The Punishing Cost of Cancer Care
“I think it’s time to switch therapies,” I told my patient, as he and his wife sat next to each other by the wall of my exam room.
He stared at me, unblinking, through his chipped, wire-rimmed glasses as his wife looked quickly down at the medication list she clutched in her hands. Her worn purse sat on the floor by her chair. “Switching therapies” was a euphemism for “your cancer is progressing,” a point I didn’t need to hammer home with them – they both knew the score.
“O.K.” he said, taking a deep breath. “What’s next?”
We had been navigating his cancer together for a year-and-a-half, balancing the most effective treatments we could devise with what his health insurance would cover, and what he could afford. The 90-mile drive to Cleveland was itself an economic strain, gas prices being what they were and their aging car becoming increasingly more finicky, particularly during the cold winter months.
“The next drug I’d suggest is a pill that you’d take every day. It can get you into a remission, and may even allow you to live a little longer. It’s the one we’ve talked about before,” I told him. He nodded, remembering.
“The real expensive drug?” he asked.
This time I nodded. When I first suggested he take this pill as part of his chemotherapy regimen, I warned him about the possible cost, as this has become a part of my standard informed consent process. I review potential risks, benefits, alternative medications, the people involved in a patient’s care, and now economic risks.
After checking with his insurance plan, which did not cover chemotherapy pills the way it did intravenous chemotherapy, I had the unpleasant task of telling my patient that the medication would cost him $5,000 per month. At the time he had laughed, a mixture of surprise and incredulity. He was too well-off to qualify for patient assistance, but too poor to afford the drug. His face was grave now.
“I won’t bankrupt my family for a month or two more time,” he said. “I have to leave them something.” His wife looked up briefly, about to interject, but remained quiet. This was ground they had already covered, and she would make her case for his taking the pill when I wasn’t present. They were private people, proud, and wouldn’t disagree with each other in front of someone who wasn’t family.
As the price of chemotherapy now routinely reaches $100,000 for a full treatment course, my patients are forced more and more into making the equivalent of Sophie’s Choice when it comes to treating their cancer: Spend down their savings for an improvement in survival that might amount to a few weeks, secretly hoping that they will be one of the lucky few at the “tail” of the survival curve – the handful of people who live years more; or decline the therapy and in so doing ensure that their families will be provided for after they have died.
I had to wonder whether anyone should be forced to make such a decision.
My patient and I discussed a couple of other treatment options, and ways that he might receive his therapy closer to home, a plan that made him visibly relax.
“Not that we don’t like seeing you,” he joked. His wife didn’t smile, though. Perhaps she wasn’t ready yet to let him go, or didn’t agree with his reasoning that she would be destitute if he chose the pill. Maybe she was incensed that hard-working people like themselves would be placed in such a quandary precisely at the time of their retirement, and in such a wealthy nation. The way she set her mouth, I guessed it was a combination of all three.
“I’ll miss seeing you,” I told them both as we all got up to leave. There was nothing else I could say – this was the part of cancer care I didn’t have the tools to fix.
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