Pennsylvania's HB433 Advances: A Landmark Bill for Breast Health Equity Unanimously Passes the House

By Lennard M. Goetze, Ed.D – AngioMedical News

In a significant step toward improving breast health care equity in Pennsylvania, House Bill 433 (HB433) passed the Pennsylvania House of Representatives with a resounding 198-5 vote on May 12, 2025. This pivotal legislation, aimed at expanding insurance coverage for diagnostic breast examinations without cost-sharing barriers, represents a victory for patients, advocates, and healthcare providers alike.

Background: The Need for HB433

The origins of HB433 trace back more than a year, when Cheri Ambrose, Founder and President of the Male Breast Cancer Global Alliance, reached out to the Pennsylvania Governor’s office and legislative stakeholders to advocate for improved access to breast imaging services — not just for women, but for all individuals, including men diagnosed with or at risk for breast cancer.

Historically, state insurance mandates have focused on screening mammograms, often leaving significant gaps in coverage for diagnostic follow-ups like MRIs, ultrasounds, and diagnostic mammograms when abnormalities are detected. This has led to financial strain and delayed diagnoses for many patients, particularly men with breast cancer, a group frequently overlooked in traditional breast health policy.

Recognizing this, the House Democratic Insurance Committee began work on HB433, designed to ensure that both screening and diagnostic breast imaging would be accessible without burdensome out-of-pocket costs — a move aligned with updated guidelines from the U.S. Health Resources & Services Administration (HRSA) and federal health insurance mandates set to take effect in 2026.

The Legislative Process: Stakeholder Collaboration and Amendment

On March 26, 2025, Joseph Keller, Senior Research Analyst for the House Democratic Insurance Committee, formally reached out to stakeholders for feedback on both the bill and a proposed amendment (A00204). This amendment refined HB433’s language to enhance its inclusivity and legal precision. Key changes included:

• Replacing gendered language: Substituting “women” with “individuals” to ensure breast health coverage for all, regardless of gender.

• Clarifying insurance applicability: Modernizing outdated legal references and definitions within Pennsylvania’s mammogram law.

• Defining covered costs: Clearly stating that “all costs” would include copayments, coinsurance, and deductibles — with exceptions for certain high-deductible health plans tied to Health Savings Accounts.

• Aligning with HRSA guidelines: Ensuring diagnostic breast examinations would include MRIs, ultrasounds, or diagnostic mammograms for any suspected abnormalities detected in initial screenings.

Cheri Ambrose remained an engaged advocate throughout the process, communicating regularly with Keller and other House staff to monitor progress. After a successful committee adoption of the amendment in April 2025, the bill was scheduled for a final House vote in May.

Final Passage and What Comes Next

On May 12, 2025, the Pennsylvania House of Representatives Led by House Speaker Rep. Joanna McClinton amended the historical act of May 17, 1921 (P.L.0682, No.0284), known as the "Insurance Company Law Of 1921. The house voted overwhelmingly in favor of HB433. Cheri Ambrose received confirmation of the vote directly from Joseph Keller, who expressed appreciation for the ongoing advocacy and stakeholder input that helped shape the bill’s passage. The bill now moves to the Pennsylvania Senate for further consideration. If approved there, it will proceed to the Governor’s desk for final enactment. “No one should have to go into debt to access the health care they need, but high out-of-pocket costs can discourage people from seeking care", states Rep. McClinton. By passing HB 433 this week, the state House took action to help more Pennsylvania men and women access diagnostic breast imaging which can save lives and reduce the overall costs to our state’s healthcare system.”

(L-Image) Representative Gina H. Curry - PA General Assembly also shared her statement about the recent historical legislative amendment. “Breast cancer does not discriminate, and neither should access to care. Men get breast cancer too, fathers, brothers, sons, yet many delay care due to stigma or cost. HB 433 ensures that if you find a lump, you can get answers no matter your gender, zip code, or bank account. Black and Hispanic women are more likely to be diagnosed at later stages and have higher mortality rates. Black women are 2.7 times more likely to face triple negative breast cancer and 28 percent more likely to die from it. This bill tears down the financial walls that keep people from getting the diagnostic tests they need. We are not just saving women’s lives, we are saving lives, period. Because cancer does not wait, and neither should we."

What This Means for the Public

For the public — particularly those affected by or at risk for breast cancer — HB433 represents a monumental step forward. Should it become law, Pennsylvanians will no longer face the burden of out-of-pocket costs for essential diagnostic breast exams if abnormalities are detected during initial screenings. This legislation ensures insurance plans offered, issued, or renewed in the Commonwealth will cover these vital services, aligning state law with evolving federal preventive care standards.

Importantly, by adopting gender-neutral language and including men within the framework of breast health care policy, HB433 acknowledges the realities faced by male breast cancer patients, a demographic long overshadowed in public health conversations.

Conclusion

HB433’s progress exemplifies the power of advocacy, stakeholder collaboration, and responsive legislation. As Pennsylvania moves one step closer to codifying these protections into law, advocates like Cheri Ambrose and legislative champions within the House Insurance Committee offer a clear reminder of what dedicated, patient-centered policy work can accomplish.

For more information on male breast cancer and ongoing advocacy initiatives, visit the Male Breast Cancer Global Alliance.

"GET SMARTER ABOUT CANCER" - Lecture Series- feat. Dr. Joshua Berka

FOREWORD
By: DR ROBERT L. BARD, Cancer Diagnostic Imaging Specialist

For the many Americans who seek a significantly improved lifestyle or an upgrade in personalized healthcare, getting better answers about our state of health is paramount. What goes into our "standard of care" is no longer acceptable to the the vast majority of general consumer. These same consumers have since been educated in what's available as far as intelligent alternative modalities from highly qualified and educated professionals that have proven wellness success in their respective specialty practices. The visionary paradigm that makes up FUNCTIONAL MEDICINE is defined as individualized medical care that recognizes the interactions between genetic and environmental factors and between the body's interconnected systems. True personalized care is patient-centered care. Subscribing to a FUNCTIONAL TESTING, MONITORING AND DIAGNOSTIC STRATEGY offers the ideal launch pad to a platform of true wellness and disease prevention.  It is for this innovative minset to problem-solving that we are proud to welcome Dr. Joshua Berka as one of the "Get Smarter about Cancer" lecture series. 

Dr. Berka is double board-certified and licensed Naturopathic Doctor (ND) and Acupuncturist (L.Ac.) as well a Certified Functional Medicine Practitioner (FMCP). He is passionate about Integrative, Preventative, Functional and Regenerative Medicine and is an advocate for personalized patient-centered care. Dr. Berka has been in clinical practice for 17 years and serves as a medical consultant supporting innovative medical technologies that non-invasively improve patient treatment outcomes as well as adjunctive therapeutics that can be used as a part of a healthy lifestyle. Dr. Berka has been a consultant within the med-tech space for the past 15 years and currently consults for BEMER Group (news source- Medium.com)

DIRECT FROM THE INTERVIEW
transcript by: Dr. Joshua Berka (10/25/2024)

I had the opportunity to work in the integrated field when I was in Los Angeles for over seven years, and to integrate the field of in integrative oncology. I trained more naturopathically functionally. Before we can get into the recurrence aspect, we have to look at the manifestation of this. Sure, we all have cancer in our body, but why this person expresses versus the next person, (and it's not just the genes), it's how those genes are being expressed. And so many cases exist within women's cancers -especially breast cancer. A lot of this is not just from the genetics- this is only one piece of this. 

Another factor is that the victim maybe not able to circulate or clear out metabolic waste products. Our estrogens (both men and women) are broken up, built up and they're all built from cholesterol.  And those metabolites can be sometimes a hundred times more toxic than the estrogens themselves. If that individual doesn't have the detox capacities, and then they're overwhelmed with, for instance, things within their environment, this sets up the perfect storm for that individual to have the (gene) expression. 

I don't care if they're treated with conventional chemotherapy radiation; the root cause has not been addressed. And in this particular case, it's a hetero or a homozygous type of situation where they can be supportive in their ability to metabolize and clear those detrimental waste products, those metabolic waste products. So it might basically be something that is supporting the gene expression for a little gap versus thinking that cancer is here. 

Let's use a targeted therapy (which is not really targeted in many cases) to take out that which is a disease. And from my perspective, I want to talk about cancer. As far as solid tumors (as opposed to lymphomas, leukemias and the like)- every time I have looked under my microscope looking at cancer or looking at measurements like Dr. Bard is doing, he's really looking functionally with ultrasound in real time during therapeutic interventions. I've done a lot of the same over the years and what I found, (without a doubt) is carcinogenic tissue is not functioning at the same level of energy production. 

So back to bioenergetics mitochondria as healthy tissue, maybe we can envision it this way. This is how stem cells used to be replicated. Imagine, I mean, it's the season, it's the fall. All the trees are dropping their leaves and pine cones are dropping.  They're doing this because winter is coming and that species and that grouping may not make it through another winter. So in hopes of survival.  It's actually seeding its environment. If you take energy or you take a cell out of the body and you expose it to an environment that doesn't have fluid (dry), one of the first things it starts to do before it apoptosis is it actually starts to replicate. It differentiates into an embryological state and then starts to replicate. These cells are not necessarily functional, but it's a response/reaction to these environmental signaling.  When treating individuals with cancer (not treating cancer) my primary goal is to target the mitochondrial bioenergetics and the functional utilization and transformation of energy with an individual. 

Courtesy of Aspen Laser

And many times those tumors will actually apoptose on their own once you start raising the energy around it. What types of medical devices do this?  Diet, food, positive thinking, neutral thinking. Lasers directly can input PHOTOBIOMODULATION photons into electron raising the electron transport chain to raise the zeta potential of erythrocyte or the outside membrane potential of a cell pulse. 

ELECTROMAGNETIC field therapy can also wirelessly inductively charge up these cells. So I think down the road, we have to rather look beyond a "kill, kill, kill" concept with these cells, and reintegrate  and reprogram those cells back into the system.  

What I was doing (research) was homing stem cells, enacting programming information into cells, not just with wireless signals but also with PEPTIDES. You don't need a viral vector to deliver that. You can actually deliver the signal in many ways, wirelessly or through aspects of light.    --- To be continued---

Video News Release: Innovations in Early Detection "Are You Dense?" Foundation Co-founder Joe Cappello joins the medical diagnostic community to promote the "Get Checked Now!" campaign. Dr. Robert Bard from the Bard Cancer Center (NYC) supports supplemental imaging including the 3D Doppler Ultrasound scanner to offer dense breast detection.  This video presents some of the latest advancements in ultrasound features to detect tumors through dense breast tissue- reportedly a significant challenge with mammograms.

PREDISPOSITION
So when I look at the predisposition of an individual, I don't just look at it from a structural perspective. There's the mental/emotional aspects, socioeconomics- and even down to a spiritual aspects. Unfortunately (or fortunately in some ways), these predispositions aren't just inherited on a genetic level. They're actually learned behaviors that we've observed from people who are close to us.  But we've perceived as close who are around us, and "living styles" and habits- ways that we've learned to cope with stress in either a functional way or in a dysfunctional way. And so, when I look at this predisposition, it's a combination of elements- and not just "that's my parents' fault... these are the genes I got!". Unfortunately, that game's NOT TRUE. This it's a bit of 'MYTHinformation' because yes, you do have the propensity to express in a certain way, but not necessarily the predisposition. 

That predisposition is a series of events or decisions that are made to allow that to be expressed. So why some people smoke their whole life and they don't get cancer, well is because they're not predisposed for that in essence.  The predisposition of each individual needs to be really looked at on a personalized level of uniqueness-- what I just call PERSONALIZED PATIENT CENTERED MEDICINE. Rather than saying "here's the disease", let's find out exactly how you got it.  It's important to find out the ideology of the cause, but it's more important to talk about RECURRENCE to prevent something that's occurred, even though when it was perceptually treated.  

We can identify our predispositions or possibilities of (gene) expression of both health or disease by looking at the parents and you could say, oh, this person died of heart disease or ovarian cancer.  But more so with early diagnostics, you can start looking at not just the genomic profiles, but you can start looking at functional diagnostics at a level of blood testing or saliva testing, looking at adrenal function, even looking at bits of certain types of carcinogenic DNA that's floating through the blood. From that perspective of predisposition, we can PREDICT nature. Once you know the predisposition of an individual, then you can predict the potential outcome. 

It's going to be harsh for a lot of the doctors out there and is something that I've observed. (If you can prove me wrong, I ask you, please do so). This aspect of ANABOLIC versus CATABOLIC metabolism. Generally, cancer patients with a solid state tumor status are in a SYSTEMIC aspect of anabolic metabolism. 

They're kind of stuck. #1: Cancer is a tumor, but it's a systemic disease. We have to understand this. #2: Cardiovascular disease or heart disease is more of a catabolic type of disease. So catabolic versus anabolic. I want to know if there's anybody who has ever seen cancer and heart disease happening simultaneously other than prostate cancer. This is a call out to the world. And I'm asking this because if we can just look at fundamental, basic anabolic catabolic cycles.  We may be able to push these metabolic cycles- not just through diet, sleep & wake cycles, but also lifestyle medicine. 

Most of lifestyle medicine is free. It doesn't cost a penny. 

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Saturday, September 21, 2024

RECURRRENCE EXPLAINED

ADVOCACY & JOINING HANDS TO MAKE A DIFFERENCE

By: Geri Barish -  Hewlett House (Cancer Resource)

Getting the word out is vital when it comes to supporting our community in the fight against cancer.  Part of the search for answers is learning how to assess your own life - including your history, the area where you live, what you eat, what you breathe and your genetic blueprint. This may lead to identifying any kind of cancer in the family.  

Staying vigilant in understanding how cancer happens and how it affects us and our families is the key to awareness. Advocacy is also about supporting one another. As we wait for the cure, we also need to live a full life- this includes staying proactive with our health and staying in touch with the latest solutions. There's a lot more work to be done- and because we are fighters, we have to keep asking questions. Look at your environment- get genetic testing for gene mutation in your lineage, don't ignore checkups- find out if you have any risk factors. That's where education and research comes together. And if you've had cancer already, please don't think it won't come back. Recurrence (or re-occurrence) is a real term- and when it happens, it can come back with a vengeance. 

There is a constant debate in the cancer community about the term "CANCER FREE". Cancer recurrence continues to be a major concern as reported in annual medical reports- identifying its tendency to “return with a vengeance". [1, 2]

Medical research has identified the major reasons why cancer recurs.  A widely reported cause for this is attributed to a deficiency in treatment performance. [2] This means the therapy induced did not successfully remove or kill all of the cancer cells, possibly due to the patient's level of drug resistance.  During treatment, Cancer cells can enter a dormant state to protect themselves from treatment and other stimuli. Over time, these dormant cells can reactivate. The cause of this may be a spike in chronic stress or the release of toxins from oxidative stress from environmental factors like smoking or repeat exposure to reactive chemicals. [3]

Inflammation has also been linked to the activation of immune cells called neutrophils. [4] Cancer cells that have spread to other areas of the body after successful treatment of the original tumor can remain dormant for years or decades before recurring as metastatic cancer. Further activators of these dormant cells have also been linked to one's personal Epigenetics. [5] This determines how your environment and lifestyle affects your cell function- including the dormancy state of your cancer cells. 

Another known cause for recurrence are Cancer stem cells or CSC's.  These are a small group of cells in tumors that have the ability to self-renew, differentiate, and give rise to all cell types in a tumor. [6] Most stages of tumor progression, including tumorigenesis, promotion, progression, and recurrence are accompanied by epigenetic alterations, some of which can be reversed by epigenetic drugs. [6]

DETECTION MONITORING

After cancer surgery, there are many preventive measures to support a safe and healthy recovery and to reduce the risk of recurrence.  A logical and preventive strategy as part of postop maintenance is called RECURRENCE PREVENTION SCANS. Through the use of affordable, real-time medical imaging such as the 3D Doppler Ultrasound, post-cancer surgery patients can subscribe to a personal monitoring regimen to scan for any potential lesions and micro-tumors that may have fallen under the radar.  Proactive monitoring can also address complications such as post-surgical Infections, recurring pain, swelling, neuropathy from nerve damage, scarring, fluid buildup or blood clots. In less than 20 minutes per visit, you earn peace of mind from a comprehensive scan by seasoned specialists trained to support postop patient management.

(1) Butow P, Sharpe L, Thewes B, et al. Fear of Cancer Recurrence: A Practical Guide for Clinicians. Oncology (Williston Park). 2018 Jan 15;32(1):32-8. (2.) Mahvi DA, Liu R, Grinstaff MW, et al. (2018). Local Cancer Recurrence: The Realities, Challenges, and Opportunities for New Therapies. CA: A Cancer Journal for Clinicians, 68(6), 488. https://doi.org/10.3322/caac.21498 (3.)Payne KK. Cellular stress responses and metabolic reprogramming in cancer progression and dormancy. Seminars in cancer biology 2022 Jan Vol. 78, pp. 45-48. (4.) He X-Y, Gao Y, Ng D et al. Chronic stress increases metastasis via neutrophil-mediated changes to the microenvironment. Cancer Cell 2024:42(3);474-486. DOI: https://doi.org/10.1016/j.ccell.2024.01.013  (5.) Costa S, Alves Sales SL, Pinheiro DP, et al. (2023). Epigenetic reprogramming in cancer: From diagnosis to treatment. Frontiers in Cell and Developmental Biology, 11. https://doi.org/10.3389/fcell.2023.1116805 (6.) aYu X, Zhao H, Wang R, et al. (2024). Cancer epigenetics: From laboratory studies and clinical trials to precision medicine. Cell Death Discovery, 10(1), 1-12. https://doi.org/10.1038/s41420-024-01803-z

ROBERT L. BARD, MD  (Diagnostic Imaging Specialist)

Having paved the way for the study of various cancers both clinically and academically, Dr. Robert Bard co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital Imaging technology has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. His most recent program is dedicated to the reporting of mental health diagnostic and innovative solutions including the use of modern neuromagnetic technologies and protocols in his MEDTECH REVIEWS program. www.BardDiagnostics.com

ROBERTA KLINE, MD (Educational Dir. /Women's Diagnostic Group)

Dr. Kline is a board-certified ObGyn physician, Integrative Personalized Medicine expert, consultant, author, and educator whose mission is to change how we approach health and deliver healthcare. She helped to create the Integrative & Functional Medicine program for a family practice residency, has consulted with Sodexo to implement the first personalized nutrition menu for healthcare facilities, and serves as Education Director for several organizations including the Women’s Diagnostic Health Network, Mommies on a Mission. Learn more at https://bobbiklinemd.com 

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HealthTech Reporter and Fight Recurrence brings you the conclusion of JIM HUNT's 6-Year personal journey report about his battle against early Prostate Cancer.  After years of ACTIVE SURVEILLANCE, a recent uptick in tumor size (5mm) was time enough to "do something more proactive about my cancer!".  Jim has been a prominent researcher on the topic of cancer care since his wife survived breast cancer 20 years ago. Today, his exploration led him to recognize the benefits of non-invasive cancer treatments including the advancements of radiation therapy such as PROTON BEAM therapy. (See his mini-documentary video: DAY 5/ Final Treatment day)

RECURRRENCE EXPLAINED

ADVOCACY & JOINING HANDS TO MAKE A DIFFERENCE
By: Geri Barish -  Hewlett House (Cancer Resource)

Getting the word out is vital when it comes to supporting our community in the fight against cancer.  Part of the search for answers is learning how to assess your own life - including your history, the area where you live, what you eat, what you breathe and your genetic blueprint. This may lead to identifying any kind of cancer in the family.  

Staying vigilant in understanding how cancer happens and how it affects us and our families is the key to awareness. Advocacy is also about supporting one another. As we wait for the cure, we also need to live a full life- this includes staying proactive with our health and staying in touch with the latest solutions. There's a lot more work to be done- and because we are fighters, we have to keep asking questions. Look at your environment- get genetic testing for gene mutation in your lineage, don't ignore checkups- find out if you have any risk factors. That's where education and research comes together. And if you've had cancer already, please don't think it won't come back. Recurrence (or re-occurrence) is a real term- and when it happens, it can come back with a vengeance. 

---

There is a constant debate in the cancer community about the term "CANCER FREE". Cancer recurrence continues to be a major concern as reported in annual medical reports- identifying its tendency to “return with a vengeance". [1, 2]

Medical research has identified the major reasons why cancer recurs.  A widely reported cause for this is attributed to a deficiency in treatment performance. [2] This means the therapy induced did not successfully remove or kill all of the cancer cells, possibly due to the patient's level of drug resistance.  During treatment, Cancer cells can enter a dormant state to protect themselves from treatment and other stimuli. Over time, these dormant cells can reactivate. The cause of this may be a spike in chronic stress or the release of toxins from oxidative stress from environmental factors like smoking or repeat exposure to reactive chemicals. [3]

Inflammation has also been linked to the activation of immune cells called neutrophils. [4] Cancer cells that have spread to other areas of the body after successful treatment of the original tumor can remain dormant for years or decades before recurring as metastatic cancer. Further activators of these dormant cells have also been linked to one's personal Epigenetics. [5] This determines how your environment and lifestyle affects your cell function- including the dormancy state of your cancer cells. 

Another known cause for recurrence are Cancer stem cells or CSC's.  These are a small group of cells in tumors that have the ability to self-renew, differentiate, and give rise to all cell types in a tumor. [6] Most stages of tumor progression, including tumorigenesis, promotion, progression, and recurrence are accompanied by epigenetic alterations, some of which can be reversed by epigenetic drugs. [6]

DETECTION MONITORING

After cancer surgery, there are many preventive measures to support a safe and healthy recovery and to reduce the risk of recurrence.  A logical and preventive strategy as part of postop maintenance is called RECURRENCE PREVENTION SCANS. Through the use of affordable, real-time medical imaging such as the 3D Doppler Ultrasound, post-cancer surgery patients can subscribe to a personal monitoring regimen to scan for any potential lesions and micro-tumors that may have fallen under the radar.  Proactive monitoring can also address complications such as post-surgical Infections, recurring pain, swelling, neuropathy from nerve damage, scarring, fluid buildup or blood clots. In less than 20 minutes per visit, you earn peace of mind from a comprehensive scan by seasoned specialists trained to support postop patient management.

1. Butow P, Sharpe L, Thewes B, et al. Fear of Cancer Recurrence: A Practical Guide for Clinicians. Oncology (Williston Park). 2018 Jan 15;32(1):32-8. 

2. Mahvi DA, Liu R, Grinstaff MW, et al. (2018). Local Cancer Recurrence: The Realities, Challenges, and Opportunities for New Therapies. CA: A Cancer Journal for Clinicians, 68(6), 488. https://doi.org/10.3322/caac.21498

3. Payne KK. Cellular stress responses and metabolic reprogramming in cancer progression and dormancy. Seminars in cancer biology 2022 Jan Vol. 78, pp. 45-48.

4. He X-Y, Gao Y, Ng D et al. Chronic stress increases metastasis via neutrophil-mediated changes to the microenvironment. Cancer Cell 2024:42(3);474-486. DOI: https://doi.org/10.1016/j.ccell.2024.01.013 

5. Costa S, Alves Sales SL, Pinheiro DP, et al. (2023). Epigenetic reprogramming in cancer: From diagnosis to treatment. Frontiers in Cell and Developmental Biology, 11. https://doi.org/10.3389/fcell.2023.1116805

6. Yu X, Zhao H, Wang R, et al. (2024). Cancer epigenetics: From laboratory studies and clinical trials to precision medicine. Cell Death Discovery, 10(1), 1-12. https://doi.org/10.1038/s41420-024-01803-z

DR. ROBERTA KLINE is an ObGyn physician, an award-winning author, an educational advocate, and an inspirational speaker for the professional and women’s communities. She holds a combined mission to upgrade how we approach health and deliver healthcare for women through education, globalized communication, research, and advocacy.  Dr. Kline develops and teaches CME programs, consults on gene expression project designs, and leads collaborative projects designed to advance the direction of women’s health. She is also a clinical advisor in integrative medicine and functional genomics to many health organizations including the Integrative Health Research Center.  In addition to her mentorship programs for women physicians, Dr. Kline is Director of Educational Programs for the Women's Health Collaborative, Editor of the Women’s Health Digest, and on faculty at the University of Western States. 

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FOR IMMEDIATE RELEASE:

8/6/2024- Dr. Robert Bard (Bard Diagnostic Imaging) and Cheri Ambrose (President of the MBCGA / Male Breast Cancer Global Alliance) officially launched the RECURRENCE DETECTION SCANS program- a life-saving diagnostic program in support of recurrence prevention.  

Program developer Dr. Lennard Goetze spearheaded this plan in 2019 during the launch of the "FIGHT RECURRENCE" educational program with the NY Cancer Resource Alliance. Under a collaboration with the AngioInstitute, Dr. Goetze aligned with national breast cancer organizations who adopted the Fight Recurrence campaign.  In the summer of 2024, a partnership with Ms. Ambrose was officially forged with a clinical blueprint for a postop diagnostic scanning program to monitor possibilities of cancer recurrence. "Getting checked for breast cancer has been an uphill battle for anyone- but it's equally important to not get complacent after surgery... saying 'cancer free' is an ideal that does not apply to everyone." 

Since the inception of his practice in 1972, Dr. Bard has been a staunch supporter of the use of the 3D Doppler Ultrasound to provide safe and quantitative scans of postop cancer cases. "Due to a significant number of cancer recurrence cases (estimated 40%) either before or after the 5 year 'cancer free' mark, we established a comprehensive and personalized diagnostic strategy for tracking potential RECURRENCE. We also wanted to send a message to maintain proactive vigilance after surgery."

One of the recognized voices for Male Breast Cancer awareness was Mark Futterweit, whose interview in the 2019 WBAB episode "Men DO Get Breast Cancer!" emphasized that he got breast cancer TWICE. This became the launch pad for the Male Breast Cancer Global Alliance and for Cheri Ambrose to be one of the first organizational partners to go national with Dr. Bard's message about proactive monitoring. 

Nancy Novack, founder of  NancysList.org, a major online cancer resource is a supportive backer of both Dr. Bard's cancer imaging practice and the MBCGA. She is an ovarian cancer survivor as well as a primary voice for the "Fight Recurrence" project. "Living with cancer is about ADVOCACY and AWARENESS ... and  maintaining regular checkups, both before treatment and after. We must be informed and wisely active regarding the tools of recurrence detection and survivorship."

Talks with the American Breast Cancer Foundation and other national cancer organizations are underway to join the FIGHT RECURRENCE educational campaign in underserved communities.  AngioInstitute outreach coordinator and research director Dr. Noelle Cutter says “In the cancer world, we see recurrence to be so prevalent and often arises with a vengeance – this detection program needs to be a default solution after every cancer procedure… I echo Dr. Bard who instills continued monitoring as a preventive measure!” 

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RECURRENCE PREVENTION FROM A 3-TIME CANCER SURVIVOR: VANESSA SILVA

My name is Vanessa Silva. I was diagnosed with breast cancer in 2007 after my father was first diagnosed with breast cancer where he was identified as BRCA2 positive.   I found out in a very roundabout way. I only went for a check-up because my doctor wanted to be proactive, and she just wanted to confirm that I was healthy.  More importantly, she wanted to check to see that I wasn't carrying the gene. But during the mammogram, they told me to go upstairs to see my doctor.  Right then and there I knew they were going to tell me I had cancer. I spoke to my doctor and she confirmed it.

I can remember crying- then saying, "Okay, you need to get yourself together. There's options. They said it was at stage zero. It's not a death sentence. We're going to do what we have to do... but you're probably going to be BRCA2 positive, as well."  The battle for me started with chemotherapy- but not radiation. In a matter of weeks, they realized the cancer was more aggressive than they thought, and it wasn't at stage zero after all because it already had gone to the lymph nodes.

RECURRENCE: PART 1

During the treatment process, I pushed to do my part and changed the way I lived starting with the way I ate. I exercised, I stopped eating meat and I did everything by the book ... and sure enough, I was told I was cancer free!.  So after five years, I felt it was safe to go back to old habits and eat the things I missed the most – including meats. I was still working out, but admittedly, junk food managed to creep its way into my system.

My cancer came back after roughly eight years. 

One day, while taking a shower, I decided to check and feel for any lumps- just to make sure everything's okay.  Surprisingly, I felt a lump. It was small but experience says to keep an eye on it.  By September, it grew to the size of a pea and it was getting bigger.  My doctor elected a sonogram then an MRI just to confirm that my cancer came back.

This time, I was angry, because I felt like I did everything I needed to do. I did the chemo. I honestly didn't believe my eating would have brought my cancer back.  They recommended four treatments of chemo, but this time it was stronger. For the first time, I had to take Taxotere, and then, this time, I had to do the AC.

I looked at my husband and said, "This is a joke. I feel like I'm being punked… we're going to do this again!" I started the first chemo treatment and became really, really sick. I was hospitalized for a week. I could not tolerate the chemo's side effects; it was way too strong. And I told them, "What are my options, because I can't do four treatments with the way I was feeling."  It really hit my body hard- so they redirected me to 6 weeks of radiation treatments.

So again, I stopped eating meat, stopped sugar, went back to the juicing, I did my daily routine of walking (I live by Central Park, so I would walk the reservoir).  I was religious with my health especially during and even after I was done with the treatments.

But a year later, I kept up with my self exams to make sure there were no lumps, and then ended up finding another one - this time on the right side! Very small again, underneath my breast - and just like the last one, it started to grow.

For the third time, the cancer had come back.

Once again, I underwent surgery to remove the cancer. It did not go to the lymph nodes, so they didn't recommend chemo this time around, but I had to do radiation again for six weeks. This was my reality. I had cancer in 2007- then again in 2014, and then the cancer came back in 2016.

What was confusing to me was that this time, I was so diligent about prevention- not having any meat, and constant juicing and exercising.  I feel as if my body produces cancer cells much faster than a regular person. I just have to be more vigilant with checking myself.

I try to make sure that I'm stress-free, that I don't put myself in situations that would make my immune system just crash.  My doctor and I are both very diligent about checkups and often do sonograms at the slightest concern. I see my breast surgeon every six months. And now, she's finally pushed it to a year, so I'm so happy with that.

FOOD 101: GOING 'CLEAN' AND ORGANIC

I think, meat plays a huge part in all of this because of the hormones that are being injected into them.  I do my best to buy products that say Non-Hormones, No Antibiotics, etc., however, how much of that is true.  I was convinced that I needed to stop eating meats all together and to stop putting all of these processed products into my body and start eating a much healthier diet.

Eventually, I would like to become a vegan, but I know there's so many things that I really enjoy eating, like eggs and cheese. But slowly, I've been pulling away from eating eggs. It's been a year since the last time I’ve eaten eggs, but cheese is a hard one to quit. I'm just trying to eat a more "clean" foods-- a lot more vegetables, a lot more fruits, and making sure that I wash them, and they're organic.

Organic and gluten-free was the way to go for me! I don't drink dairy milk anymore only almond milk. I'm really trying NOT to introduce the bad stuff to my children. Two of them are already grown, I really try to give my youngest one ZERO red meat except maybe once a month.  Sometimes, it's turkey or chicken, but even that, we've really pulled away from. I try not to be as restrictive with them because they're young, and they should make their own decisions later, however, I want them to be knowledgeable of what they put into their bodies.  Zero sugar is hard to do but we try to stay away from candy, donuts and pastries.

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ONCOGENOMICS 101: TUMOR VARIANTS & RECURRENCE OPTIONS

ONCOGENOMICS: PRECISION ONCOLOGY 

Precision medicine, also known as personalized or individualized medicine, utilizes information gained from a person’s genetic makeup, along with their environment and lifestyle, to guide disease prevention, diagnosis, and/or treatment strategies. [1]  Oncogenomics is a form of precision medicine that enables more personalized approaches to cancer diagnosis, treatment, and prognosis. [2]  Cancer is often considered a genetic disease, whereby genetic mutations in the DNA of cells lead them to grow uncontrollably and become cancerous. With the increased emphasis on studying DNA and its role in cancer, the next step was to study the genetic characteristics of cancers to develop better treatments.

 

GENETIC CHARACTERISTICS OF A TUMOR 

Oncogenomics was launched in 1998 with the FDA approval of Trastuzumab (Herceptin) for HER2+ breast cancer. It was the first chemotherapy agent developed using genetic analysis of tumors to create a more effective and less toxic treatment that is still used today. [3]. Classified as a “targeted” therapy, it is an antibody that blocks specific receptors called HER2+ that are present in about 20% of breast cancers, and more recently have been found in other types of cancers as well. [4] Since then, more than 150 new therapies targeting specific components of tumors have been approved by the FDA, and just over half of these are considered “precision oncology” drugs targeting specific DNA mutations in tumors. But despite this tremendous progress, most tumors still do not have identifiable mutations that can guide or predict treatment response. [5]

One of the reasons for this is that, while there are some core genetic mutations common across many cancers, each tumor type can also have many variations that vary from individual to individual. This makes the process of identifying and confirming each mutation, as well as matching it to a specific treatment, quite time-consuming and costly. 

MATCHING TUMOR GENETICS WITH TREATMENT

When sequencing the DNA of a tumor, we are looking for mutations in specific types of genes known to contribute to cancer development and growth. However, our current knowledge still has gaps, so the DNA has to be evaluated very closely and analyzed for potentially new mutations as well. With this information, the next step is to try to match them to a specific therapy that would be effective. This is a very fine-tuned way to try to match the treatment with that tumor. 

Another obstacle is the emerging role of epigenetics in cancer development and growth. Separate from genetic mutations, epigenetics regulates the expression of genes by turning them on and off. Research is revealing epigenetic alterations as yet another layer that contributes to all cancer types. Precision oncogenomics now includes some drugs for cancers that target these epigenetic changes - especially hematologic cancers, as solid tumors appear to be more challenging. [6]. 

As technological advances enable us to do this faster and easier, we will continue to accelerate progress toward a vision of truly personalized approaches to treating cancer. The pharmaceutical companies are investing heavily in the efforts to come up with personalized drugs. It’s big business to do this, in addition to improving patient care.  OncoType DX is a great example of the impact of this approach. Assessing the estrogen receptor and HER2 characteristics of breast tumors has resulted in more precise treatment, as well as better prediction of recurrence risk.

GENETICS OF THE PERSON INFLUENCE TREATMENT

Even in the era of precision oncology, conventional chemotherapies still play a major role in treatment, either by themselves or in conjunction with these newer precision drugs. These drugs are often toxic to the person as well as to the tumor, causing side effects. 

One of the contributors to recurrence can be linked to how well people tolerate chemotherapy – as well as how they respond. Vastly underutilized is the role of pharmacogenomics, which looks at how a person’s genes influence how they process medications. This includes effectiveness as well as risk of adverse effects. Despite research showing that 99% of people carry at least one genetic alteration that affects their response to medications [7], and the FDA has approved genetic associations for more than 250 medications [8], it is still rarely utilized when selecting chemotherapy drugs and doses. 

 

L-Image source: Rendell T, Barnett J, Wright D. How community pharmacy pharmacogenomics testing services around the world can inform their design and delivery in the UK. 2021 The Pharmaceutical Journal.

PREVENTING CANCER RECURRENCE: THE HOLY GRAIL

Allopathic medicine doesn't typically focus on prevention. Rather, it is primarily concerned with diagnosing and treating diseases – including cancer.  Clearly, we want to do everything we can to try and really get precise about what each person’s cancer is about so we can treat it most effectively. 

But the next question beyond this is how to reduce the risk or even prevent recurrence. Recurrence typically happens for three reasons: 

1. Treatment did not remove or kill all of the cancer cells. 

2. Reactivation of dormant cells.

3. Not addressing all of the underlying factors that contributed to the cancer developing in the first place.

You’ve likely heard that ‘we all have cancer cells somewhere in our bodies’. It is a normal part of our biology to have damage or errors like mutations happen to our DNA. We also have built-in ways to detect and fix these or destroy those cells so they never become cancerous. This then leads to the question of why some people develop cancer, and other people don't – and this includes recurrence. Answering this question is the directive of where I believe we should be when it comes to research and genetic testing of cancer patients. For this, we need to dig deeper into our genetics, epigenetics, and our biology.

Cancers are designed to evade the immune system, and this is one way they can grow beyond single cells or resist treatment. As an example, research has demonstrated the ability of breast cancer cells to “hide” these receptors, only to have them reappear later. It's a dynamic process because tumors are living things that respond to their environment in ways that help them survive. [9] This is one reason it is challenging to not only fully treat cancers, but to also prevent their recurrence.

Strategically speaking, the focus on the complexity of the genetic and epigenetic makeup of cancers is part of the challenge as to why we keep missing this ‘Holy Grail’ of curing cancer.  I feel that having reviewed enough testing paradigms, the community is neglecting the DNA and epigenetics of the person who developed the tumor in the first place.

Image source: Vignoli, A., Risi, E., McCartney, A., et al (2021). Precision Oncology via NMR-Based Metabolomics: A Review on Breast Cancer. International Journal of Molecular Sciences, 22(9), 4687. https://doi.org/10.3390/ijms22094687

MULTIPLE INTERACTIONS: A WHOLE ECOSYSTEM

It is now possible to find out more information about this person that might help us fill in some missing pieces, including their own DNA and epigenetics. Genetic, genomic, and epigenetic testing can provide insights into their predispositions for altered functioning and predisposition to many diseases, including cancer. This helps give us a more precise map for that individual so that we can actually identify their vulnerabilities and create personalized strategies to address these. Addressing hidden factors that may have contributed to developing cancer in the first place may help to decrease the recurrence of the cancer.

Estrogen-sensitive breast cancer is one of the most studied in terms of genetics and risk of recurrence. With standard treatment of surgery and 5 years of endocrine therapy, one of the first and most successful precision medicine stories, the risk of 20-year recurrence is still as high as 50%. Research has thus far discovered genetic alterations in the tumor that can explain about 40% of relapses, indicating there is still much more to learn. New research is giving insights into the mechanisms by which dormant cancer cells adapt to endocrine therapies, including altering genetic expression through epigenetics. [9 

 

Image source: [Barozzi I, et al. Cancer Discov (2024) 14 (9): 1612–1630]. 

These epigenetic changes result from the interaction of the tumor cells and the environment of the tumor – called the microenvironment. The microenvironment is regulated by the person’s DNA and epigenetics, which are, in turn, interacting with that person’s total biology - influenced by their diet, lifestyle, exercise, stress and trauma, toxin exposures, medications, and more.

Alterations in a person’s DNA can alter gene expression and how their biology is functions, thus influencing potential development of cancer. BRCA1 and BRCA2 mutations are some of the most well-known mutations that can predispose to cancer. But there are also smaller genetic alterations called SNPs that can also affect a person’s cancer risk. Although these SNPs create more subtle influences than mutations, each of these can interact with each other and a person’s environment to increase or decrease a person’s cancer risk. [10] 

LINK TO THE LYNCH SYNDROME/NEW HOPE FOR GENETIC DISEASES ARTICLE. Epigenetics adds yet another layer to the complex biological processes that can lead to cancer development and growth, and modify genetic risk. [11]

FIGHTING RECURRENCE: THE MAGIC TRIO

With all of the advances in oncogenomics, as well as analyzing a person’s DNA and epigenetics, we have some powerful tools to fight recurrence. But we need to use them. 

The first is to choose the most effective treatment – for the person and the cancer. This involves the latest advances in precision oncology as well as other approaches to treatment.

The second is identifying contributing factors that may have contributed to their cancer. Here, the focus is on assessing the person’s genetics, epigenetics, diet, lifestyle, and environment - and then creating personalized strategies to support more optimal functioning of these biological systems – potentially reducing the risk of recurrence. 

 

Image: Rulten, S. L., Grose, R. P., Gatz, S. A., et al (2023). The Future of Precision Oncology. International Journal of Molecular Sciences, 24(16), 12613. https://doi.org/10.3390/ijms241612613

The third is active surveillance for early detection, enabling a higher chance of success if recurrence does happen. This is best done with a combination of lab testing and diagnostic imaging. Lab testing can provide reassurance that strategies are working as intended or guide adjustment, as well as give early clues to abnormalities that may indicate recurrence. Newer epigenetic tests can now look for cancer cells before they are visible by imaging. Regular imaging can evaluate for early signs of local recurrence or metastasis, providing peace of mind that all is well or ensuring that any recurrence is detected early. 

THERE IS HOPE

Research continues to build on this foundation, and we are expanding the ways that genetics, genomics, and epigenetics can help us better understand the causes and choose the best treatments for various cancers. But we don’t have to keep waiting for more to take action. We have the knowledge and tools now to give us crucial insights into the biology of cancer, how best to treat it, and ways to reduce the risk or even potentially to prevent recurrence. 

References:

1. https://www.genome.gov/genetics-glossary/Precision-Medicine

2. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/precision-medicine

3. Ferreira-Gonzalez, A., & Mardis, E. R. (2019). Precision oncogenomics. Cold Spring Harbor Molecular Case Studies, 5(2). https://doi.org/10.1101/mcs.a004150

4. Maadi, H., Soheilifar, M. H., Choi, S., et al (2021). Trastuzumab Mechanism of Action; 20 Years of Research to Unravel a Dilemma. Cancers, 13(14). https://doi.org/10.3390/cancers13143540

5. Suehnholz ,S. P., Nissan, M. H., Zhang, H. et al. Quantifying the Expanding Landscape of Clinical Actionability for Patients with Cancer. Cancer Discov (2024) 14 (1): 49–65. https://doi.org/10.1158/2159-8290.CD-23-0467

6. Yu, X., Zhao, H., Wang, R., et al. (2024). Cancer epigenetics: From laboratory studies and clinical trials to precision medicine. Cell Death Discovery, 10(1), 1-12. https://doi.org/10.1038/s41420-024-01803-z

7. Ji, Y,. Skierka, J. M., Blommel, J. H., et al. Preemptive Pharmacogenomic Testing for Precision Medicine: A Comprehensive Analysis of Five Actionable Pharmacogenomic Genes Using Next-Generation DNA Sequencing and a Customized CYP2D6 Genotyping Cascade. J Mol Diagn. 2016 May;18(3):438-445. doi: 10.1016/j.jmoldx.2016.01.003. 

8. Pritchard, D., Patel, J. N., Stephens, L. E., & McLeod, H. L. (2022). Comparison of FDA Table of Pharmacogenetic Associations and Clinical Pharmacogenetics Implementation Consortium guidelines. American Journal of Health-System Pharmacy: AJHP, 79(12), 993-1005. https://doi.org/10.1093/ajhp/zxac064

9. Barozzi, I., Slaven, N., Canale, E. et al. A Functional Survey of the Regulatory Landscape of Estrogen Receptor–Positive Breast Cancer Evolution. Cancer Discov (2024) 14 (9): 1612–1630. https://doi.org/10.1158/2159-8290.CD-23-1157

10. Fahed, A.C., Wang, M., Homburger, J.R. et al. Polygenic background modifies penetrance of monogenic variants for tier 1 genomic conditions. Nat Commun 11, 3635 (2020). https://doi.org/10.1038/s41467-020-17374-3

11. Baylin, S. B., & Jones, P. A. (2016). Epigenetic Determinants of Cancer. Cold Spring Harbor Perspectives in Biology, 8(9). https://doi.org/10.1101/cshperspect.a019505