Tits. Who Needs Them?
The meticulous screening protocol that just saved my life.
I have been writing about longevity since the start of this year, and most of what I cover is what you can do every day to live longer and feel better while you’re at it. Sleep…strength…protein…creatine…peptides…the mitochondrial triad…nasal breathing…things you can actually do, take, control.
This post is not about that.
This post is about the part of longevity that gets less attention, because it’s less fun, less optimizable, and harder to feel smart about: screening. The boring, scheduled, sometimes annoying, sometimes uncomfortable appointments that don’t make you feel optimized but that occasionally save your life.
I’m writing about it now because one of those appointments just saved mine.
The diagnosis
Seventeen days ago, I got a phone call I genuinely did not think was coming. My doctor’s office, asking if I could come in that afternoon to discuss my biopsy results. Anyone who has ever gotten a call like this knows: they don’t ask you to come in the same day to deliver good news. By that afternoon, I had a name for what was wrong. Early-stage breast cancer.
Let me back up further, because the timeline is part of why I am writing this. I had a routine breast MRI just a week prior. A few hours after it, the radiologist called me himself. He told me he had seen an area that looked “suspicious,” and he already had his assistant on the line waiting to book me for a biopsy. The biopsy happened the following Tuesday. Three days later, I had a diagnosis.
Now let me give you the rest of the picture. I’m 46. My sister had breast cancer 17 years ago, at age 24…she is (knock on wood) fine. Her biopsy and mine were on exactly the same date, 17 years apart. I have no idea what to do with that fact other than say it out loud. When she was diagnosed, I started screening too. We both tested for the genetic mutations most strongly associated with breast cancer (BRCA1, BRCA2); my sister’s came back positive, mine did not.
For most of my adult life, that has been the data point I leaned on. The lightning had struck once in our family, and the genetic test seemed to say it would not strike me. My hyper-surveillant doctor added MRI to my screening protocol about three years ago, mostly out of caution due to the family history, but somewhere along the way, I had come to believe I was probably in the clear.
Last Thursday, I had a double mastectomy. I am writing this from my recovery setup at home, in a recliner, with a pillow propped under each arm and a full house: my sister, in the cosmic role reversal of the century; my mother, who is on her second tour of this particular duty; and my husband, who is handling all of this with the calming competence of someone who clearly committed the post-op instructions to memory.
The pathology will guide whatever comes next, but the surgical team is confident they caught it early. I am, in every meaningful way, lucky.
I’m writing about this for two reasons:
I figured you would rather hear it from me than wonder where I went.
The thing that made the difference between “early stage and treatable” and “a much bigger conversation” was a screening protocol that doesn’t get nearly enough airtime. I want to talk about it.
So here we are. A post about a longevity basic that deserves attention, because it’s the one that finds the things you can’t outrun.
What optimization misses
I take care of myself. I lift heavy. I run. I sauna. I sleep really, really well. I eat protein at every meal. I take a curated, thoughtful, evidence-based supplement stack. I don’t drink alcohol. I don’t smoke, never touched a drug. My most recent bloodwork was, in a word, gorgeous: cholesterol, ApoB, fasting glucose, inflammatory markers, all of it tracking exactly where I want them to track. I am, by most longevity-newsletter standards, doing it right.
And I still got cancer.
This is not a “what was I doing wrong” story. There is no peptide I should have been on. There is no supplement I missed. There is no protocol that would have outrun this. This is a genetic speed bump; a story written into my DNA decades before any of us were taking creatine or chasing VO2 max scores.
You can actually do everything right and still need the mechanic to look under the hood. Optimization is what you do every day. Screening is what you do because you can’t see inside your own body. They are different jobs. The first one extends your healthspan; the second one catches the things that don’t care how clean your morning routine is.
In plain English: Lifting heavy and sleeping well does not make you cancer-proof. It makes the body you live in more resilient. The screening is what catches the things resilience can’t outrun.
How it was caught
Here is the part that explain just how lucky I am:
Self-exam: nothing.
Clinical breast exam: nothing.
Mammogram (6 months ago): all clear.
Ultrasound (6 months ago): all clear.
MRI: found it.
The cancer was almost certainly there during the earlier scans six months ago, and, according to the radiologist, only an MRI would have picked it up at this stage…it wasn’t that somebody missed something previously. It was not small, but it was not yet organized…(Ahnold voice please) not a tumor. It had likely been growing through both of those clean reports, and four out of five tools said I was fine.
If I had been getting only mammograms (which is what the standard recommendations would have given me at age 46 with a negative gene panel), the cancer would have continued growing, untouched, until it eventually became palpable or symptomatic. By the time that happened, we would be having a much, much different conversation right now. The MRI bought me something a mammogram could not buy me at any price: time.
There are real reasons for this. The big one is that mammograms are significantly less sensitive in dense breast tissue, and dense breast tissue is much more common than most women realize. In dense tissue, the sensitivity of a mammogram can drop to around 70 to 77% (Cureus, ScienceDirect). MRI, in the same population, picks up roughly three times more invasive cancers than mammography alone (RSNA). Roughly 76% of the cancers caught only on MRI in those studies were invasive; meaning these are not benign findings being over-detected. They are real cancers that mammography missed.
If you have dense breast tissue (which roughly 40% of women over 40 do), and you are not getting some form of supplemental screening, you have a meaningful blind spot.
And, let me give credit where it is due: my doctor, who added the MRI to my protocol and fought on my behalf with the insurance company to cover it time and time again…the radiologist who flagged it immediately…they are the reason any of this happened on the timeline it did.
In plain English: Mammograms are great. They are also the floor, not the ceiling. For high-risk women, women with dense breast tissue, or anyone with a family history; a mammogram alone is not enough.
The genetic question
Back to the genetic story, because it is driving this whole ordeal.
Seventeen years ago, when my sister was diagnosed at 24, her panel came back positive for a known cancer-predisposition mutation. Mine, run at the same time, was clean. Same family, same parents, same DNA pool, completely different result. My grandmother also had breast cancer in her 40s, so there was a history.
I currently have an updated panel in progress. The panels have expanded considerably; what they could test for in 2009 is a tiny subset of what they can test for now. The current panel looks at over 70 genes that influence breast and ovarian cancer risk. At the time of this writing, I’m still waiting on those results.
What I have learned, from the genetic counselors and oncologists I’ve talked to in the last two weeks, is that the field has a working concept they sometimes call “BRCA-adjacent.” It refers to families with patterns of cancer that strongly suggest a hereditary component but that don’t fit the classic BRCA1/BRCA2 mutations. Some of these are now identified (CHEK2, ATM, PALB2, BRIP1, RAD51C/D, and more are being discovered, probably as I type). The genetics are unchanged; the science is just still catching up.
What that means in practice is: a negative genetic panel from a decade ago is not the same as a negative panel today. And even a negative panel today is not the same as low risk if your family history is loud enough.
If you have a sibling, parent, child, aunt, or grandparent who had breast, ovarian, pancreatic, or prostate cancer (especially if it was caught young), your screening protocol should reflect that, regardless of what a genetic test says. Family history is its own data, and it should be factored in, even when the genes haven’t given up their secret yet.
In plain English: Genetic testing is a tool, not an oracle. A clean test does not mean clean. A family history of cancer is itself a high-risk signal, and it should drive your screening.
The screening protocol
Here is what my current annual protocol looks like, layered up over the years. (The mammograms and ultrasounds started early; the MRI was added three years ago, which turned out to be the most important addition.) Some of this is standard for high-risk women. Some of it is what my screening ninja doctor has built specifically for me. None of it is medical advice for you; talk to your own doctor. But it gives you a sense of what an aggressive, modern, high-surveillance protocol looks like. Also to note is that my protocol will now change, given my surgery.
Annual breast MRI with contrast. The single most important imaging tool, especially for those with dense breast tissue and/or family history.
Annual mammogram with tomosynthesis (3D). The standard of care. Mine was offset six months from the ultrasound so something was being checked every few months.
Annual breast ultrasound. Offset six months from the mammogram, again never going more than six months without something looking.
Twice-yearly clinical breast exam with an oncologist or breast specialist (not a generalist).
Annual transvaginal ultrasound and CA-125 for ovarian surveillance.
Annual full-body skin check with a dermatologist that includes an annual derm-led mole map if you have any family history of melanoma.
Annual colonoscopy or interval imaging based on family and personal history (most people start at 45, but if you have GI cancer in the family, sooner).
Annual cervical screening (Pap and HPV), per current guidelines.
Semi-annual full bloodwork including a comprehensive metabolic panel, lipids, ApoB, hsCRP, fasting insulin, HbA1c, full thyroid panel, and ferritin.
Semi-annual dental and periodontal exam because gum health is now strongly linked to cardiovascular and cognitive risk.
A baseline calcium score at some point in your forties to assess cardiovascular risk.
A baseline DEXA scan in your forties to track bone density and body composition over time.
Genetic testing, even if you’ve had it before. Re-test with the latest expanded panel if it’s been more than five years.
It is a lot. It is, in fact, an annoying number of appointments. It also exists for a reason. Each of these tools is looking for something another tool can’t see.
In plain English: Screening is a portfolio, not a single test. Each modality has a different blind spot. The point is to layer them so the gaps are filled.
What about the fancy commercial tests?
I get asked about these constantly, and now they interest me more.
Galleri / multi-cancer early detection (MCED) tests. These are blood tests that look for circulating tumor DNA shed by cancers. The Galleri test, made by Grail, is the most widely available; it screens for signals from over 50 types of cancer with a single blood draw and currently lists at $949. The promise is enormous. The reality is more complicated.
In February 2026, a major UK clinical trial of Galleri, run on roughly 140,000 people, did not show a reduction in late-stage cancer diagnoses; the metric the test was designed to improve. The test still detects some early cancers that other screenings miss, and it may yet prove valuable for specific high-risk populations, but it has not yet been shown to actually save lives at the population level. It is not, today, a substitute for established screenings (mammogram, MRI, colonoscopy, etc.). It is a layer on top.
I had not done a Galleri test before this. I’m now considering it. If I’m in the BRCA-adjacent camp, my risk profile for other cancers (ovarian, pancreatic, others) may also be elevated, and a blood-based screen for the cancers we don’t routinely image for is the kind of layer that, even with imperfect data, may be worth the $949 in my specific case.
Full-body MRI (Prenuvo, Ezra, etc.). These are upright MRI scans that image your entire body and look for incidental findings. They are popular in the longevity-optimization world and run roughly $2,000 to $3,000. The data is genuinely mixed. Full-body MRI catches some things very early. It also produces a lot of false positives (incidental findings that aren’t cancer but require follow-up imaging, biopsies, or anxiety) and has not been shown to extend lifespan in any general population. For a high-risk individual, in addition to (not instead of) standard screening, it can be reasonable. As your only protocol, it is not.
The Cleerly heart scan. A coronary CT-angiogram with AI-driven plaque analysis. Genuinely useful for cardiovascular risk stratification, especially in people with a family history of heart disease. Worth considering if your calcium score is elevated or if cardiovascular disease runs in your family.
In plain English: Commercial tests can supplement a strong baseline. They cannot replace it. Get the established screenings dialed in first; then layer the new tools on top if your risk profile or budget makes sense.
In Case You Skimmed
I was diagnosed with early-stage breast cancer, caught on a routine MRI. Mammogram missed it. Ultrasound missed it. No lump. I had a double mastectomy and the prognosis is good, because we caught it early.
This is a genetic speed bump, not a longevity-optimization failure. Doing everything right does not make you cancer-proof.
Optimization extends healthspan. Screening catches the things optimization can’t. They are different jobs.
Mammography is the floor, not the ceiling; sensitivity drops in dense breast tissue, and dense tissue is common.
A negative genetic panel from years ago is not the same as a negative panel today. The technology has expanded enormously. Re-test if it’s been a while.
Family history is itself a high-risk signal, even with a negative gene panel.
The right screening protocol is a portfolio: MRI, mammogram, ultrasound, derm, GI, ovarian, cardiovascular, bone, blood. Each one looks for something the others can’t see.
Commercial tests like Galleri can be useful layers, but they are not yet substitutes for established screenings.
Ask your doctor for the maximum your insurance and risk profile allow.
Now, indulge me for a moment as I climb up onto my sanctimonious soapbox: this is the lesson. Use it. Use my detour as the reason you finally make the appointment you have been putting off. I do not care if you have to call your doctor four times to get the appointment. I do not care if you have to sit on hold with your insurance company until you grow a beard. I do not care if your last mammogram was clean and you feel fine and you are too busy and you are sure it can wait. Schedule it. Schedule the next one. Schedule the one after that. If you have a family history, push for the MRI. If your breast tissue is dense, push for the MRI. If your gut tells you something is off, push for the MRI. If your doctor brushes you off, find a new doctor and then push for the MRI.
And if you have not had your colonoscopy, your skin check, your dental cleaning, your bloodwork, your pelvic exam, or whatever else has been collecting dust on your to-do list since 2023, book it before you finish reading this post. I will wait.
I had a very different post scheduled for this week, but instead, I am writing this. Take it. Use it. I am lucky because someone caught it early; let that be the only takeaway you need.
…And we’ll be back to regularly scheduled longevity programming next Monday.
See you then,
Susan
P.S. This post’s title credit goes to my friend Six Pics I Clicked // Ana Gambuto, whose response to my diagnosis (after a generous run of expletives) was, and I quote, "Tits. Who needs them?" Which was exactly the right response. Ana also recently launched her own Substack, Six Pics I Clicked: part photo diary and part ADHD survival guide. She’s amazing and funny, and for a good time, subscribe immediately.
Longevity in the Wild The Call Was Coming From Inside the House
For more information, for someone you love who needs it, or to send a few dollars somewhere they will do real work: BreastCancer.org is where you want to go.
It was founded in 2000 by Dr. Marisa Weiss, a breast oncologist who looked at what her patients were finding on the early internet, decided they deserved better, and built it herself. Twenty-six years later, it is the most trusted, most rigorous, most patient-centered breast cancer resource on the planet. The organization has also been championed for decades by my dear friend, Geralyn Lucas, breast cancer survivor, force of nature, and author of Why I Wore Lipstick to My Mastectomy. Two real powerhouses that have been influential, but mostly helpful to countless women.
I recently had dinner with them both (post-diagnosis, pre-surgery…which is a terrible kind of limbo), along with other friends whose club I’ve now had the pleasure of joining (man, that initiation fee is rough), and let me tell you they have nailed the perfect balance of humor, compassion, action, and intelligence. Support can look like dollars, but it can also look like a fun dinner with friends, or a post that was forwarded to a friend who might need it.
Thank you for sharing your story!!! 🤝