, I said, who is the poor guy that’s going through male castration?

And they said, well, we’re talking about, you know, potential treatment for you. And it was, that was how I was approached with it. it was soon after that is when I changed physician offices, not that I don’t understand now in the education as to what they were speaking about, but they could have possibly explained it in a different way was

the way I look back on it now. So that was kind of my baptism by fire, so to speak, into the potential treatments. At that time, we didn’t know what a Gleason score on my situation was or anything. We didn’t know what the diagnosis was gonna be. That appointment was leading up to a test where they go in and take samples, the biopsies for prostate cancer.

I guess all I’m saying is that was before anything was ever even diagnosed. I was approached with that. So it scared me. I’ll be honest with you.

Joelle Kaufman (06:04.811)
I’m sure did. And Daniel, what about you? What was your experience?

Daniel G Garza (06:09.326)
Sure, so let’s talk about sex, baby. And there was no conversation about it. I think the idea when you go in for the diagnosis and they’re like, okay, so we have a treatment plan for you. You know, we’re to go deep chemo radiation and you’re going to be happy that you don’t have cancer anymore. And yes, there is definitely that grateful side that, yay, I don’t have cancer. But at the time, Christian and I, I was diagnosed on May 5th. Our anniversary was May 9th.

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Earlier that day, he’d caught himself on the sidewalk beside oncoming traffic, thinking about stepping into it. Not because of the cancer. Because nobody had told him there was a way back to the intimate life he and Shirley had built over 49 years of marriage.

His surgeon had listened. He’d done nerve-sparing surgery and told Mike to expect recovery in 18 to 24 months. But nobody talked about the in-between — those months when your body doesn’t work and your mind starts telling you it never will again.

A week later, his physical therapist — not his surgeon, not his urologist — handed him a piece of paper about a vacuum erection device. When Mike called his doctor’s office to ask why nobody had mentioned it, he learned they’d been using the device for 15 years.

Mike says that device may have saved his life. Not because it fixed everything overnight, but because it told him a path back to Shirley existed.

Only 5.4% of cancer patients say their healthcare provider brought up sexual health before treatment started. Five out of a hundred. The other 95 were left to figure it out alone — or never figure it out at all.

Tim Baker was 50 when Stage 4 prostate cancer took his testosterone, his libido, and eventually his marriage. Nobody offered alternatives. Daniel Garza’s anal cancer and ostomy took away the sexual identity he’d carried his entire adult life as a gay man, and no one on his team ever acknowledged the loss. Three men, three different cancers, the same silence.

In this week’s episode of Kicking Cancer’s Ass, all three sit down — along with Shirley — and get specific about what works, what doesn’t, and what they wish someone had said before treatment started.

Here’s what I’d ask you to do with this episode: share it with a man in your life. And the next time you or anyone you love faces a medical procedure — cancer or not — ask the doctor directly: how will this affect my sex life, and what are my options to preserve it? Because if 5.4% of providers are starting that conversation, the other 94.6% are waiting for you to bring it up.

The subscriber article this week digs into why that number is so low and what it would take to change it.

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One hour out of 8,000. That’s 0.01% of a doctor’s training dedicated to a side effect that will affect up to 90% of their female patients and up to 85% of their male patients.

How does that gap not close itself? Why does a medical system that performs nerve-sparing robotic surgery with extraordinary precision not require a single hour of training on what to say to the patient afterward about their sex lives?

The study’s authors, led by Jennifer Barsky Reese at Fox Chase Cancer Center, found that most programs relied on clinical exposure rather than formal instruction — fellows learn by watching practicing oncologists.

As the researchers noted, fellows whose training consists of watching clinicians who don’t discuss sexual health are essentially learning how not to have the conversation. The silence replicates itself.

And patients feel it. Only 5.4% of cancer patients in a 2024 survey said their healthcare provider initiated a discussion about sexual health before treatment. A separate study found 87% of patients reported treatment changed their sexual function, but only 27.9% were ever formally asked about it.

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Three men on this week’s episode of Kicking Cancer’s Ass lived inside that silence — and each one paid for it differently.

Mike Prescott told his surgeon before his prostatectomy that his sex life with his wife, Shirley, mattered. The surgeon listened, performed nerve-sparing surgery, and told him recovery could take 18 to 24 months. But nobody talked about the gap between surgery and recovery. Three weeks post-op, unable to control his bladder, convinced he’d never be intimate with Shirley again, Mike found himself beside oncoming traffic with thoughts he couldn’t shake. His physical therapist — not his surgical team — eventually handed him information about a vacuum erection device. When Mike called his doctor’s office to ask why nobody had mentioned it, he learned they’d had it available for 15 years. That device didn’t just help Mike recover sexually. He says it may have saved his life.

The clinical evidence backs up what Mike’s physical therapist knew. Vacuum erection devices are well-established, non-invasive tools for penile rehabilitation after prostatectomy — they increase blood flow and oxygenation to tissue that would otherwise atrophy during the recovery window. Erectile dysfunction after radical prostatectomy affects anywhere from 14% to 89% of patients, and nerve recovery can take up to two years. Surveys show 86 to 87% of urologists say they use penile rehabilitation protocols. The tools exist. The knowledge exists. They just aren’t reaching men when they need them most.

Tim Baker’s experience shows what the gap costs over time. Diagnosed at 50 with metastatic prostate cancer that had already spread to bone, Tim was started on hormone therapy that shut down his libido and erectile function almost immediately. Nobody offered Viagra, a vacuum pump, or intracavernosal injections — all options Tim later discovered through his own research. Without guidance on maintaining intimacy, his marriage ended. He describes hormone therapy as feeling like some essential part of himself was being drained away. Tim has now outlived his prognosis by years, and he’s dating again in his 60s — but that marriage didn’t have to end the way it did.

Daniel Garza’s story adds a dimension that most oncology training programs never touch. As a gay man, Daniel’s sexual identity was tied to a specific physical experience. Anal cancer and a subsequent ostomy didn’t just affect function — they dismantled how he understood himself as an intimate partner. He and his partner, Christian, were four days from their third anniversary at diagnosis. No one on Daniel’s treatment team asked how cancer would change his sexual life with his partner or helped them think about what intimacy could look like after. Daniel describes spending years wondering if he was enough for Christian, whether he should walk away for Christian’s sake. They’re still together, 14 years in, but that journey didn’t need to be so solitary.

There’s also a gender gap layered on top of the silence. One study estimated 80% of prostate cancer patients received some information about sexual dysfunction, compared with only 33% of breast cancer patients. That doesn’t mean men are well-served — Mike, Tim, and Daniel make that clear — but it means women are even less likely to get the conversation. And when I went through my own cancer treatment, the full extent of my sexual health guidance was: use condoms with your husband. We’ve been married since 1998. I have no ovaries. When I was finally nudged to ask why to use condoms, I learned it was to prevent pregnancy. A situation that was clinically impossible. That was my cancer and sexual health conversation.

So what changes this? Training and shining a light on the gap.

One hour out of 8,000 is not an oversight. It’s a message: this doesn’t matter enough to teach. That needs to change, and patients and advocates should be pushing medical schools and residency programs to make sexual health a required part of oncology training, not an afterthought.

Asking changes it. If you’re facing cancer treatment — or any medical procedure that could affect sexual function — ask your doctor before treatment starts: how will this affect my sex life, and what are my options?

Men should ask about vacuum erection devices, PDE5 inhibitors, and intracavernosal injections. Both men and women can ask for a referral to a pelvic floor physical therapist. Don’t assume your doctor will bring it up. The data says there’s a 94.6% chance they won’t.

And if you’re a partner, know that the shift from lover to caregiver is one of the hardest transitions in cancer — and one of the least supported. Daniel and Christian navigated it alone. Tim and his wife didn’t survive it. Mike and Shirley made it through because they both insisted their intimate life wasn’t negotiable. Couples counseling with someone who works with cancer patients isn’t a luxury. It’s a practical tool.

Nobody should have to overhear nurses discussing their own castration before anyone talks to them about what treatment will do to their body. Nobody should discover a device that could save their life from a piece of paper their physical therapist hands them as an afterthought. And nobody should be walking beside oncoming traffic because the medical system that saved their life forgot they were a whole person.

5.4%. We can do better than that.

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Sources:

1. Reese et al., “Hematology and Oncology Fellow Education About Sexual and Reproductive Health: A Survey of Program Directors in the United States.” JCO Oncology Practice, 2024; 20(6):852-860. https://ascopubs.org/doi/10.1200/OP.23.00499

2. ASCO Educational Book, “Sexuality After Cancer as an Unmet Need: Addressing Disparities, Achieving Equality.” (87%/27.9% statistic, gender gap data) https://ascopubs.org/doi/10.1200/EDBK_100032

3. Agrawal et al., “Enhancing Sexual Health for Cancer Survivors.” ASCO Educational Book, 2025; 45(3). (90% female / 40-85% male prevalence data) https://ascopubs.org/doi/10.1200/EDBK-25-472856

4. AUA News, “Penile Rehabilitation 2024: Where Are We?” (86-87% of urologists using rehabilitation protocols) https://www.auanews.net/issues/articles/2024/august-2024/aua2024-recaps-penile-rehabilitation-2024-where-are-we

5. Oncology News Central, “Sexual Health of Female Cancer Survivors Goes Largely Ignored, Experts Say.” Feb 2026. (5.4% provider-initiated conversation; fewer than half of fellowships training data) https://www.oncologynewscentral.com/oncology/sexual-health-of-female-cancer-survivors-goes-largely-ignored-experts-say

6. PMC, “The Use of Vacuum Erection Devices in Erectile Dysfunction After Radical Prostatectomy.” (14-89% ED rate, VED efficacy evidence) https://pmc.ncbi.nlm.nih.gov/articles/PMC3784970/

New episode of Kicking Cancer’s Ass. Apple | Spotify | YouTube

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When she finally found out about scalp cooling, she got treatment. She rang the bell. She is alive.

Get the episode: Spotify | Apple | YouTube | Everywhere

Eight percent of female chemo patients say they would refuse treatment rather than lose their hair. The U.S. sees roughly 300,000 new breast cancer diagnoses a year. That’s 24,000 women putting their lives at risk because no one told them about scalp cooling (cold caps). Scalp cooling has been FDA-cleared since 2015.

A 2022 national survey of oncology providers found that only a minority discuss scalp cooling with their patients consistently. The top reason cited for not bringing it up wasn’t lack of awareness of the technology. It was cost. Fifty-eight percent said they were concerned the patient couldn’t afford it — so they didn’t mention it.

They made that call before you sat down.

Bethany Hornthal led the five-year clinical trial that secured FDA clearance for scalp cooling in the United States. Then she watched insurance refuse to cover it, watched patients skip a treatment they didn’t know existed or couldn’t afford, and built Hair to Stay — a national nonprofit that has awarded over 8,000 subsidies to make scalp cooling accessible to patients who can’t pay the $1,500 to $3,000 out-of-pocket cost.

Two states (New York and Louisiana) now mandate private insurance coverage. Eleven more are moving. And Hair to Stay will still need to exist — because state mandates can’t touch Medicare or Medicaid, and the women those programs cover are among the most underserved patients in this country.

This episode covers what scalp cooling is, whether it applies to your treatment protocol, how to afford it, and what to say if your oncologist doesn’t bring it up.

For paid subscribers: the full article goes into the physician communication gap, the specific limits of the new state mandates, and a concrete action list for patients on private insurance, Medicare, and Medicaid — because the path forward is different depending on where you start.

Listen to the episode here:

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I want to thank Paxman for making this episode possible. When I was going through chemo at UCSF in 2023, I used their scalp cooling system. It worked. I kept my hair when I thought I’d lose it, which mattered more than I expected it would.

It’s the same technology that’s helped tens of thousands of cancer patients worldwide over the past 25 years.

This episode was recorded at the 2026 UCSF RiseUp for Breast Cancer Prevention & Women’s Health. Because of Paxman’s sponsorship, we can share research and insights from the UCSF RiseUp conference with you. If you’re facing chemo and want to explore scalp cooling, visit coldcap.com

When I submitted the claim, it was rejected. First, because of the location and procedure codes. Then, because it wasn’t explicitly listed as covered (it wasn’t listed as excluded either), in my durable medical equipment benefit. The wig would be covered. Then they made the claims process so deliberately confusing that most people would have given up. Countless hours of research, negotiation, and on-hold music — over a treatment that was FDA-cleared, oncologist-recommended, and already approved by the same company I was fighting.

What the data says about that conversation

A 2022 national survey of oncology providers published in JCO Oncology Practice found that while 62% of providers supported scalp cooling therapy always or most of the time, only 26% reported actually initiating those discussions with patients consistently. The leading reason for not bringing it up was financial — 58% cited concern about cost, followed by efficacy concerns (31%), staffing or facility limitations (24%), and safety (15%).

More than half of the oncologists who weren’t having this conversation weren’t having it because they assumed it was out of reach financially. A decision made on the patient’s behalf, before the patient was in the room.

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I want to thank Paxman for making this episode possible. When I was going through chemo at UCSF in 2023, I used their scalp cooling system. It worked. I kept my hair when I thought I’d lose it, which mattered more than I expected it would.

It’s the same technology that’s helped tens of thousands of cancer patients worldwide over the past 25 years.

This episode was recorded at the 2026 UCSF RiseUp for Breast Cancer Prevention & Women’s Health. Because of Paxman’s sponsorship, we can share research and insights from the UCSF RiseUp conference with you. If you’re facing chemo and want to explore scalp cooling, visit coldcap.com

Research on patient-oncologist communication consistently documents gaps between what patients want to discuss and what actually gets covered. In one survey of breast cancer and melanoma patients, 63% wanted to talk about the effects of cancer on other aspects of their life — only 35% actually did. Scalp cooling sits directly in that territory: it’s about side-effect mitigation, with identity, dignity, and daily life during treatment rolled into it. It’s also, in some cases, about whether a patient shows up for treatment at all.

Evidence suggests that up to 8–10% of women may consider refusing chemotherapy or opting for a less effective regimen specifically to avoid hair loss. That number has appeared in academic literature and state legislative analyses for years. It keeps surfacing because the underlying problem hasn’t been solved.

The legislative wins, and what they don’t cover

Two states have now mandated private insurance coverage of scalp cooling. New York and Louisiana were the first, with New York’s law taking effect January 1, 2026. As of March 2026, eleven states have active legislation. West Virginia’s bill passed both chambers and is heading to the governor. Seven additional states have pending bills: Kentucky, Massachusetts, New Jersey, Ohio, Pennsylvania, South Carolina, and Virginia.

That momentum is real. But a mandate requires a conversation to activate it. If a patient doesn’t know to ask, and her oncologist doesn’t mention it, insurance coverage sits unused.

There is also a harder structural limit. New York law applies to large-group fully insured policies — it does not cover self-insured employer plans, small-group policies, or government programs. Every mandate currently moving through state legislatures is built the same way: private insurance only. State legislatures have no jurisdiction over Medicare or Medicaid. The women most likely to be on those programs — older women, low-income women — are outside the reach of every bill being celebrated right now.

This is the gap Bethany Hornthal built Hair to Stay to fill. She spent five years getting scalp cooling through FDA clearance, only to watch the system fail to deliver it to the patients who needed it most. Over 8,000 subsidies and more than $5 million later, Hair to Stay remains essential not despite the legislative progress, but because of who that progress structurally excludes.

What to do, depending on where you start

The distance between a treatment existing and that treatment reaching you runs through your oncologist’s office and your insurance plan. Both gaps can be closed, but the path is different depending on your situation.

If your oncologist hasn’t mentioned scalp cooling, ask directly: “Am I a candidate for scalp cooling, and does your facility offer it?” Not every protocol is compatible. Blood cancers, lymphoma, leukemia, and immunotherapy-based treatments are generally not indicated. Breast, ovarian, and gynecologic cancers treated with the most common chemo regimens often are. Leading cancer centers, including Memorial Sloan Kettering, have developed standardized talking points to ensure patients receive consistent information about scalp cooling options and financial resources. The best centers have made this a system. Many centers haven’t.

If you have private insurance in a mandate state, Ask your insurer directly whether scalp cooling is covered under your specific plan type. The New York mandate applies to large-group fully insured policies — self-insured employer plans and small-group policies are excluded, even in states with laws on the books. Know what you have before assuming you’re covered. And if you are part of a self-insured plan, consider advocating with your Benefits Manager to add this low-cost benefit that maximizes the probability that a cancer patient can continue to work.

If cost is the barrier, regardless of insurance, Apply to Hair to Stay at hairtostay.org before assuming you don’t qualify. The application is designed to move fast enough to be useful before treatment starts. They prioritize underinsured and uninsured patients.

If you’re on Medicare or Medicaid: State mandates don’t apply to you. Hair to Stay is your primary resource. Paxman also maintains a Patient Assistance Program that functions as a safety net for patients who are underinsured or uninsured and meet the eligibility criteria. Pursue both simultaneously — treatment timelines don’t wait.

If your facility doesn’t offer scalp cooling: Ask whether another infusion site in your network does. Research suggests only roughly 40–60% of chemotherapy treatment locations currently offer automated scalp cooling. The facility you were assigned may not be the only option.

Listen to the full conversation with Bethany Hornthal on Kicking Cancer’s Ass: [LINK]

Sources and further reading

Novice M, et al. “Identifying Barriers and Facilitators to Scalp Cooling Therapy Through a National Survey of the Awareness, Practice Patterns, and Attitudes of Oncologists.” JCO Oncology Practice, 2022. https://ascopubs.org/doi/full/10.1200/OP.21.00273

Maryland Health Care Commission. “Health Insurance Scalp Cooling Systems Required Coverage — Legislative Study.” October 2025. https://mhcc.maryland.gov/mhcc/pages/plr/plr/documents/2025/hb1187_scalp_cooling_system_mandate_study.pdf

Medscape Medical News. “Two States Now Require Coverage of Scalp Cooling to Prevent Chemo-Related Hair Loss.” January 2026.

https://www.medscape.com/viewarticle/two-states-now-require-coverage-scalp-cooling-prevent-chemo-2026a10000ou

Paxman. “Momentum Accelerates as 11 States Pursue Scalp Cooling Coverage Legislation in the U.S.” March 2026.

https://www.prnewswire.com/news-releases/paxman-momentum-accelerates-as-11-states-pursue-scalp-cooling-coverage-legislation-in-the-us-302712661.html

Risk Strategies. “New York Large Group Insured Policies Must Cover Chemotherapy-Related Scalp Cooling Devices in 2026.”

https://www.risk-strategies.com/blog/new-york-large-group-insured-policies-must-cover-chemotherapy-related-scalp-cooling-devices-in-2026

Oncology Nursing Society. “Reimbursements Are Making Scalp Cooling More Accessible for Patients With Cancer.” November 2024.

https://www.ons.org/publications-research/voice/news-views/10-2024/reimbursements-are-making-scalp-cooling-more

Paxman Patient Assistance Program. https://paxmanscalpcooling.com/access-support/us-access-and-support/

Hair to Stay — subsidy application.

https://hairtostay.org

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00:07
Dr. Anju Nohria
Early cardiac damage can be silent. You don’t usually feel any symptoms from cardiac damage until you have overt heart disease.

00:18
Joelle Kaufman
What are the ways patients should be advocating for su…

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I found out almost 20 years later. Not from a cardiologist. Not from my oncologist. From a new gynecologist who specialized in survivorship care (see The Cancer Survivorship Gap: What Doctors Don’t Know About Life After Cancer with Dr. Mindy Goldman), who wanted to know whether my heart could handle HRT. The calcium score came back, and there were the calcifications. In someone who lifts weights three days a week, does cardio the other days, eats well, and has zero family history of early-onset heart disease.

Full Episode on: Apple |YouTube |Spotify

The leading killer of cancer survivors is heart disease. A 2024 meta-analysis found that cancer survivors are approximately 55% more likely to die from cardiovascular disease than the general population.

Dr. Anju Nohria directs the Cardio-Oncology Program at Dana-Farber Brigham Cancer Center. She works at the intersection that barely exists in most hospitals: where cancer treatment meets long-term cardiac risk. In this episode, she was explicit: heart damage from cancer treatment is usually silent. No symptoms. No warning signs. By the time you feel shortness of breath or chest tightness, you’ve already missed the best window to intervene.

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Two things from this conversation you can act on right now:

Know your treatment’s cardiac profile. Not every cancer drug damages the heart, but anthracyclines, Herceptin, and chest radiation all carry specific cardiac risks. Ask your oncologist: what are the long-term cardiac side effects of my treatment, and what screening should I be getting? The answer depends entirely on what you were treated with.

Check your blood pressure. Dr. Nohria was unequivocal: blood pressure is the single most important cardiac number to track. Under 130/80 is the target. If yours is elevated, monitor it daily for a week and bring that log to your doctor. It’s the one metric with the most impact on long-term heart outcomes.

My blood pressure was and is great…But I had other cardiac blood markers, and it’s easy to get comprehensive blood work and a CT calcium score if you want to be more aggressive in your cardiac health monitoring.

This week’s episode gives you the specific questions to bring to your next appointment and the information to understand the answers. For paid subscribers, I’m going deeper into the research on silent cardiotoxicity and the cardiac risk that comes with long-term estrogen deprivation after cancer treatment.

New episode of Kicking Cancer’s Ass. Listen wherever you get your podcasts.

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The population who experienced early menopause was both too small and historically died too young for research. Both of those factors are no longer true.

That gap between what the research shows and what patients are told is what this episode is really about. So I went looking for the data behind what Dr. Nohria described, and the picture is stark.

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The scale of the problem

A 2024 systematic review and meta-analysis published in Cancer Medicine, covering 136 studies from 16 countries with sample sizes ranging from 157 to over 7.5 million, found that cancer survivors face a 55% higher risk of cardiovascular death compared with the general population. That’s not limited to patients who received the most aggressive treatments. The elevated risk held across nearly all individual cancer types, from a 14% increase in testicular cancer survivors to a nearly threefold increase in brain and central nervous system tumor survivors.

A 2025 UK Biobank cohort study and meta-analysis of 104 published cohorts, totaling nearly 40 million participants, found a 34% increased cardiovascular risk among cancer survivors even after adjusting for competing risks. Notably, that association was consistent regardless of whether patients had received chemotherapy or radiation. That last finding matters. It suggests the relationship between cancer and heart disease is more complex than treatment toxicity alone.

And yet, as Dr. Nohria explained in our conversation, “people who have traditional cardiac risk factors, whether it be high blood pressure, high cholesterol, diabetes, obesity, sedentary lifestyle, smoking, are at higher risk for developing cardiotoxicity.” Those risk factors don’t pause during cancer treatment. They compound.

The silent damage problem

What makes this especially dangerous is that early cardiac damage is almost always asymptomatic. Dr. Nohria was blunt: “You don’t usually feel any symptoms from cardiac damage until you have overt heart disease.” The fatigue, the shortness of breath, the chest tightness that might signal a cardiac problem are indistinguishable from the side effects of cancer treatment itself. By the time symptoms are clearly cardiac, you’ve likely missed the optimal intervention window.

A 2024 JACC: CardioOncology expert panel review confirmed that current guidelines recommend annual clinical screenings and cardiovascular risk factor optimization for all cancer survivors, with additional testing for higher-risk patients. Yet the panel noted significant gaps in the existing literature regarding how to implement that surveillance effectively.

In other words, the guidelines exist. The infrastructure to deliver them to every cancer survivor does not.

For patients treated with anthracyclines specifically, the numbers are sobering. In a study of Hodgkin lymphoma survivors, anthracycline exposure increased the risk of heart failure by a factor of nearly three. For those who also received chest radiation at higher doses, the 25-year cumulative risk of heart failure reached nearly 33%. These are not small numbers. And they play out over decades, long after oncology has signed off.

The estrogen gap nobody’s watching

This is personal for millions of women who’ve been through cancer treatment and for me. My geneticists and OB-GYN recommended a prophylactic salpingo-oophorectomy to prevent ovarian cancer, which is notoriously difficult to detect early. It was the right call. Even knowing what I know now about the cardiac implications 20 years later, I’d make the same decision. Ovarian cancer is a threat you can remove. But removing my ovaries also removed my estrogen. And nobody connected that to my cardiac future for the next two decades.

Estrogen isn’t just about fertility. As Dr. Nohria explained, “estrogen is so important for making your blood vessels flexible. It’s important for cholesterol metabolism.” Losing it prematurely accelerates cardiovascular risk in ways that most care teams aren’t monitoring, especially when the surgery was preventive, and the patient isn’t being followed by oncology anymore.

The North American Menopause Society’s position statement is clear: women with premature or early menopause have higher risks of bone loss, heart disease, and cognitive disorders associated with estrogen deficiency, and hormone therapy is recommended at least until the average age of natural menopause unless contraindicated.

But here’s the bind: if you had estrogen-receptor-positive breast cancer (I did not), systemic estrogen replacement is generally off the table because it raises the risk of recurrence. The surgery that prevented one cancer removed a hormone your heart needs, and the replacement that could help your heart might feed a different cancer. That’s not a failure of any single doctor. It’s a failure of connection between specialties.

A 2025 consensus statement in Menopause from a 25-member multidisciplinary panel acknowledged that breast cancer survivors struggle with menopausal symptoms due to treatment-induced hormone deficiency, but that estrogen replacement is not recommended after breast cancer because it can increase the risk of relapse. The panel also noted that transdermal estradiol carries a safer cardiovascular profile than oral formulations, with a lower risk of blood clots and stroke. Vaginal estrogen, which isn’t absorbed systemically in meaningful amounts, addresses genitourinary symptoms but isn’t likely to protect the heart. Neither is approved for cardiac prevention, but transdermal delivery has some potential to provide some cardiovascular benefit with lower risk than oral estrogen.

A large study presented at The Menopause Society’s 2025 Annual Meeting found that women who initiated estrogen therapy during perimenopause had approximately 60% lower odds of developing breast cancer, heart attack, and stroke compared with those who started after menopause or never used hormones. The timing question matters enormously. And for women like me who had a prophylactic oophorectomy years ago, the timing window may have already closed.

Dr. Nohria suggested something important: depending on your cancer type, you may be able to take some form of estrogen supplementation, and the conversation should involve a subspecialist who understands the intersection of oncology and endocrinology. “Those people exist,” she said. “It’s just that they’re kind of siloed in the major academic oncology centers.”

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What you can do right now

If you’re a cancer survivor or someone who is a previvor who has done prophylactic cancer prevention, here’s what this research and this conversation point toward:

• Ask your oncologist for a cardiac risk summary based on your specific treatments. Don’t assume someone else is tracking this.

• Get your blood pressure checked and tracked regularly. Dr. Nohria called it the single most predictive cardiac metric.

• Consider comprehensive cardiovascular screening including blood work and CT calcium score.

If you went through early menopause because of treatment, ask about a referral to an onco-endocrinologist or a menopause specialist with cancer experience. Don’t assume your standard OB-GYN has the expertise for this specific situation.

Don’t stop managing your existing cardiovascular risk factors just because you’re focused on cancer. Cholesterol, blood pressure, blood sugar, weight, and exercise. None of these takes a break because you have a diagnosis.

The system is getting better at keeping us alive through cancer. It’s not yet good enough at watching what happens to our hearts afterward. Until it is, that job falls to us.

New episode of Kicking Cancer’s Ass. Listen wherever you get your podcasts.

Research sources cited:

• Ng et al. — “Cardiovascular mortality in people with cancer compared to the general population: A systematic review and meta-analysis,” Cancer Medicine, 2024

  https://onlinelibrary.wiley.com/doi/abs/10.1002/cam4.70057

• Mulder et al. — “Risk of Cardiovascular Disease in Cancer Survivors after Systemic Treatment: A Population-Based Cohort Study,” JACC: CardioOncology, 2025 https://www.jacc.org/doi/10.1016/j.jaccao.2025.03.008

• Tung et al. — “Cardiovascular disease risk in cancer survivors: a population-based cohort study from the UK Biobank, and meta-analysis of cohort studies,” Heart, 2025 https://pubmed.ncbi.nlm.nih.gov/40017970/

• JACC: CardioOncology Expert Panel — “Cardiovascular Considerations After Cancer Therapy: Gaps in Evidence and Expert Panel Recommendations,” 2024

  https://www.jacc.org/doi/10.1016/j.jaccao.2024.06.006

• Consensus statement on menopausal hormone therapy after breast cancer — Menopause, 2025

  https://journals.lww.com/menopausejournal/fulltext/2026/01000/menopausal_hormone_therapy_for_breast_cancer.13.aspx

• North American Menopause Society Position Statement — 2022 https://www.letstalkmenopause.org/our-articles/nams-2022-hormone-therapy-position-statement

• Chidi et al. — “When Women Initiate Estrogen Therapy Matters,” presented at The Menopause Society Annual Meeting, 2025 (reported by Contemporary OB/GYN) https://www.contemporaryobgyn.net/view/early-estrogen-use-linked-to-lower-disease-risks

• Zhu et al. — “Cardiovascular Mortality Risk After Cancer Diagnosis by County-Level Characteristics in the United States 2000–2021,” Cancer Medicine, 2026 https://pmc.ncbi.nlm.nih.gov/articles/PMC12935517/

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The standard dose of tamoxifen has been 20mg daily for five years since the 1980s. That dose was established because it worked in trials and it was safe, not because anyone asked whether a lower dose might work just as well with a fraction of the consequences. For decades, no one seriously ran that trial.

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Dr. Andrea De Censi is a world-renowned researcher who believes patients deserve the minimum dose to be effective. He looked. His TAM-01 trial tested tamoxifen at 5mg daily — a quarter of the standard dose — for three years. It cut breast cancer recurrence by more than half. Side effects were barely distinguishable from placebo. And here’s the part that should make you furious: there has never been a head-to-head trial comparing baby TAM to the standard 20mg dose. Because tamoxifen went off patent 30 years ago and there’s no financial incentive for industry to run it.

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My sister was diagnosed with breast cancer in 2003. Same gene as me. Same tumor type. She got four rounds of the Red Devil — Adriamycin and cyclophosphamide — because that was the standard of care. It worked. It also left her violently ill after every infusion and carried real risk of long-term cardiovascular damage. That was the trade oncology had decided was worth making.

Twenty-three years later, I sat in the same chair at UCSF and was offered something different. Twelve weekly low-dose infusions of carboplatin and Taxol. Less toxic. Less intense. If my tumor didn’t respond, we’d escalate. It responded. Pathological complete response. No evidence of disease. I kept my hair. My labs looked like I wasn’t having chemotherapy.

Same disease. Twenty-three years of research. Completely different trade-off.

The minimum effective dose question isn’t just about tamoxifen. Dr. De Censi is now asking the same question about metformin — a cheap, widely available diabetes drug — and what it might mean for cancer prevention entirely.

I talked with him about all of it. What he found. What it means for women navigating treatment and prevention decisions right now. And why he believes baby TAM is already a new standard of care that most women with hormone-receptor positive breast cancer diagnoses and high-risk lesions aren’t being offered.

The full episode is live on Kicking Cancer’s Ass wherever you listen.

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Subscribers get the full breakdown — the data behind baby TAM, the honest state of the metformin research, and the specific questions to bring to your oncologist before your next appointment.

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I don’t say that to be humble. I mean it literally. I had watched cancer move through my family for forty years. I knew how to read a pathology report. I knew which questions to ask and which doctors to push back on. I had good insurance, financial stability, and the experience to advocate well.

Most people don’t have any of that. And here’s the part that should make you angry: none of it should be required.

Matthew Zachary was 21 when he got his brain tumor diagnosis. Medulloblastoma is a cancer found predominantly in young children. After surgery and radiation, his oncologist recommended a preventative treatment plan that included two drugs that would have permanently destroyed his hearing and the nerve function in his fingers. His oncologist never mentioned those life-altering side effects. His family found out because his uncle, a geneticist, researched it before treatment started. Matthew was a piano prodigy, a composer, a producer. His hearing and his hands are essential to who he is.

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That’s not a story about one bad doctor. That’s a story about a system that assumes you either know how to navigate it, or you don’t — and if you don’t, that’s your problem.

Matthew spent the next two decades building what became the largest adolescent and young adult cancer ecosystem in the country. He knows this system inside out. And when I talked to him, he was direct about something most cancer organizations won’t say out loud: the advocacy infrastructure that exists today was never designed to give patients power. It was designed to raise money.

Now he’s trying to build the thing that has never existed in the United States: a real cancer patient voter bloc. WeThePatients.org. Fifty million Americans affected by cancer. Zero coordinated political power. He wants to change that, state by state, starting with three protections every patient should have and almost none of us do.

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This conversation will make you want to do something. That’s the point.

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Listen to the full episode wherever you get your podcasts, or watch on YouTube. And if you’re a subscriber, the full article goes deeper on what the research actually shows about what happens to cancer patients who don’t have someone in their corner — financially, medically, and in terms of survival.

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Joelle Kaufman: Out of patients. He was the host of Stupid Cancer. He is been podcasting and spreading, if you will, the gospel about a different way to think about cancer and higher expectations for patients to have of the system since 2007. He is a huge personality. He’s a force of nature. I’m so excited to have you…

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It took thirty-four years.

The first patient navigation program in the United States launched in 1990, created by Dr. Harold Freeman at Harlem Hospital, specifically to help underserved Black women access breast cancer care. The outcomes were immediate and measurable. Patients who receive navigation services have a shorter time to diagnosis and treatment, are more likely to complete their course of treatment, and report a better understanding of their condition, as well as an overall higher quality of life. Cancer Researchers have replicated those findings dozens of times since. And yet, for three decades, nurse navigators remained one of the most underfunded, inconsistently deployed, and frequently uncompensated roles in oncology.

That’s the backdrop for the conversation I had with Matthew Zachary.

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Matthew was 21 in 1995 when he was diagnosed with medulloblastoma, a brain tumor typically found in young children. He got through surgery and radiation. Then his oncology team recommended prophylactic (preventative) chemotherapy. The protocol included two drugs that would cause permanent hearing loss and irreversible nerve damage in his fingers. Nobody mentioned that. His family found out because his uncle happened to be a geneticist and caught it before the first infusion. The information existed. It just wasn’t offered.

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He refused the “preventative” drugs. His life was saved. But the experience left him with a question he has spent thirty years trying to answer: why does your outcome depend so heavily on what you happen to know, who you happen to know, and what you can afford?

What a Navigator Actually Does

When people hear “nurse navigator,” they sometimes picture someone who hands out pamphlets and schedules appointments. The research tells a different story.

In a quality improvement study on lung cancer care, oncology nurse navigator involvement improved time from biopsy to initial consult by 18% — and the average time from biopsy to treatment initiation for navigated patients was 25 days, compared to the national benchmark of 42 days. Getting to treatment faster matters. A diagnosis-to-treatment interval of fewer than 35 days is associated with improved survival.

Underserved, rural, and economically disadvantaged patients with cancer who are under the care of an oncology nurse navigator are better prepared to begin treatment and require fewer services than non-navigated peers. Regular check-ins with a nurse have also been shown to improve breast cancer survivors’ quality of life, reduce fear of recurrence, and support mental health compared to standard physician follow-up.

The problem is access. Navigation services are often funded externally through grants or treated as unreimbursed administrative costs because, until January 2024, there was no reimbursement mechanism. Which means whether you got a navigator depended almost entirely on whether the hospital you happened to walk into had grant funding to pay for one.

That’s not a care system. That’s a lottery.

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The Financial Side of This That Nobody Wants to Talk About

Matthew’s third protection — bankruptcy protections before treatment starts — is the one that most cancer organizations quietly sidestep. The data is hard to look at.

A 2024 Harvard Medical School study cited by US News & World Report, which was tracking nearly 100,000 cancer patients, found that survivors had five times higher odds of filing for bankruptcy compared to people without a cancer diagnosis. Their average credit scores were nearly 80 points lower — and the damage persisted for up to 9.5 years after diagnosis per ASCO. This was in Massachusetts, a state with mandated health coverage.

More than 40% of patients spend their entire life savings in the first two years of treatment. And that number doesn’t capture the full picture. Between 40% and 85% of cancer patients stop working during initial treatment, with absences ranging from 45 days to nearly six months. The mortgage doesn’t pause. The car payment doesn’t pause. The cost of getting to treatment — gas, parking, flights for those without a major cancer center nearby — doesn’t pause. Income stops. Everything else keeps going.

Cancer patients who declared bankruptcy had a nearly 80% greater mortality risk than those who did not, not because they had more advanced cancers, but because they had the same curable cancers, received the same treatments, and still died at higher rates.

Financial toxicity kills people. Not metaphorically. Measurably.

Matthew’s argument is that no patient should make decisions about whether to start, delay, or stop treatment based on what it will do to their credit score. Bankruptcy protections that activate before treatment begins — not after a patient has already lost everything — are the floor, not the ceiling.

Why the Voter Bloc Has Never Existed

Matthew is not subtle about this: the organizations that could have built a cancer patient voting bloc over the last thirty years didn’t, because their funding models depend on relationships with the same institutions that benefit from the status quo. Patient power was never the goal.

WeThePatients.org is built on a different premise. Fifty million Americans are affected by cancer. If even a fraction of them showed up to state legislatures with a unified ask — a reimbursable nurse navigator, a legally protected cancer steward, bankruptcy protection before treatment — the math changes.

He’s going state by state because that’s where health policy actually gets made, and because state legislators are more accessible than federal ones. He’s not waiting for the advocacy establishment to come around.

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What You Can Do Right Now

Listen to the full episode. Then share it with someone who has been through cancer, is in it, or loves someone who is. Not as a gesture — but because this conversation gives people language for something they’ve been feeling and didn’t know how to name.

The system was built for people who already know how to navigate it. Matthew is trying to change that. You can be part of it at WeThePatients.org.

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Links

• President’s Cancer Panel — Patient Navigation Report https://prescancerpanel.cancer.gov/reports-meetings/enhancing-patient-navigation-2024/achieving-equity-cancer-care

• Journal of Oncology Navigation & Survivorship — Lung Cancer Nurse Navigation Study (2024) https://jons-online.com/issues/2024/february-2024-vol-15-no-2/5031:incorporating-upstream-oncology-nurse-navigation-to-improve-timeliness-to-treatment-in-lung-cancer-a-quality-improvement-project

• HealthDay / U.S. News — Harvard/Beth Israel 2024 Bankruptcy Study https://www.usnews.com/news/health-news/articles/2024-10-18/a-cancer-diagnosis-takes-devastating-toll-on-family-finances

• STAT News — Financial Toxicity and Cancer Costs https://www.statnews.com/2023/05/23/financial-toxicity-cancer-costs-cost-sharing/

• PMC — Washington State Cancer Bankruptcy Study https://pmc.ncbi.nlm.nih.gov/articles/PMC4240626/