“Roughly a third of patients will remain cancer free for a long time,” Dr. Choti said. “About half will still be alive after five years. In a minority, there’s a long-term cure. In some, we turn it into a chronic disease, if you will. She may recur, and we might be able to reoperate. We can prolong survival significantly.”

A few days after surgery, Ms. Pasqualetto was walking laps around the hospital corridors, thinking about things she had not allowed herself to consider, plans she had not dared to make, like whether Isabel would someday like to have a horse.

“I can’t believe it,” she said. “This is pretty exciting.”

But weeks later, at home again, she found herself back in the trenches, unsure of what the next step in her care would be. Her oncologist refused to see her until he spoke with the surgeon, and yet neither of them had called the other. Meanwhile, she was trying to decipher a worrisome report indicating that a CT scan had found minute lesions on her spleen.

“It’s like I’m flapping in the wind,” she said.

Far From Typical

Karen Pasqualetto is exceptional not only for her determination and confidence in dealing with problems that would intimidate many other people, but also for her financial wherewithal. So far her treatment has cost more than $400,000, almost all of it covered by health insurance from Starbucks, where her husband works in disaster-response planning.

When she joined a cancer support group, she recalled, “It was amazing to me the different experiences people were having based on what they could afford or who their provider was. I was able to say, ‘If the provider won’t pay, my family will. I don’t care, I’m going for a second opinion.’ ”

In the support group, it saddened her to hear other patients with advanced disease take the word of a single oncologist, because she believes that if she had done that, she would already be dead. She has come to think that survival may depend on money and access, and, she said, on “your own drive and motivation — are you Type A? — your education and your ability to sort through the medical world and the insurance world terminology.”

Ms. Pasqualetto’s doctors have accepted her insurance payments, but if they had not, she said, “I would find resources. I would get people to pay. I do have resources. I have access to people who wouldn’t sit by and let me die because of $200,000.”