This is the journey of a single new cancer diagnosis through a self-insured plan — month by month, dollar by dollar. The story is a composite, drawn from public stop-loss and oncology cost-of-care data. The numbers are real-world medians.
A 10,000-life self-insured employer. Average claim severity in line with national medians. Stop-loss attaches at $300K.
By the math of working-age cancer incidence, this plan will see roughly 47 new cancer diagnoses this year. Most will resolve with standard care. A handful won't.
Sarah is 47, a marketing director, mom of two. She lives in a Tier-2 metro, sees a primary care doctor she trusts, and uses the plan rarely.
She doesn't know yet that the next twelve months will cost her plan close to a million dollars — and that almost half of that is going to be avoidable.
A routine self-exam in March. A primary care visit. A community-hospital imaging order. A biopsy two weeks later. Stage II HER2-low breast cancer.
From this point on, every decision is high-stakes. The plan has no protocol for what comes next.
Imaging, biopsy, pathology, MRI staging, baseline labs. Sarah is referred to a community medical oncologist.
The fork in the road: a community oncologist is competent. But HER2-low breast cancer in a 47-year-old is exactly the kind of case where subspecialty review changes the regimen 30–43% of the time.
The community team starts a standard chemotherapy regimen. Two infusion cycles. One ER visit for nausea. One inpatient admit.
The treatment plan is reasonable. It's also not the one a subspecialty oncologist would have chosen for this exact tumor profile.
Re-staging imaging shows partial response, but disease progression in the regional nodes. The team pivots to a second-line regimen, including a high-cost biologic.
Stop-loss attaches mid-month. Sarah's case moves into catastrophic-claim territory.
An ER visit for febrile neutropenia. A 6-day inpatient stay. A planned surgery, then an unplanned readmission for a wound complication. A second biologic added to the regimen.
The clinical and financial trajectories are now both running ahead of plan.
Sarah is in active maintenance therapy. The plan has paid $920K. Stop-loss has reimbursed $620K. Year two is projected at another $310–410K.
By any measure, this is the kind of claim that defines a self-insured plan's year. The question is how much of it had to happen.
Same Sarah. Same plan. Same diagnosis. The only difference: at month two, an NCI-designated subspecialty oncology team reviewed the case, refined the treatment plan, and stayed engaged through the journey.
Watch what happens next.
An NCI-designated subspecialty oncology team reviews Sarah's full file in four days. They confirm the diagnosis, refine the HER2 staging, and recommend a different first-line regimen tailored to her exact tumor profile.
Sarah's community oncologist agrees with the refinement. The regimen changes. The cost trajectory diverges.
The refined regimen achieves a deeper initial response. No second-line pivot is needed in month six. The inpatient admit from the first scenario doesn't happen.
Sarah feels better, faster. The plan logs a 38% drop in cumulative spend through month six.
A ClearOnc oncology navigator stays in weekly contact with Sarah. When her white count drops, the navigator escalates within 24 hours. The ER visit becomes an outpatient infusion suite visit.
The 6-day inpatient admit doesn't happen. The wound complication readmit doesn't happen.
Plan-paid cost: $548K, down from $920K. Stop-loss reimbursement falls proportionally. Sarah remains in active therapy, but in a regimen designed for her, not improvised around her.
The same patient. The same plan. The same diagnosis. One refinement at month two changed the trajectory of the year.
Of those 47 new cancer cases in a 10,000-life plan this year, roughly 19 are the kind where expert review materially changes the treatment plan. The math at the plan level is what makes this a CFO problem, not a clinical curiosity.
The calculator runs the same model live, with your headcount, your industry, and your claim severity.
Sarah is not a real patient. Her journey is a composite drawn from common HER2-low breast cancer treatment trajectories, blended with national stop-loss high-cost claim cost data and oncology cost-of-care research.
The dollar figures are real-world medians; the timeline matches the most common pattern of first-line, second-line, and complication-driven escalation in the public oncology literature.
The intervention scenario applies the same blended reduction (~36% on the avoidable share) used in our cost calculator, which is the floor — not the ceiling — of published subspecialty-review program outcomes.