Tyree said doctors told her Neulasta was "completely routine and everybody got it." She had no idea how much she and her insurer would have to pay for it until the bill came.
A recent American Cancer Society survey found that one-quarter of U.S. cancer patients put off getting a test or treatment because of cost, the group's chief medical officer, Dr. Otis Brawley, writes in his new book "How We Do Harm," which discusses costs and argues for more rational use of health care. One out of 5 survey respondents over 65 said they had used all or much of their savings on cancer care.
The burden hits hard on the middle class — people too well off for programs that cover the poor but unable to afford what cancer care often costs.
Dr. Amy Abernethy, director of the cancer care research program at Duke University, did a study of 250 such patients from around the country. Most were women with breast cancer, including Tyree. All but one had insurance, and two-thirds were covered by Medicare. The vast majority also had prescription drug coverage.
Their out-of-pocket expenses averaged $712 a month for doctor visits, medicines, lost wages and travel to appointments. To pay for cancer drugs, half spent less on food and clothes, and 43 percent borrowed money or used credit. Also, 26 percent did not fill a prescription, 22 percent filled part of one and 20 percent took less than prescribed.
"Patients don't just have cancer, and that's becoming more and more of a problem" because they also are struggling to buy medicines for heart disease, diabetes and other conditions, Abernethy said.
The challenge will grow as the newest trend in cancer care takes hold: using the new, gene-targeting drugs in combination. There has been limited success using them one at a time — they tend to buy a few more months or a year or two of life but usually are not cures.
"Almost certainly we will have to use multiple drugs" to shut down all of a tumor's pathways rather than just the main one attacked by a single drug, said Dr. Allen Lichter, the oncology society's chief.
Ironically, "one of the answers to making cancer therapy more cost-effective is to find these targeted agents" and use genetic tests to narrow down which patients really benefit instead of giving them to everyone with a particular type of cancer, Lichter said. For example, the new lung cancer drug Zalkori targets a gene that is present in only 5 percent of lung cancers, but it helps 60 percent of those patients.
Here's where things get sticky. Desperate patients often demand treatments that have a very small chance of helping them. And many doctors feel they have a duty to offer anything that might help, regardless of the cost to insurers and society, said Hassett, the policy researcher from Boston.
An example is the outcry over the government's recent withdrawal of approval of Avastin for breast cancer. Studies showed the drug did not improve survival for most women and there are no biomarkers to identify the few it does help. Many doctors and patients still want access to the drug, and Medicare is still paying for it.
But denying "useless" treatment isn't just about saving money — it's about avoiding harm and false hope, Brawley writes in his book. "A rational system of health care has to have the ability to say no, and to have it stick," he contends.
Cost can still be a concern long after initial treatment. Many breast cancer patients take medicines for five years to prevent a recurrence. Tyree, the woman from Virginia, is about to start on one of these, Arimidex. It is newer and somewhat more effective than tamoxifen, a medicine long used to prevent cancer's return, but it is also more expensive.
If insurance covers only part of it, "I'll have to pay," Tyree said. "And I don't have any idea how much it is."
Advice on costs: http://bit.ly/arjDb2
Questions to ask doctors: http://bit.ly/wdzaj3