By Elaine Schattner, MD

“Walt, is that you?” Skyler asks her husband in the final scene of the Breaking Bad pilot. They’re in bed, she’s pregnant, and he’s come toward her in a new way. He’s changed, and she doesn’t yet know why. In this acclaimed cable TV series, a lung cancer diagnosis serves as a catalyst, transforming actor Bryan Cranston’s Walter White—a modest, nonsmoking high school chemistry teacher in Albuquerque, New Mexico—into a ruthless drug kingpin. He starts cooking and selling methamphetamine, nominally to provide after his death for his wife, son, and unborn baby. Breaking Bad upturned the conventional idea of cancer patient as victim: Walter White is an antihero.

Breaking Bad elevated attention to cancer treatment’s costs. With inoperable lung cancer, Walter hesitates before starting chemotherapy in season 1. The oncology practice requires a $5,000 deposit and estimates his out-of-pocket costs at $90,000, an out-of-reach sum for a high school teacher. In a memorable scene, Walter’s family confronts him about his reluctance. Their discussion encapsulates many real families’ deliberations and feelings about whether cancer treatment is worth taking. Seated in the living room, they pass around a “talking pillow” and share thoughts. Skyler is upset, she says, because Walt will die if he doesn’t take the medicine. Walter Junior, their disabled teenage son, says he’s angry; he thinks his father lacks courage to take chemotherapy. Hank, Walter’s brother-in-law, speaks confusedly. Skyler’s sister, a radiation technologist, says it should be Walter’s decision to take chemo or not. She says she’s known cancer patients who took treatment only because their families wanted them to, while they would have preferred spending their remaining days away from doctors. Walter asserts that what he wants most is a choice. He’s concerned about leaving his family with debt, and that treatment is unlikely to help much. He doesn’t want to spend his final months of life feeling sickly.

If Breaking Bad were to begin today, the show’s creator, Vince Gilligan, would probably assign his protagonist a different diagnosis, because Walter wouldn’t be doomed by his lung cancer. In 2008 when the pilot aired, tumor DNA sequencing was not available except for research, targeted lung cancer treatment existed for only one gene, and immune agents were not yet approved. Since Walter’s 2013 “death,” the FDA has approved more than a dozen novel lung cancer drugs. Today, an oncologist would check Walter’s malignant cells for changes in over a half dozen genes—EGFR, ALK, ROS-1, MET, N-TRK, BRAF, RET, and others— that confer sensitivity to nonexperimental agents. Or they might offer Walter an immune checkpoint inhibitor, an antibody drug that shrinks or stabilizes a significant fraction of lung cancers. However, the costs of Walter’s cancer therapy would be exorbitant. As we’ll consider, as treatments become more effective, financial toxicity becomes limiting and potentially lethal.

Elaine Schattner is a former hematology-oncology physician and author of From Whispers to Shouts: The Ways We Talk About Cancer.