How My Insurance Company Is Deciding My Breast Cancer Treatment

Last week I had my first cycle of chemo for Stage IV breast cancer.  The results of the PET Scan were not as bad as expected.  I do have Stage IV breast cancer, but that’s because it has moved to the lymph nodes underneath both arms.  No cancer cells were found in my organs nor bones.

That doesn’t mean it won’t spread because my insurance company is denying my oncologist the drug that stops division of the cancer cells.

Also this week, as friends and families educate themselves to help me get through this, I’ve found that I have to keep reminding them that there are different types of breast cancer cells. As my friends and family talk to cancer survivors and read things online about breast cancer, survival rates, etc. it’s important for them to remember that breast cancer has different cells.  The type of cells are important for diagnosis and treatment.

The parasites that are trying to give life to themselves by eating my body from the inside out are HER2-positive cancer cells.  They are aggressive.  Four days after the biopsy, the tumor had grown 2 inches.   By the time the PET Scan was taken and the results in, the MUGA Scan was taken, and the first chemo scheduled, that parasitical, invasive tumor was even larger.

If you’ve been reading this blog for years, then you probably know that I’m one who trusts in vitamins, herbs and other supplements.  I do not reject traditional medicine.  I also follow Dr. Peter J. D’Adamo’s Blood Type Diet as close as possible.    It all seemed to pay off for me because in order to start chemo, I needed a MUGA Scan score of at least 50.  My MUGA Scan score was 72.  My blood pressure and blood work were all fine.

I had been taking supplements all along, but after my diagnosis, I looked for specific supplements.  I want my body to heal in between treatment cycles.  But first, I needed to know more about my enemy.  I tried reading reputable websites, and found Healthline.com.

“When you have a breast biopsy, the tissue is tested for hormone receptors (HR). It’s also tested for something called human epidermal growth factor receptor 2 (HER2). Each can be involved in the development of breast cancer.”

“HER2 is a gene that creates HER2 proteins, or receptors. These receptors help control growth and repair of breast cells. An overexpression of HER2 protein causes out-of-control reproduction of breast cells.

HER2-positive breast cancers tend to be more aggressive than HER2-negative breast cancers. Along with tumor grade and cancer stage, HR and HER2 status helps determine your treatment options.”

My insurance company tossed a wrench into the battlefield.

Without naming my medical providers, staff, or other identifying features, I will name my insurance company.  It is Humana.  This week, my first chemo cycle was delayed for about an hour as my oncologist informed me that he had been on the phone with a doctor with Humana who first denied one of the drugs to be used in my chemo.

The drug, Taxotere and cyclophosphamide (TC) destroys quickly dividing cells. It can be given either to shrink the size of the tumor before surgery to remove it, or after surgery to kill any cancer cells that may be still present in the body.  The goal of TC is to cure.   But there are only two sites where I was able to find that it’s the drug’s goal.  One site is guess what?  That of trial attorneys.  More on that later.

The FDA describes

“Here’s how Taxotere works:

Every cell in your body contains a supporting structure (like a skeleton). Damage to this “skeleton” can stop cell growth or reproduction. Taxotere makes the “skeleton” in some cancer cells very stiff, so that the cells can no longer grow.”

Humana does not believe that Stage IV breast cancer can be cured.  For that reason, they did not want to approve my oncologist using Taxotere. He put up a good fight with them and got approval for 3 cycles.  That is half of the number of cycles he wants me to receive.

I don’t understand the rhyme and reason behind it Taxotere’s manufacturer nor Humana.  None of this seemed to make sense until I read information on the Gilman & Bedigian Trial Attorneys website.  Emphasis added;

“Taxotere is approved by the FDA for the treatment of breast, lung, prostate, gastric, and head and neck cancer. Taxotere in the treatment of breast cancer, however, is unique because it is used to combat early stages of the disease. With all four other cancers on this list, Taxotere is only used as a second line or palliative treatment option. This means that other drugs, radiation, and/or surgery have failed to cure the patient, or the disease has already progressed past the point of long-term recovery. For this reason, patients with these cancers who receive Taxotere do not often survive to experience the long-term effects of the drug. Only breast cancer patients, who may receive Taxotere in relatively early stages of their disease, are exposed to the possibility of having to live with permanent hair loss. Most lawsuits against the company which manufactures Taxotere, Sanofi-Aventis, Inc., are, therefore, filed by women who have had breast cancer.”

After I learned the above, I thought that Humana first denying approval for my oncologist to administer me Taxotere must be related to the law suits regarding permanent hair loss to women who the company feels will not survive to experience the long-term effects of the drug curing their type of breast cancer.

Sounds crazy.  When a patient has cancer, any type of cancer, 5 years might be considered long-term.  It’s certainly better than 5 months.

“Oh, I’m going to live the next 5 years with permanent hair loss so I’m going to sue the company because I don’t want to die bald.”

Ridiculous!

Then I wondered how they distinguish between “aggressive” and “early stages.”  As I experienced, there is a practice of turning patients away for mammograms because of previous, non-cancerous issues.  I was turned away because since I had previous, non-cancerous issues, they require a diagnostic mammogram.  Diagnostic mammograms are only performed with a doctor’s order.  That means that I had to call my primary care physician for an order, and the nurse who gate-keeps the phone said that my primary care physician will not write the order without seeing me.  The closet appointment was a week away.

No problem!  Why, you ask?  Because I was told that I could go to Prompt Care for an examination and order.  Fine.  The situation was too serious for me to debate with Humana’s choices of having a zero copay to see my primary care physician, as opposed to a $25.00 co-pay for Prompt Care.  The insurance company has made a deal with the network and so be it!  My life is not worth haggling over $25.  There is nothing on the hospital’s website that tells you if you’ve had previous issues, to speak first with your primary care physician to order a diagnostic mammogram.

The Prompt Care doctor wrote the order and sent it directly to the Women’s Center.  I did not receive a call from the Women’s Center. Two days later, I saw my primary care physician and was told that the Women’s Center does not call patients to schedule appointments for diagnostic mammograms.  Patients must call them.  He made sure that the order went through.

Eight days, three inches. Five more days until biopsy.  According to a published study, HER2-positive tumors grow an average of 0.859 %/day.

Four more days, and it grew.  I can’t help but wonder if I had met the “early stage” requirement to be treated with Taxotere if insurance companies didn’t require patients to jump through hoops to get diagnostic exams that are classified as “wellness” until you make the call.

Oh – and that biopsy?  It’s costing me a $250.00 copay because Humana says it was performed in a stand-alone facility according to the hospital’s billing code.  A stand-alone facility is an office or facility separate from a physician’s office or the hospital.  The biopsy was performed in the hospital, but their billing department told me there is nothing they can do to change the billing code.  The hospital’s billing under the incorrect code requires me to fork over $250 rather than a $20 copay.

In the midst of dealing with the disease and treatment, I’m not sure if I’m up to writing letters to the hospital about their incorrect billing practices.   The last letter I wrote to the hospital’s Risk Management Department about their Women’s Care Center has gone unanswered.  In the alternative, I can send Humana all of the documentation that I received for where the tests took place, but I’m not in the mood for being given the run-a-round.  Maybe next week.

The way of the system that delays making an “early stage” cancer into palliative care is no exaggeration on my part.  The following is from Cancer.Net, doctor approved patient information from ASCO, which is the American Society of Clinical Oncology.

“About 5% of women have metastatic cancer when they are first diagnosed with breast cancer.”

“If the cancer has spread to the regional lymph nodes, the 5-year survival rate is 85%.”

Taxotere is a drug that Humana is saying it will only approve to stop the growth of cancer cells as long as they are in breasts.  Those same cancer cells in lymph nodes — naw.  Let them grow beyond the lymph nodes into organs and bones because they are more interested in saving breast parts than giving women with metastatic breast cancer a chance to live — permanently bald or not.

Based on an article by the law firm, Sanofi-Aventis Corp., the manufacturer of Taxotere, has no problem paying out settlements. I suppose that’s because if they can argue that the average life-span with metastatic breast cancer is five-years, then the amount of settlements is low, compared to settlements for women who might live longer bald.

Humana is not my oncologist, — my oncologist who looks into my eyes and the eyes of my family, who talks to us, and who respects me as a human being.

Last night I ended up going to the ER.   I’ve not yet had the port installed for chemo, so last week they ran it through a regular IV.  My hand became swollen and I was told to use hot compresses.  Three days of hot compresses and my hand began swelling in other areas all the way down to my wrist.  Turns out that I have blood clots – deep vein thrombosis.  The nurse practitioner in the ER gave me a Xarelto and a prescription. Because my hand is also red, she also prescribed an anti-biotic.

This morning I had a nose bleed.  I was instructed that if it bleeds for more than an hour to get to the ER.  Chances are that the surgery for the port will be postponed.  I trust the medical professionals treating me and I am sure this is not their first time seeing this situation.  My hope is that the chemo will not have to be delayed.  I am in pain.  I want the cancer cells to stop eating through my tissue.  I want the cancer cells to die.

By the way, I’m posting this under the category “Happiness and Kindness” because in spite of things, my attitude towards others and life itself, shall not change.

To interject a sense of humor, women in Stage IV breast cancer should always early vote.  If they die before election day, it will run people crazy trying to figure out how dead people voted.