Cancer is the leading cause of death for Canadians aged 35 to 64 and is also the leading cause of critical illness claims in Canada.

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1 Underwriting cancer In this issue of the Decision, we provide an overview of Canadian cancer statistics and the information we use to make an underwriting decision. The next few issues will deal with specific cancers and provide examples of cases. Cancer is the leading cause of death for Canadians aged 35 to 64 and is also the leading cause of critical illness claims in Canada. And, there will be an estimated 171,000 new cases of cancer and 75,300 deaths from cancer in 2009, according to the Canadian Cancer Statistics Current incidence rates indicate the lifetime probability of developing cancer is 40% for females and 45% for males. The likelihood of dying from cancer is 24% for females, 29% for males. Cancer incidence is rising for young females between the ages of 20 to 39. With these important statistics in mind, the rates that we charge for insurance for each type of cancer are developed based on a number of factors: age at diagnosis stage of cancer five-year relative cancer survival statistics type of treatment family history lifestyle compliance with follow up. Underwriters have very few tools to determine the risk of early mortality or morbidity from cancer. Family history is the most useful piece of information underwriters have available. Age at diagnosis Depending on the type of cancer, the younger the age, the worse the prognosis will be. For example, a male age 45 with prostate cancer will likely have a more aggressive cancer and more invasive treatment that someone age 78 who will likely die with, not of, prostate cancer. Stage of cancer As part of the diagnosis, staging is performed to determine the invasiveness of the cancer and the type of treatment that will be undertaken. There are different staging methods for different cancers and these range from in situ (localized) to invasive with metastasis (spread) to other organs, regional or distant 1

2 lymph nodes. Naturally, the less invasive the cancer, the better the prognosis. Staging methods are generally the same globally and they continue to evolve making treatment decisions more complex and resulting in more effective treatment. Life insurance applicants who have undergone treatment for cancer will generally be accepted provided there have been no metastasis or local metastasis only. The waiting periods will vary depending on the type of cancer. Cancers diagnosed with distant metastasis may be insurable, but only after a lengthy waiting period. Staging information is generally best obtained through an Attending Physician Statement (APS) from the doctor who has the most complete records including the pathology report(s). Five-year relative cancer survival statistics The insurance industry continually monitors the changes to these statistics. The five-year relative survival rate (RSR) is the probability of being alive five years after the cancer diagnosis was made. These statistics, along with staging and treatment type, factor greatly in the rates charged for a history of cancer in life insurance and the rates charged for living benefits products. The five-year relative survival rate is dependent on age, sex and other co-morbid conditions. The Canadian overall rate for 2002 to 2004, for all cancers combined, was 62%. The highest five-year RSR for this period was for thyroid cancer at 98% followed by testicular cancer at 96% and prostate cancer at 95%. The lowest five-year RSR was for pancreatic cancer at 6%, cancer of the esophagus at 14% and lung cancer, males at 13% and females at 17%. Over the period reported, five-year survival rates improved overall by 4.5% compared to people diagnosed between 1992 and The highest improvements were seen in non-hodgkin s lymphoma, prostate, breast and colorectal cancer largely due to the combination of early detection due to screening programs and better treatment protocols. These improvements in five-year survival rates result in more and more applicants being approved for life insurance. The rates charged to cancer survivors are generally flat extras, although sometimes there is an additional permanent mortality rating. These charges reflect the risk of early relapse of the cancer and we apply a permanent charge if there is a long-term risk of a subsequent cancer resulting either from the primary cancer or, from time-to-time, from the treatment that was given. Over the last few years, the duration of the flat extra and the rates charged have been decreasing as the RSR improved. Type of treatment Treatment for cancer has improved dramatically over the years. The ability to track cancer survivors has allowed the medical community to determine what works for specific cancers, what doesn t work and the long-term implications of different therapies. Dr. Wilson s article on treatments, which follows at the end of this article, provides an overview of current and experimental treatments. Depending on the staging, the patient will undergo either a single treatment (e.g. surgery) or a combination of treatments. For underwriting purposes, we determine the waiting period for considering coverage to start from the date of the last treatment. For example, if your client has undergone surgery, chemotherapy and radiation, the date of the most recent treatment is used. Chemotherapy and radiation can go on for several months after surgery. The type of treatment has some bearing on the rating, as well as the likelihood of having an application approved. If treatment was not completed, it is unlikely coverage can be approved. The more complex the treatment, the higher probability of a substantial rating. Family History Some cancers, like other diseases, have a genetic component and this is an important factor when considering a cancer history. Cancers with strong genetic links include certain types of breast, ovarian and colorectal cancer. The age at onset of the disease in the family member is important as well. 2

3 In many cases where there is a family history of a specific type of cancer, there is more surveillance to ensure early detection; for example, mammograms or colonoscopies are done at younger ages. While this testing facilitates early detection and therefore a better prognosis, there are specific genetic tests that can also be done to determine the probability of developing the disease. In some cases, this leads to prophylactic treatment of the cancer rather than waiting for the disease process to begin. Any genetic testing that has been completed will be taken into account during underwriting if there has been a diagnosis of cancer or not. It is important to note we will not ask for testing to be completed for underwriting purposes, but if it has been completed we need to know the results. For clients who have had cancer that has a strong genetic link, we generally base ratings on the extent of the disease at the time of diagnosis. There is a tendency for these cancers to present or be detected at younger ages and as a result, ratings may be higher due to the age and subsequent risk of other cancer. Lifestyle Just as in coronary artery disease (CAD), lifestyle and environment have an impact on underwriting cancer histories. Clearly, someone with a history of cancer who continues to smoke is a different risk than someone who has the same history and is a non smoker. The lifestyle issues we consider from an underwriting perspective where there is a cancer history are similar to CAD risk factors. Build, alcohol intake, mental health and the general overall health after cancer treatment are all factors we consider, as they may have an impact on surviving a further health crisis. There is evidence in medical literature that a healthy diet, normal build and a good support network will enable faster recovery from any disease. Compliance with follow up and treatment As with any significant medical history, follow up after cancer treatment is a significant factor in long-term survival. Depending on the severity of the cancer, follow up is continued for a number of years on an annual or semi-annual basis. It is important for this follow up to continue and for routine medical care to continue to ensure any return of the original disease or secondary cancers are discovered early. From time to time, we see applications where the proposed insured has a significant cancer history and has not seen a physician in a number of years. Unfortunately, these people are not insurable until they reestablish routine medical care. There are a number of long-term treatments that are required to help prevent the recurrence of cancer. These treatments can be prescription and non-prescription drugs or other therapy. The best cases are those where the proposed insured continues their treatment and follow up. Our underwriting approach to cancer history is based on a number of factors including the likelihood of recurrence or secondary cancers, type and staging as well as treatment. The good news is, we are seeing improvements in long-term survival; cancers that were not insurable 10 years ago now are insurable. With an increase in early diagnosis and survival rates, you are more likely to come across clients with a history of cancer and it s likely they will be insurable, some at standard rates. As you record the information on the application, keep the above factors in mind and consult the Underwriting Handbook for Advisors to determine a possible rating. A cover letter indicating any additional information explaining the condition, compliance and current lifestyle is always helpful in these cases. Our next issue of the Decision will look at some specific cancers and case examples to further help you in writing and placing these cases. Source for most statistics used in this document: Canadian Cancer Statistics

4 The Doctor s View Cancer Rates and Treatment Options By Dr. Lorne Wilson, BSc, MD Here is information about cancer rates among Canadian men and women, the various treatment options, as well as an underwriter s perspective on underwriting cancer. Incidence and mortality Cancer incidence refers to the number of new cancers diagnosed each year while cancer mortality is the number of cancer deaths each year. Non melanoma skin cancers are the most commonly diagnosed new cancers, but they cause very few deaths, so they have not been included in this discussion. Over half of new cancers diagnosed are caused by prostate, lung and colorectal cancer in men and breast, lung and colorectal cancer in women. Prostate cancer in men and breast cancer in women are the most commonly diagnosed cancers. Lung cancer remains the leading cause of death in both men and women, but the total number of lung cancers diagnosed in both men and women combined is less than the number of prostate cancers diagnosed in men and just over the number of breast cancers diagnosed in women. Colorectal cancer is the second leading cause of cancer mortality in both men and women. The incidence and mortality by cancer type in both men and women can be viewed in the Canadian Cancer Society s 2009 Canadian Cancer Statistics. See Incidence and Mortality by Cancer Type Table 1.1 and Figures 1.1 and 1.2). Treatment The most well known forms of cancer treatment are surgery, radiation and chemotherapy. Each can be used alone or in combination with other types of treatment. Surgery Ideally, this involves the removal of the entire cancer lesion with the goal of obtaining a cure. This is dependent on the cancer site being accessible and the cancer being localized without spread to other sites (metastases). Other forms of treatment may be used before or after surgery to improve the chances of destroying all of the cancer cells. Palliative surgery refers to the removal of cancerous tissue to relieve symptoms only. 4

5 Radiation Radiation therapy is the use of a type of energy called ionizing radiation to kill cancer cells and shrink tumours. Radiation injures or destroys cells in the area being treated by damaging their genetic material and preventing growth and further division. It is most effective in cells that are growing rapidly. Damage to adjacent healthy cells may occur, especially in those cells with a higher turnover rate, and lead to symptoms which resolve when the damaged cells recover. An example would be vomiting and diarrhea from damage to cells that line the gastrointestinal tract. Radiation can be delivered by an external beam, by radioactive implants (referred to as brachytherapy) or systemically by mouth or injection.. The external beam can be adjusted to cover small or large areas and to penetrate to different depths. The dose and the frequency of the dosing can be adjusted to specific requirements. This radiation can be used to treat almost all types of solid tumours including cancer of the bladder, brain, breast, cervix, larynx, lung, prostate and vagina. It may also be used in the treatment of leukemia and lymphoma. Internal radiation therapy or brachytherapy places a radiation source into the tissue close to the tumour. This is most commonly used in prostate cancer, but may also be used in head and neck, ovary, breast and perianal and pelvic cancers. Systemic radiation, using radioactive materials such as iodine 31 and strontium 89, are used to treat thyroid cancer and adult non-hodgkin s lymphoma. Radiation therapy has been used before surgery and chemotherapy to shrink the tumour mass and afterwards to destroy any remaining cells. Radiation therapy can also be used to relieve pain and other symptoms of cancer. Chemotherapy Chemotherapy uses drugs that have direct tumour-killing properties. It is most effective against cancer cells that divide rapidly and have a good blood supply. These drugs either interfere with cell division by confusing the DNA by directly reacting with it or they interfere with cell metabolism which blocks chemical reactions that cells require to replicate. As with other types of treatment, chemotherapy may be used to cure the disease, to maintain long term remission, to increase the effectiveness of surgery or radiation and to help control pain and other symptoms. Anticancer drugs are used most often in combinations to increase effectiveness and minimize side effects. Other Treatments There are a number of other treatments being used for cancer. Some are widely accepted while others are in the experimental stage. Bone marrow and peripheral stem cell transplantation (BMT and PBSCT) are procedures that restore stem cells to the bone marrow when these cells have been destroyed by high dose radiation and/or chemotherapy. BMT and PBSCT are the most common treatments for leukemia and lymphoma and may also be used to treat neuroblastomas in children and multiple myeloma in adults. Cryosurgery is a technique for freezing and killing cancer cells. It involves the application of extreme cold by the use of liquid nitrogen or argon gas. It has been used as an alternative surgery for liver cancer (that has not spread or that has spread to the liver from another site), for prostate cancer confined to the prostate gland, for precancerous conditions of the cervix and for cancerous and noncancerous tumours of the bone. The topical application of liquid nitrogen is used to treat early stage skin cancers and 5

6 precancerous skin growths such as an actinic keratosis. The use of cryosurgery inside of the body requires a small incision in the skin and the application of cold through a cryoprobe guided by ultrasound or MRI. Cryosurgery is still being studied and its long term effectiveness is still being assessed. Hyperthermia or thermal therapy uses high temperatures (up to 113 F) to damage and kill cancer cells by damaging protein and other structures within the cancer cell. It is almost always used in conjunction with either radiation or chemotherapy. Several methods of hyperthermia are currently under investigation including local, regional or whole body hyperthermia. Laser light is a light of high intensity and a narrow beam that can be used for carrying out precise surgery to remove cancer or precancerous growths or to relieve the symptoms of cancer. It can be used to treat cancer on the surface of the body. It can be applied through a thin tube called an endoscope to treat cancers that line the trachea, esophagus, stomach or colon. When compared with standard surgery, there is usually less bleeding and damage to normal tissue, but it is expensive and the results of treatment may not be permanent. Photodynamic Therapy (PDT) involves the injection of a photosensitizing agent into the body that is absorbed by cells and that stays in cancer cells after being eliminated from normal cells. This drug is then activated by a specific wavelength of light and produces an active form of oxygen that destroys nearby cancer cells. The drug also damages the blood vessels that bring nutrients to the tumor. PDT currently is being used as an adjunctive treatment to relieve the symptoms of esophageal and non-small cell lung cancers. The limited penetration of the light (about one centimeter) restricts use to tumours just under the skin or on the lining of internal cavities. Research continues to find ways to improve the effectiveness of PDT. Angiogenesis Inhibitors Therapy is a process that stimulates cells to repair damaged blood vessels or form new ones and is controlled by certain chemicals in the body. Angiogenesis inhibitors are designed to prevent the formation of new blood vessels that provide oxygen and nutrients to the rapidly growing cancer cells. Although this therapy does not eradicate the tumour, it is able to control growth and may keep tumours stable and extend the lives of patients. Gene therapy for cancer is an experimental treatment that involves introducing genetic material (DNA or RNA) into a person s cells to fight or prevent disease. A gene can be delivered into a cell using a carrier known as a vector. The most common types of vectors used in gene therapy are viruses. Several ways to treat cancer using gene therapy are being studied. Some approaches target healthy cells to enhance their ability to fight cancer while other approaches target cancer cells to destroy them or prevent their growth. Gene therapy is being studied in clinical trials and is not currently available outside of these trials. The ethical, legal and social implications are also under review. In metastatic bowel disease, the identification of a specific genotype will allow us to select a group of cancer patients who will likely benefit from a newly developed drug. The presence of the breast cancer genes, BRCA1 and BRCA2, will allow the patient to better mange their increased cancer risk. This may include increased frequency of surveillance for earlier detection of cancer or even prophylactic mastectomy and/or oophrectomy to remove the tissue at increased risk for developing cancer. In breast cancer, a relatively new test, the Oncotype DX test, measures the activity of several cancerrelated genes to generate a recurrence score that can aid in assessing the patient s risk for recurrence and predict how well the patient will respond to chemotherapy. Recent research indicates that lung cancer patients should undergo genetic testing before treatment begins. Iressa, a new drug for lung cancer, is almost 100% effective in patients of a specific genotype and not effective in those who don t have this genotype. Identifying the presence of specific gene abnormalities in certain cancers can assist in determining the most appropriate treatment. 6

7 Underwriting Cancer Presentations To underwrite a presentation of cancer, we must consider the type of cancer, the stage of the cancer when detected, the likelihood of a cure with the treatment(s) chosen, the risk of recurrence and the risk of a secondary cancer. Cancers are classified according to the primary tumour (based on the grade, size or amount of organ involved), the number and location of lymph nodes involved and the presence or absence of spread to other organs or sites (metastases). Obviously, a cancer detected early will have a better chance of being treated for a cure. The greatest risk of recurrence is early after treatment; therefore, a temporary rating can be applied. This rating will fall off with each year that is documented as recurrence free. Some cancers have a significant risk of recurrence many years later and therefore a permanent rating may be applied in addition to the temporary rating. In addition, the type of treatment of certain cancers, especially childhood cancers, may increase the risk of developing a secondary cancer later in life and for this risk a small permanent rating may be applied. To accurately underwrite, we require the pathology report of the actual cancer removed, all investigations to stage the cancer and follow up that specifically assesses for cancer recurrence at the original site and/or spread to secondary sites. Information for this article was obtained from the websites of the Canadian Cancer Society and the National Cancer Institute. This newsletter has been developed by Manulife Financial for information purposes only and it is intended, but not promised or guaranteed, to b correct, complete and up-to-date. It does not provide medical advice, diagnosis, treatment or care. If you have a health problem, medical emergency, or a general health question, you should contact a physician or other qualified health care provider for consultation, diagnosis and/o treatment. Under no circumstances should you attempt self-diagnosis or treatment based on anything you have seen or read in this newsletter. 7

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