In this first interview of a 4-part series, Dr. Achim Regenauer answers questions relevant to Life & Health underwriters on general cancer trends, including trends relating to incidence, detection at earlier stages and overdiagnosis.
For several reasons. Advances in cancer medicine have been substantial over recent decades and this trend is even intensifying. As more patients survive cancer, more underwriting cases will involve cancer. After cardiovascular disease, cancer is the most frequent disease group that Life insurance underwriting and claims are working with. In addition, there is substantial complexity here. Cancer is not just one disease. Over 200 cancer types and subtypes are currently known, resulting in a multitude of differing diagnostics, therapies, including tailored therapies, and outcomes. Equally, the associated medical data from cancers is evermore technically challenging. Underwriters need to keep pace with everything that’s happening in this field.
The answer is “both”. Why are there reports of it increasing? Well, that’s primarily because cancer is usually a disease of older ages. As a result, if a country has an ageing population, its prevalence of cancer diseases will, in general, be rising. This trend will be amplified by advances in molecular medicine that are now clinically not at all far away, advances which will enable the diagnosis of evermore cancers and at an earlier stage, cancers that might previously have remained undetected (I refer here to liquid biopsy and pan-cancer tests, which I’ll discuss in more detail in the next issue).
And why then are there also reports of incidence decreasing? Well, that’s mostly linked to positive lifestyle changes. But we need to go deeper here. Cancer type is a key variable. Common cancers, such as breast cancer, prostate cancer and life-style related cancers including skin cancers, are expected to increase in incidence, while cancers such as colorectum, lung, cervical and stomach cancers are expected to decrease1. An example, high-level outcome of this is the US’s Center for Disease Control’s prediction of an increase in the overall age-standardized incidence rate for women of 1% and a decrease of 9% for men by the year 20502.
Unfortunately, the majority of cancers detected today are still only detected at late stages, i.e., stages III and IV. This is because most cancer types do not yet have population-level screening investigations in clinical use. Such screening investigations mainly only exist for breast, colorectal, cervical, lung and prostate cancer. In the medium-term, pan-cancer tests enabling the earlier detection of more types of cancer will hopefully change this situation for the better.
At the end of last century, cardiology, covering coronary artery disease and stroke, had experienced the most notable medical advances. Over the first decade of this century, genomics took the lead for congenital and rare diseases. Today, most medical advances are occurring in the field of cancer medicine.
Dealing with underwriting risk complexity. Cancer cases are now the most complex for medical underwriters to assess. In contrast to other disease groups, submitted medical files on cancer contain molecular biomarkers, immunohistochemistries and a lot of genetic features such as mRNAs, tumor mutational burden, circulating tumour cell numbers and hormone receptors. It is a major challenge for reinsurers to keep underwriting guidelines both updated and comprehensible, and at the same time to avoid the hyper-segmentation of risk groups.
Cancer overdiagnosis can be interpreted as the detection, through screening, of an asymptomatic cancer that is so slow-growing that it would never be a cause of death for the patient. This has been described for groups of thyroid cancers, uterine and prostate cancers. Cancer overdiagnosis is now thought to have occurred more often than previously assumed and is likely to become more common once pan-cancer tests are introduced into clinical practice. This phenomenon has a particularly notable impact on Critical Illness claims.
Long Covid is now associated with a spectrum of diseases, but based on current knowledge, cancer is not one of them. So, the first reply would be no, but if you extend this question to the indirect effect, then yes, there is a significant impact. Routine cancer screening has been interrupted to such an extent by the pandemic’s waves that in many countries these waves are considered to be a disruption of cancer care. If cancer is as a result diagnosed at a later stage and/or treated later, both morbidity and mortality are negatively impacted, affecting the underwriting and pricing of all Life insurance products.
Unfortunately, yes. The move now across Europe is towards the “right to forget” cancer in an individual’s medical history. Beginning in France and now also in the Netherlands, Belgium and Luxemburg, after 10 years, cancer survivors are allowed for not being charged anymore for mortgage related insurance policies in underwriting The European commission is currently discussing the expansion of this to all European markets. Once such a precedent is set, other disease groups may well follow.
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Achim Regenauer, Chief Medical Officer, Europe and Asia Pacific
1 https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21654
2 https://www.cdc.gov/pcd/issues/2021/21_0006.htm and https://progressreport.cancer.gov/trends