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For some, it can be the most distressful toxicity of all. As oncologists, we often focus on the anticipated physical burdens of treatment without much, or any, time spent preparing patients for what the monetary side effects may look like. This is the subject of investigation in last month’s Jama Onc research letter. It reports that one-third of insured cancer patients face unanticipated amounts of medical bills, with a median out-of-pocket cost of care surpassing 10% of household income. And among those with “overwhelming” distress levels (16% of patients), that cost approached one-third of household income. Why talk about this now? Sadly, the author is steered by her own personal experience with snowballing health care costs, which can seem impossible to navigate (or prioritize) when simultaneously faced with a life-threatening illness. In the era of ever-emerging targeted therapies, Big Pharma runs the show….so we can only expect the financial toxicities of our treatments to sky rocket. And that means any worthwhile risk-benefit discussion on cancer care has to include anticipated monetary burden.