Genomic Sequencing of Tumours – Driving all New Developments in Cancer Medicine

In this, the last of our 4-part series of insurance-focused articles on cancer, Dr. Achim Regenauer, Chief Medical Officer, presents a high-level overview of how genomic sequencing of cancers is blasting a trail for improved, early diagnosis and precision medicine by providing a powerful and ever-expanding means to detect, identify, subdivide and monitor cancer – and how this remarkable development could impact Life & Health insurers.

Dr. Regenauer’s content is presented in a concise tabular format – so there’s no need for you to wade through complex medical descriptions or interpret sensationalised headlines.

Alongside the observations, Bryce Shepherd, Head of Capabilities Development, Life & Health APAC, adds valuable market insights and solutions relating to how the industry can adapt to these changes to ensure that our products and services stay relevant, valued and sustainable over the next decade.

What is genomic sequencing?

Treatment responses and clinical outcomes in cancer patients are highly variable and often hard to predict.
Cancer, however, is a genetic disease, i.e., caused by changes in DNA/genome that control the way that cells function, grow and divide.
Genomic sequencing of a tumour provides insights into the cancer’s specific genetic defects (mutations). With this knowledge, doctors can better identify the appropriate drugs, therapies and/or clinical trials for a patient. Genomic sequencing therefore enables precision or personalised cancer medicine. For more on treatment advances, see the third article in this series, Targeted Cancer therapy – Road to Precision Medicine¹.
Genomic sequencing has also enabled liquid biopsy, the exciting advance in cancer detection and identification via a simple blood test that’s available for some late-stage cancers, but which also holds great promise for wider cancer screening, including multi-cancer testing. For more on liquid biopsy, see the second article in this series, Cancer Diagnostics – Earlier Detection & Impact on Incidence & Mortality².
Through liquid biopsy and precision medicine, genomic sequencing also gives patients access to effective, personalised cancer care at every step of their treatment plan – not just at the start – which is important since even the same cancer type or subtype can affect patients differently.

Business solution: Proposition evolution is underway

The availability of genomic sequencing has long been elevated as having huge potential, with many possibilities for positively helping society.

In the Life & Health insurance industry, how we use or plan to use advances made possible through genomic developments in our products, services, pricing and underwriting is still hotly debated. Practical solutions, however, have begun to emerge, e.g., personalised health plans and tailored wellness solutions.

Specifically, in the area of cancer screening, diagnosis and treatment, genomic sequencing has opened a door for the industry to help drive accessibility and affordability in areas such as personalised therapies and medicines to improve patient outcomes.

Current use and outlook

Over 75% of US-based oncologists reported using genomic sequencing in 2017 to guide treatment decisions³.
Currently, however, sequencing is mostly performed for a small subset of advanced cancers, i.e., it is not in widespread clinical use, in part due to the high cost and the long time required for test results.
Costs range from USD 400 – 1,000. However, as biotechnology companies continue to develop ever faster and cheaper sequencing techniques, cost is expected to fall further over the next few years⁴, approaching the price of a routine check-up.

Business solution: Next imminent change

As access to genomic sequencing increases and costs fall, advanced medical techniques have been able to make leaps and bounds; there is no better case than the current Covid pandemic, where genomic sequencing and m-RNA technology facilitated vaccines to be developed and produced in record time.

From an insurance standpoint, this impact is also seen in the widening availability of targeted cancer therapies and associated personalized drugs plans. As these become more readily available via cheaper genomic sequencing, the products we design must keep up to provide access to these cutting-edge, personalised treatments.

The changes we are likely to begin to see first will be in the changing of product definitions and wordings. These may begin to separate product coverages into more specific cancers with the aim of making benefit payouts more aligned to the specific cancer and attributed personalised treatment. Note, this would, however, go against the trend we see today in the simplification of wordings for more customer friendly products.

Rapid progress is underway

The UK’s NHS became the first national health service in the world to routinely offer genomic medicine from October 1, 2019⁵.
In Japan, cancer societies have issued consensus clinical practice guidance for next-generation sequencing-based gene panel tests⁶.
In the US, researchers reported that 37% of 10,000 investigated cancer patients harboured at least one actionable mutation⁷, meaning that the particular cancer could be treated with a targeted cancer drug, mostly derived from new immunotherapies. Genomic sequencing of specific cancers in the US is currently done for approximately 5% of all cancer cases; this is expected to rise.
Multi-cancer tests, each containing hundreds of actionable mutations, are increasingly coming onto the market – e.g., the FDA recently approved a genetic test panel called FoundationOne^R CDx⁸, with a cost of around USD 5,800. For more on liquid biopsy and multi-cancer tests, please refer to the second article in this series, Cancer Diagnostics – Earlier Detection & Impact on Incidence & Mortality².

Expected impact on Life & Health insurers

Improving cancer mortality rates. These advances are projected to translate into materially improving mortality rates over the next two decades.
Genome-based cancer definitions in Life & Health covers. Cancer medicine has until now relied on the paradigm that cancer is an organ- and tissue-specific disease, which is the basis for underwriting and definitions in Critical Illness and Medical Reimbursement covers. This is expected to change to a more genome guided oncology for common mutations which exist among different organ cancers. Ultimately this may mean that a cancer is primarily defined by genetic biomarkers and less by localisation and histology.
New subdivisions complicate underwriting. Cancers are likely to be subdivided into numerous prognostic groups, complicating underwriting guidelines.
Increased cost of targeted cancer drugs/therapies. Expenses for targeted cancer drugs/therapies are likely to rise rapidly and significantly above medical inflation⁹.
Uncertain timeline. The timing and magnitude of all these changes will primarily depend on the clinical access to targeted cancer therapies (availability and cost).

Business solution: Product & underwriting evolution

As research in this field continues to advance, Life & Health products will need to stay in step to ensure accessibility and alignment to the new status quo in terms of cancer outcomes and customer expectations, i.e., a future where the industry sits fully behind genetics and genomic sequencing as part of a holistic cancer proposition and ecosystem to screen, prevent, diagnose and dynamically treat and provide recovery services tailored to the individual.

For this, considerable change will need to happen in how protection products are designed in terms of the definitions (i.e., triggers), structure and adjoining value propositions (i.e., the services provided). Underwriting will correspondingly also change, fundamentally evolving from its current cohort-based, retrospective approach to be more personalized, dynamic and data-driven.

At PartnerRe, for example, we are in the process of developing an innovative, flexible multi-pay benefit solution that would align benefits to an individual’s evolving diagnosis and treatments/outcomes over time.

Evolving product wordings to accommodate new, genetically defined cancer subclassifications and implementing impact/therapy-aligned solutions like the one mentioned above could, however, both go against the grain in terms of simplifying coverages and improving customer satisfaction. How such dynamic, personalized coverages are presented to and interacted with by the customer will be key. As we go through this evolution, it is also paramount to consider how products are redesigned to protect as much as possible against the ‘unknown’, i.e., building with flexibility and future proofing in mind.

Prediction for the next 10 years

It is almost certain that within the next decade, almost every cancer patient will be checked by a genome sequencing of their tumour tissue, paving the way to a more personalised and effective cancer therapy.
Some cancers may become curable, others may experience a less chronic disease, and a third group will not benefit from the developments.

Business solution: An exciting future for proposition innovation

This area holds so much promise and potential for advancing the health of societies – it’s hard not to get excited about the look and feel of the propositions of the future.

As we in the industry focus on creating the propositions to meet that potential, we must do what we do best – have clear views of the risk, lower or spread that risk through intelligent product innovation, and at the heart, provide increased value to the customer.

PartnerRe has the expertise and a keen interest in innovative cancer propositions. We look forward to a conversation around your protection product suite and how cancer benefits may evolve.

This is the last article in our 4-part series on cancer advances. If you missed any of the previous articles, these contain many interesting insights and discussions, and are all available to view on the PartnerRe website, covering the topics of: global trends in cancer, cancer diagnostics and targeted cancer therapy.

Contributors

Achim Regenauer, Chief Medical Officer, Europe and Asia Pacific
Bryce Shepherd, Head of Capabilities Development, Life & Health, APAC

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Our approach is one of partnership, shared expertise and the creation of success for our clients.

We look forward to discussing these trends and concepts with you, and to turning them into concrete solutions for your business.

This article is for general information, education and discussion purposes only and does not constitute legal or professional advice.

References

1 Targeted Cancer Therapy – Road to Precision Medicine

2 Cancer Diagnostics – Earlier Detection & Impact on Incidence & Mortality

3 https://ascopubs.org/doi/full/10.1200/po.18.00169

4 https://sequencing.com/education-center/whole-genome-sequencing/whole-genome-sequencing-cost

5 E.g. https://www.england.nhs.uk/genomics/nhs-genomic-med-service/

6 https://www.ncc.go.jp/en/information/press_release/20190717/20190717152024.html

7 https://www.cancer.gov/news-events/cancer-currents-blog/2017/mutations-metastatic-cancer

8 https://www.foundationmedicine.com/test/foundationone-cdx

9 E.g. https://www.pharmexec.com/view/rising-tide-next-generation-cancer-treatments & https://www.nature.com/articles/nrclinonc.2017.31

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