Cancer Vixen: A Graphic Memoir of Breast Cancer, and the Insurance That Had Lapsed

Marisa Acocella Marchetto was a cartoonist in New York, publishing in The New Yorker and Glamour. She was engaged to a restaurateur, and by her own account enjoying the city very much. In 2004, three weeks before her wedding, she found a lump in her breast. It was cancer.

Her health insurance had lapsed.

Cancer Vixen is the book she drew about the eleven months that followed. It is a full-color graphic memoir, roughly 200 pages, and it began life as a six-page comic in Glamour before expanding. Knopf published the book in 2006.

The persona in the title is deliberate. Marchetto declines the role of patient-as-victim and instead draws herself as a woman going to chemotherapy in good shoes. Whether that reads as armor or as denial is one of the things the book is actually about, and she is more self-aware on the point than the cover suggests.

Two things distinguish it from most breast cancer memoirs. The first is form: comics can put a thought bubble next to a mammogram, and Marchetto uses that constantly, showing the gap between what she says in the room and what she is thinking. The second is money. The insurance problem is not a footnote here. It is a thread running through the whole story, and it is the reason the book still circulates in the US in a way it never quite did elsewhere.

The structure follows the calendar of her treatment, with chapters marked by month and by milestone.

The opening sequence is diagnosis: the lump, the imaging, the biopsy, the phone call, and the immediate collision with a wedding date. Then the coverage problem, handled in comics as a series of increasingly absurd conversations.

The middle is treatment. Surgery, then chemotherapy, then radiation, drawn in detail: the infusion chair, the cold cap discussion, the eyebrows, the nausea, the port. She draws her oncologist, her surgeon and her nurses as recurring characters with dialogue, which is unusual and effective.

Around that sits the rest of a life. Her mother, drawn as an unstoppable force. Her new husband and his restaurant. Friends, some of whom are excellent and some of whom vanish. Work deadlines that do not move.

There are recurring visual devices: the cancer drawn as a monster in stilettos, dream sequences, and pages laid out as fashion spreads. There is no medical appendix, no glossary and no treatment summary. The information in it is the information she was given at the time.

The book found a general readership, not only a cancer readership. It sold widely, and has been listed among the notable graphic memoirs of its decade. That matters mainly because it means many people meet breast cancer for the first time through these pages, which is a reason to be clear about what has changed since.

On the texture of being newly diagnosed, it is very good. The disbelief. The compulsive research. The way one's own body becomes a scheduling problem.

On the social side, it is sharper than it looks. Marchetto catches the friend who makes the illness about herself. She catches the near-stranger with a supplement to suggest, and the polite fiction that everyone is handling this well.

On money, it is close to unique among cancer memoirs. Very few of them show a patient calculating what a scan costs, or negotiating, or being frightened of the mail. NCI's own material treats exactly this as a known problem. It defines financial toxicity as problems a cancer patient has related to the cost of treatment. It says this has become increasingly common among patients and their families.

And the comics form earns its place. A page can hold the clinical fact and the private reaction at the same time, which prose has to do sequentially.

It is also a useful record of how a diagnosis lands in the middle of a life that has already been scheduled. The wedding does not move. The restaurant still opens. The deadlines still arrive. Marchetto draws that pile-up rather than clearing the calendar for cancer, which is closer to how most people's first months actually go.

The treatment is from 2004 and 2005. Since then, decisions about who benefits from chemotherapy have changed a great deal. Receptor status and gene-expression testing now drive them. Care for nausea and low blood counts has also improved. Reading her regimen as a forecast of anyone's own would be a mistake.

The insurance storyline is also a specific moment in US policy. It predates the Affordable Care Act. The rules on pre-existing conditions, marketplace plans and Medicaid expansion did not exist then. Those rules shape someone's options today. The predicament is still recognizable; the mechanics are not the same.

The tone will divide readers. The glamour is the point, but a reader who is broke, exhausted and not in New York may find the designer clothes and the restaurant tables hard going. It is worth knowing that in advance rather than discovering it in chapter four.

Finally, this is one woman's cancer. Her stage, her surgery, her response and her outcome are hers, and the book's confidence about how things went should not be read as a general prognosis.

NCI splits breast cancer treatment into two categories, and that split explains most of the sequencing questions people arrive with.

Local treatments are directed at the area with cancer and not the whole body. Surgery and radiation are the local treatments. Systemic treatments are drugs that can reach cancer cells throughout the body, and chemotherapy is the example NCI gives.

NCI lists surgery first, most often lumpectomy or mastectomy. Then radiation therapy, with protocols that vary by situation. Then chemotherapy, and NCI states plainly that not everyone with breast cancer will get chemotherapy. Then hormone therapy, which lowers the risk of return for certain types. And then targeted therapy and immunotherapy for particular subtypes, including triple-negative disease.

On sequence, NCI does not give a single order, and that is the important point. It says the person and their cancer care team work together to decide the treatment plan. That plan may include more than one type of treatment. It says stage weighs heavily on which approaches are recommended. Some people have drug treatment before surgery, some after, and the reasons are specific to the tumor. Marchetto's order was hers.

Breast cancer treatment sets out the options in more detail, and breast reconstruction versus going flat covers the decision the book touches on only lightly.

NCI's page on managing cancer care costs is more practical than most people expect a federal page to be.

It lists what to ask, and who to ask. Coverage details from an insurance benefits coordinator. Copays, deductibles and coinsurance amounts. How and when payment is expected. The steps for getting a treatment approved when it is not covered. Whether a generic version or a different dose is possible. Discount pharmacy options.

It names three roles that exist to help. Social workers, who can point to organizations and programs beyond insurance. Hospital financial counsellors, who discuss payment plans, reduced rates, patient assistance and charitable resources. Insurance case managers, who provide a consistent contact for coverage questions.

It also names specific assistance programs. Among them are CancerCare and its A Helping Hand database, and the Cancer Financial Assistance Coalition. It names the HealthWell Foundation for copays, premiums and deductibles, and the Leukemia and Lymphoma Society. It names Triage Cancer for legal and practical guidance. And it names GoodRx, NeedyMeds, RxAssist and Rx Outreach for medication discounts. Its standing advice is to talk to the treating clinician about cost rather than treat it as a separate, private problem.

For people on Medicare, the arithmetic is published. Medicare.gov states that Part A covers chemotherapy for a hospital inpatient, and Part B covers it for a hospital outpatient or in a doctor's office or freestanding clinic. After the Part B deductible, the patient usually pays 20 percent of the Medicare-approved amount. In a hospital outpatient setting, the copayment cannot exceed the inpatient deductible amount. What someone actually pays depends on other coverage, what the provider charges, and whether the doctor accepts assignment.

None of that removes the problem Marchetto draws. It does mean there are named people whose job is the bill. What is financial toxicity and paying for cancer treatment cover the US picture as it stands now. Marchetto's insurance had lapsed weeks before she found the lump. The cost of a diagnosis is rarely the part anyone is warned about.

It suits readers who want a cancer book that is funny, visual and fast, and who are put off by solemnity. It suits people newly diagnosed who cannot concentrate on prose; comics ask less of a chemotherapy brain.

It suits anyone whose diagnosis arrived with a coverage problem attached, who has not seen that written about honestly.

It does not suit a reader wanting current treatment information, and it does not suit someone who finds the glamour grating or the New York setting alienating. It also is not the book for a reader who wants restraint. Cancer Vixen is loud on purpose.

• NCI — Breast Cancer Treatment (PDQ), Patient Version
• NCI — Managing Cancer Care Costs
• Medicare.gov — Chemotherapy coverage
• Cancer Vixen: A True Story — catalogue record, 2006 Knopf edition

This page discusses Cancer Vixen for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care.