Know Your Risk. Then Screen for It.
For years, I called it my half-yearly I don't have cancer day.
Twice a year I got screened, and on those mornings I knew, with certainty, that I did not have breast cancer. Because I was high-risk, my doctors kept a low threshold for a biopsy: if they saw anything even possibly suspicious, they took a sample. I used to call myself a human pincushion. I was grateful, and I was annoyed, often in the same hour.
What I had, though I didn’t call it this at the time, was a screening plan built around me. Not the calendar, not my age. Me. That is exactly what Dr. Charles Balch wants for everyone, and it’s the heart of what he came on the show to say.
Balch built surgical oncology into a specialty, ran MD Anderson and City of Hope, led ASCO, and is now professor emeritus, while turning the last chapter of his career toward prevention through ISOPT. His message is simple: know your risk, then let that knowledge decide what screening is right for you.
He described a tumor the size of a dime, the kind we reassure ourselves is “early.” It already holds a billion cells and has been growing for five or six years. We built screening around symptoms and around age, screen at 45, at 50, when the guideline says so. But a symptom you can finally feel is usually late, and cancer is rising among people the guidelines call too young.
Colorectal cancer is now the leading cause of cancer death in men under 50 and the second in women under 50, and in 2022 nearly one in seven new colorectal cancers were diagnosed before age 50. My own sister heard a version of “you’re too young,” and had to push for the surgery that likely saved her from triple negative breast cancer. Age is too blunt an instrument.
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The Three Pillars of Precision Risk
Balch’s fix is precision, and precision needs a target. He wants three things from every one of us:
Know your family history, and not just your parents, but grandparents, aunts, uncles, cousins, several generations deep.
Know your lifestyle risk, the parts you can proactively change including vaccinations, screening schedules, and diet/exercise/smoking/drinking/vaping choices.
Know your inherited genetic risk, if you can, the genes that you can’t change but absolutely should understand.
Put those together, and you have a picture specific enough to act on.
If you learn you carry a higher risk for colorectal cancer, you start colonoscopies early and remove polyps before they ever become cancer. If your risk is low, Balch is just as quick to say you can safely wait and skip years of unnecessary tests and anxiety.
Knowing also opens doors that otherwise stay closed, because it often unlocks reimbursement pathways for advanced screening that insurers won’t cover without a documented reason. And the tools have never been cheaper. Sequencing your genome cost about a million dollars in 2001 and now runs a few hundred dollars in the USA. A FIT test, the slightly undignified at-home stool test, costs very little and can flag who actually needs a colonoscopy, yet most people are never offered one at a physical.
The treatments have caught up too, which is what makes catching things early worth so much. Immunotherapy, the therapy that reshaped Balch’s own field, now clears stage 3 melanoma so well that most patients who respond avoid surgery entirely, with two-year relapse-free survival above 95% for those who reach a complete response. Catch the right thing early enough and you may not need the operation at all.
New Tests on the Horizon
A wave of new tests is arriving to sharpen the picture further, though every one of them makes sense only once you know what you’re looking for.
Broad multi-cancer blood tests scan for dozens of cancers from a single draw: GRAIL’s Galleri and Exact Sciences’ Cancerguard. They are promising and not yet FDA-approved, sold for now as lab-developed tests, with a limitation: they catch later-stage cancers, stage three and four, far better than the stage one and two disease early detection is meant to find. In the large NHS-Galleri trial, the test cut stage four diagnoses but missed its primary goal of reducing late-stage cancer overall.
Targeted tests are further along for the people who need them. ClearNote Health’s Avantect hunts for pancreatic and ovarian cancer in people at elevated risk, and was selected for the NCI’s Vanguard study. Auria reads proteins in your tears to flag breast abnormalities. A team at the Francis Crick Institute just reported a 14-protein plasma signature that flags lung cancer risk more than five years before diagnosis, the same head start Balch describes with his billion-cell dime.
Every one of these is a precision tool, and a precision tool needs to know who to point at. That is your risk.
Moving Past Fear
Fear is what stops most people before they start. Doctors and scientists kept asking me the same worry: don’t people fall apart when they learn they’re high-risk?
I asked Kathleen Blazer at City of Hope, and she pointed to what the research shows. The initial moment can bring a jolt, sometimes real grief. But the distress tends to fade over time, and for most people it turns into something else: motion. A plan.
Balch said it’s a gift, because knowing your risk hands you a reason to do the specific thing that could save your life.
My half-year I don’t have cancer day was never really about the scans and biopsies. It was about having a plan built around me instead of waiting for a symptom to make the decision. Balch wants that for everyone.
Know your family history. Know your lifestyle. Know your genes. Then sit down with your medical team and build the screening that fits the specific you, and skip what doesn’t. I built gettoknowmyrisk.org to help you take that first step.
The scariest sentence in medicine isn’t “you have cancer.” It’s “we caught it too late.” Knowing your risk is how you make sure that if the first sentence ever comes, it comes early enough to do something about.
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