My name is Michael LaPelusa and I'm a hematologist and medical oncologist. I graduated from hematology and medical oncology fellowship at MD Anderson Cancer Center in 2026. This post is about why I wrote this book.
Part of the reason I felt compelled to explain why I'm doing this is that I am a generally skeptical person and, for the most part, am lukewarm regarding the idea of influencers building personal brands in medicine. That is not the goal of this book.
MCED Testing Is Coming
I believe multi-cancer early detection (MCED) tests will become a routine part of healthcare in the US, partly because of how I believe the technology will incrementally improve, but more so because of what I've observed about how the US makes decisions regarding healthcare (and cancer care, in particular). The US does not consistently prioritize cost-effectiveness over individual choice, perhaps most obviously seen by the fact that cancer drugs that do not demonstrate an overall survival benefit are routinely approved. This happens because the American healthcare system defaults to more information, more options, and more agency for the individual patient. I have not thought about this phenomenon long enough to determine whether I think this is necessarily a bad thing.
MCED tests fit squarely into that tradition.
My Cognitive Dissonance
I, and everyone in oncology, would always rather talk to a patient about treating their early-stage cancer with curative intent rather than explaining how palliative treatment could reduce the burden of their symptoms. If a blood test could shift even a fraction of late-stage diagnoses earlier, I believe the clinical value would be enormous.
The main issue at the core of this concept is that the cost required to detect cancer through population-scale MCED-based screening is high. The downstream consequences of a positive result, which include scans, biopsies, specialist consultations, and weeks (or months) of anxiety, are massive, and for the people whose positive result turns out to be a false positive, those consequences carry no clinical benefit at all. The question of who pays for the diagnostic workup after a positive MCED test result, particularly when someone elects to purchase an MCED test out of pocket, has no clear answer. Should the healthcare system absorb thousands of dollars in imaging and procedures triggered by an elective, self-funded screening decision? I don't know.
This may be controversial, but I will probably get one of these tests in the future (in addition to guideline-concordant cancer screening). Even with the modest sensitivity of these tests, adding one on top of standard screening raises the probability of catching a cancer. Guideline-concordant cancer screening covers only a handful of cancers (breast, colorectal, cervical, lung for smokers, and prostate by shared decision). The cancers I most want to catch with an MCED test are ones without guideline-recommended screening and are often lethal once they cause symptoms (for example, esophageal, stomach, liver, bile ducts, pancreas, and certain lymphomas, among others). These cancers have a short median overall survival when found at an advanced stage and can be curable when found early, albeit with a risk for recurrence. I am also willing to accept the consequences of a false positive result, meaning that if a test detects a signal but I don't actually have cancer, I am prepared to undergo the scans, procedures, and uncertainty of determining whether and where I have cancer.
I say probably, and not definitely, because I would rather wait for these tests to improve, particularly in early-stage sensitivity. The incidence of cancer increases with age, and I am still young enough that my pre-test probability is low.
The population-level economics of MCED screening deeply trouble me, and I am describing the individual calculation that, multiplied across millions of people, creates the costs and bottlenecks I worry about (including whether someone with a positive result takes a slot in a CT scanner or a specialist appointment from someone who already has cancer).
My Writing
I have spent the past decade of my life in academic medicine (first as a medical student, then as an internal medicine resident, and finally as a hematology and medical oncology fellow). Throughout those periods, I have come to enjoy conducting original research and putting my analysis of recently published data into a presentation or long-form writing. Community oncology practice, which I am entering with unmatched enthusiasm, does not offer many outlets for that kind of work. Before Stage I is my way of maintaining the part of my professional life that involves reading papers, thinking carefully about what they mean, and writing the pertinent points down.
In terms of the use of artificial intelligence - I used large language models as an editing tool and fact-checker, to help format this book, to guide the creation of the Before Stage I website, and for "search engine optimization", meaning that after I wrote a post of this book, I asked a large language model for help optimizing titles and structuring the post in a way that will help it score higher on algorithms so that it can reach a broader audience. All writing is my own.