Cancer

1
Cancer Insurance 25 years on

• Professor Robert Rubens
• Presidential Address
• Assurance Medical Society
• 5 February 2003

Swiss Re Life Health
2
To consider

• Life Assurance
• epidemiology - changing mortality
• evidence-based underwriting
• breast cancer
• childhood cancer
• Critical Illness Insurance
• risk factors and anti-selection
• definitions and admission of claims

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3
US cancer deaths mortality rates
3
6
Year
Deaths x 10
Population x 10
Age-adjusted
mortality
1994
534.3
260.3
170.6
1995
538.4
262.8
168.8
1996
539.5
265.3
166.6
1997
539.6
267.8
163.7
1998
541.5
270.2
161.5
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J Natl Cancer Inst 2001931769
4
Cancer changes in 5-year relative survival rates
http//seer.cancer.gov
5
Trends in survival rates forcommon cancers,
England Wales
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S Mayor BMJ 2001 3231283
6

Model for underwriting applicants who have been
treated for cancer for life insurance
Survival
Normal
Cancer
Postpone Extra Premium
Ordinary Rates
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Years
7
Breast cancer determinants of outcome

• Staging
• especially lymph node involvement
• Histological differentiation
• Tumour size
• Treatment

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8
Survival breast cancerGuys Hospital Breast
Unit (1975 - 1999)
100
2
X 1689.
3
P lt .001
80
60
Stage I (n1686)
Cumulative surviving
40
Stage II (n1826)
20
Stage III (n556)
Stage IV (n242)
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Time (years)
9
Survival breast cancer Guys Hospital Breast
Unit (1975-1999)
100
80
Node Negative (n1686)
60
Cumulative surviving
40
2
Node Positive (n1826)
X 260.7
1
20
P lt .001
4
8
12
16
20
24
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Time (years)
10
Survival breast cancer - node negativeGuys
Hospital Breast Unit (1975-1999)
100
80
Grade I Ductal (n192)
Grade II Ductal (n516)
60
Grade III Ductal (n493)
Cumulative surviving
Infilt Lobular (n182)
40
2
X 24.39
3
20
P lt .001
4
8
12
16
20
24
Time (years)
11
Survival breast cancer - node negative, grade
IGuys Hospital Breast Unit (1975-1999)
100
80
lt 2cm (n102)
60
gt 2cm (n69)
cumulative surviving
40
2
X 6.66
1
P .01
20
time (years)
4
8
12
16
20
24
12
Survivalbreast cancer-node negative,not grade
IGuys Hospital Breast Unit (1975-1999)
100
80
lt 2cm (n484)
60
gt 2cm (n665)
Cumulative surviving
40
2
X 26.2
1
P lt .001
20
4
8
12
16
20
24
Time (years)
13
Survival of women withnode-negative breast
cancer lt 1 cm
100
n 191
80
60
Cumlative Surviving
Comparison with age-matched healthy female
population
40
20
2 4 6 8 10 12 14 16
Time (Years)
Rubens Gregory Lancet 1992 339 810
14
Survival by age and nodal status breast cancers
lt1cm
100
Age gt50 N0 (n129)
Age lt50 N0 (n103)
80
Age gt50 N (n49)
Cumulative surviving
60
Age lt50 N (n54)
40
x 24.18
2
3
P lt .001
20
3
6
9
12
15
18
21
Time (years)
Fentiman et al. Eur J Cancer 1996 32A417
15
Survival breast cancer - node positiveGuys
Hospital Breast Unit (1975-1999)
100
80
Cumulative surviving
60
1 - 3 positive (n1137)
40
2
X 121.1
20
1
gt 4 positive (n689)
P lt .001
4
8
12
16
20
24
Time (years)
16
Survival breast cancer - nodes positive
1-3Guys Hospital Breast Unit (1975-1999)
100
80
Grade I Ductal (n97)
60
Cumulative surviving
Grade II Ductal (n396)
40
Grade III Ductal (n346)
2
X 49.19
Inf Lobular (n115)
3
20
P lt .001
4
8
12
16
20
24
Time (years)
17
Survival breast cancer - node positive gt4Guys
Hospital Breast Unit (1975-1999)
100
80
60
Grade I Ductal (n29)
Cumulative surviving
Grade II Ductal (n223)
40
Grade III Ductal (n217)
2
X 50.72
20
3
Inf Lobular (n103)
P lt .001
4
8
12
16
20
24
Time (years)
18
Frequent incurability of cancerby local therapy
alone
excision
death
12
clinical disease
remission
10
8
Log 10 No cells
metastasis
6
4
2
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time
19
Adjuvant ChemotherapyEBCTCG, 1998

• Overview of 47 randomised trials including 17,723
  women

Chemotherapy regimen CMF CMF extra
drugs Other regimens All
Reduction in death rate (SD) 14 (4) 15
(5) 17 (4) 15 (2.4)
P 0.00009 0.003 0.00004 lt0.00001
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Lancet 1998 352 930
20
Adjuvant Chemotherapy - EBCTCG, 1998
Age (years) lt 40 40-49 50-59 60-69 All
Reduction in death rate (SD) 27 (8) 27
(5) 14 (4) 8 (4) 15.2 (2.4) p lt 0.0001
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Lancet 1998 352 930
21
Mortality from breast cancer adjuvant
chemotherapy
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EBCTGG, Lancet 1998 352930
22
Mortality from breast cancer adjuvant
chemotherapy
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EBCTGG, Lancet 1998 352930
23
Adjuvant tamoxifenEBCTCG, 1998

• Overview of 55 randomised trials including 36,689
  women

Duration tamoxifen - years 1 2 5
Reduction in death rate (SD) 10 (3) 15
(2) 22 (4)
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Lancet 1998 352 930
24
Adjuvant tamoxifen (5 years) - EBCTCG, 1998

• Reduction in death rate (SD)
• -3 (11)
• 21 (9)
• 28(5)

• Oestrogen Receptor
• Negative
• Unknown
• Positive

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Lancet 1998 352 930
25
Adjuvant tamoxifen (5 years) - EBCTCG, 1998

• Reduction in death rate (SD)
• 25 (5)
• 28 (6)
• 26 (4)

• Node status
• Negative
• Positive
• All

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Lancet 1998 352 930
26
Adjuvant tamoxifen (5 years) - EBCTCG, 1998

• Reduction in death rate (SD)
• 32 (10)
• 11 (8)
• 33 (6)
• 34 (13)
• 26 (4)

• Age (years)
• lt 50
• 50-59
• 60-69
• 70
• All

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Lancet 1998 352 930
27
Mortality from breast cancer adjuvant tamoxifen
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EBCTGG, Lancet 1998 3511451
28
Breast cancer annual death rate per 100,000 women
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Lancet 1998 355 1822
29
Breast Cancer Survival Operable -stages 1 2
(Guys Hospital Breast Unit)
100
80
1987 to 1999 (n1775)
60
Cumulative surviving
1975 to 1986 (n1630)
40
2
X 34.29
1
P lt .001
20
4
8
12
16
20
24
28
Time (years)
30
Incidence survival of womenwith breast cancer
(England Wales)
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M P Coleman, Lancet 2000 356 590
31
Survival breast cancer-node negative grade I
lt2cmsuperimposed on life-expectancies for age
ranges
lt 40
41 - 50
51 - 60
61 - 70
Over 70
32
Trends in Survival in Children(age under 15)
treated for Cancer in USA
5-yr relative survival 56 62 65 68 70 74
Year of Diagnosis 1974-76 1977-79 1980-82 1983-85
1986-88 1989-94
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1974-76 v 1989-94 Plt0.05
SH Landis et al Cancer Statistics, 1999
33
Cumulative mortality in 5-year survivorsof
childhood cancer by decade of diagnosis

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Moller et al J Clin Oncol 2001193173
34
Childhood Cancer Survivors Study (CCSS) Deaths
Standardised Mortality Ratios (SMR) of 5-year
survivors
Deaths 2,030 1,216 814
Alive 18,197 9,916 8,236
SMR 10.8 8.5 18.2
95 CI 10.3-11.3 8.0-9.0 17.0-19.5
Total Male Female
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Mertens,AC et al J Clin Oncol 2001193163
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CCSS - Deaths SMR by Diagnosis
Deaths 722 377 328 93 65 59 171 215
Alive 5,927 2,443 2,283 1,391 1,617 1,281 1,641 1,
514
Leukaemia CNS tumours NHL Hodgkins
disease Wilms tumour Neuroblastoma Soft-tissue
sarcoma Bone tumours
SMR 15.5 15.7 8.3 5.1 6.2 7.8 8.6 10.1
95 CI 14.3-16.6 14.1-17.3 7.4-9.2 4.1-6.2 4.8-7.9
5.9-10.1 7.4-10.0 8.8-11.5
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Mertens,AC et al J Clin Oncol 2001193163
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CCSS - SMR by Survival after Diagnosis
Years 5-9 10-14 15-19 20-24 25-29
Deaths 1,130 556 241 89 14
SMR 22.6 8.6 4.9 4.0 6.2
95 CI 21.3-24.0 7.9-9.4 4.3-5.6 3.2-4.9 3.4-10.4
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Mertens,AC et al J Clin Oncol 2001193163
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CCSS - Relative Risk of Death by Yearof
Diagnosisadjusted for years since diagnosis
1970-73 1974-77 1978-81 1982-86
RR death 1.4 1.2 1.0 1.0
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Mertens,AC et al J Clin Oncol 2001193163
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CCSS - All-cause mortalitysex-specific survival
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Mertens,AC et al J Clin Oncol 2001193163
39
CCSS - Causes of Death (n1848)

• Recurrence
• Treatment related
• subsequent neoplasm
• cardiac
• pulmonary
• other
• Non-treatment-related 208

• 1246
• 394
• 235
• 83
• 33
• 43

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Mertens,AC et al J Clin Oncol 2001193163
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CCSS - Cause-specific mortality

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Mertens,AC et al J Clin Oncol 2001193163
41
Critical illness insurance

• With the availability in the UK of
• life assurance
• terminal illness cover
• disability insurance
• mortgage protection cover
• medical expenses
• What is it for ?

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42
Critical Illness Policy Sales 1992 - 2000
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43
Categories of CIC claims presented in 2001
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Legal General
44
Anti-selective factors for cancer

• Family history
• Pre-existing benign conditions (e.g. breast)
• Population screening
• Individual screening (PSA)
• Previous cancer

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45
Cancer - ABI, May 2002

• A malignant tumour characterised by the
  uncontrolled growth and spread of malignant cells
  and invasion of tissue. The term includes
  leukaemia and Hodgkins disease but the following
  are excluded
• All tumours which are histologically described as
  pre-malignant, as non-invasive or as cancer in
  situ.
• All forms of lymphoma in the presence of any
  Human Immunodeficiency Virus.
• Kaposis sarcoma in the presence of any Human
  Immunodeficiency Virus.
• Any skin cancer other than malignant melanoma
• T1 prostatic cancer

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Critical illness insurance-problems with cancer
definition

• Transition between a pre-malignant condition and
  established cancer
• Whether a neoplasm is benign or malignant
• Whether invasion has occurred
• The anatomical site of a tumour

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47
Some specific issues - 1

• Invasion v. cytological appearances
• carcinoma
• sarcoma
• leukaemia lymphoma
• Benign or malignant?
• carcinoid

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48
Some specific issues - 2

• Should CLL be included ?
• staging (Rai or Binet)
• Skin
• melanoma
• sweat gland tumours
• cutaneous lymphoma
• Aggressive benign tumours

49
Benign Brain Tumour - ABI, May 2002

• A non-malignant tumour in the brain resulting in
  permanent deficit to the neurological system.
  Tumours or lesions of the pituitary are not
  covered.
• But
• exceedingly rare
• acoustic neuroma ?
• meningioma ?

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50
Cancer - CI claims anomalies

• Poor prognosis
• Lung cancer
• Dukes C colon cancer
• Glioblastoma multiforme

• Good prognosis
• Thin melanoma (level II)
• day case surgery
• Microinvasive cervical cancer
• Papillary thyroid cancer

Claims result in identical payments
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51
Graded benefits for cancer claims

• Payment on scale of 0-100 according to severity
• in inverse proportion to the rating for life
  assurance
• balance payable on recurrence
• Partial payment (e.g. 10-25) for localised
  disease (i.e. when radical treatment has curative
  intent)
• balance payable on recurrence
• 100 for primary advanced disease

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52
Conclusions

• In the last 25 years, cancer incidence has
  increased, but mortality has lessened
• These changes have had significant implications
  for both life critical illness insurance
• Our evidence-base for underwriting continually
  improves. It needs regular up-dating which should
  lead to periodical adjustments to ratings
• Increasing problems with critical illness
  insurance are foreseen, unless
• definitions become more rigorous and
  comprehensive
• the product becomes more equitable

53
Acknowledgments

• Colleagues
• Guys Hospital
• Swiss Re Life Health
• Legal General