Cancer and how your policy works. General & Medical

Transcription

1 Cancer and how your policy works General & Medical

2 This booklet, like others in our information book series are designed to help you understand the various aspects of General & Medical private healthcare schemes and must be read in conjunction with your policy documents (part 1 and 2)

3 Cancer and how your policy works 2 What is Cancer 2 What Causes Cancer 2 What do Malignant and Benign Mean? 3 Does Cancer Spread 3 Typical Symptoms of cancer 4 How we cover treatment for cancer 9 Example: Breast Cancer 10 Prosthesis 11 Speech Therapy 11 Drugs and Treatment 12 Example: Herceptin 12 When cancer becomes incurable 15 Patient care and other national organisations 15 Known cancers 16 General & Medical Finance Ltd No part of this document may be reproduced without the express written permission of General & Medical Finance Ltd

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5 What is Cancer? Cancer is a general term used to describe a wide range of diseases that are characterised by the development of abnormal cells that divide quickly and have the ability to infiltrate and destroy healthy body tissue. Put simply, cancer is a failure of the body s ability to regulate the growth and division of cells. When the body s ability to do this is compromised cells grow and divide rapidly, forming a mass of cancerous cells. The general term for such a mass is a tumour. The diagnosis of cancer may seem a frightening one, but understanding what is happening can help sufferers feel more in control of the condition. What Causes Cancer? Cancer is caused by damage to DNA (Deoxyribonucleic acid), often called mutation. DNA contains the instructions that tell cells how to grow and divide, so any mutation is potentially a cause of cancer. Fortunately DNA has the ability to repair most mutations that occur, but if it cannot then a cancer will usually be the result. Mutations that cause cancer also affect the normal life cycle of the cell, meaning that it does not die as it should. When cancerous cells divide, the mutation is passed on to the new cells, which also grow and divide out of control. This causes an accumulation of cancerous cells, creating a tumour. Cancer cells in culture. 3

6 How Cancer develops Normal Cell 1st Mutation Outwardly cell the cell appears normal but is predisposed to excesive cell division 2nd Mutation The cell while appearing normal begins to multiple excessively 3rd Mutation Cells reproduce faster while undergoing structural changes 4th Mutation Cell grows uncontrollably with obvious chnages in structure of cell. 4

7 What do Malignant and Benign Mean? The term benign refers to a condition, tumour, or growth that is not cancerous. This means that it does not spread to other parts of the body or invade and destroy nearby tissue. Benign tumours usually grow slowly. In general, a benign tumour or condition is not harmful. However, this is not always the case. If a benign tumour is big enough, its size and weight can press on nearby blood vessels, nerves, or organs, or otherwise cause problems. A malign tumour on the other hand is one that has infiltrated the surrounding tissue, spreading into nearby organs. These tumours can cause serious damage to the organ they invade, and can eventually be fatal. How Does Cancer Spread? Metastasis is the process through which cancer spreads through the body from one organ or tissue to another. When an expanding malignant tumour comes into contact with the bloodstream or the lymph system cells can circulate the body. If this happens then the cancerous cells can be carried around the body, eventually becoming stuck in a smaller vessel. Once they have become stuck the cells begin to divide once more, eventually forming a new tumour. This is known as a secondary tumour, or metastases. 5

8 Cancer is the second most common cause of death after heart disease. However, a significant percentage of newly diagnosed cancers can be cured and cancer is more likely to be successfully cured when detected early. Cancer gives you no symptoms or signs that exclusively indicate the disease. Every complaint for cancer can explain a harmless condition as well. For peace of mind symptoms should be referred to a GP for further evaluation. Examples of some common symptoms are as follows: Persistent cough or blood-tinged saliva: These symptoms usually represent simple infections such as bronchitis or sinusitis, however they may be symptoms of cancer of the lung, head, or neck. A change in bowel habits: Doctors sometimes see pencil-thin stools with colon cancer. Occasionally, cancer exhibits continuous diarrhoea. Some people with cancer feel as if they need to have a bowel movement and still feel that way after they have had a bowel movement. Any of these abnormal bowel complaints which last more than a few days, require evaluation by a medical professional. Blood in the stool: Haemorrhoids frequently cause rectal bleeding, but because haemorrhoids are so common, they may exist with cancer, therefore a doctor should examine a patients entire intestinal tract when there is blood present in bowel movements. Unexplained Anaemia: Anemia is a condition in which fewer than cancer is more likely to be successfully cured when detected early 6 the expected number of red blood cells are present in the blood. There are many kinds of anaemia, but blood loss almost always causes iron deficiency anaemia. Unless there is an obvious source of ongoing blood loss, as there is for menstruating women, this anaemia needs to be explained. Many cancers can cause anaemia, but bowel cancers most commonly cause iron deficiency anaemia. Evaluation should include endoscopies or x- ray studies of upper and lower intestinal tracts. Breast lump or breast discharge: Most breast lumps are noncancerous tumours such as fibroadenomas or cysts. But all breast lumps need to be thoroughly investigated. A negative mammogram result is not sufficient to evaluate a breast lump, generally, diagnosis requires a needle aspiration or biopsy (a small tissue sample). Discharge from a breast is common. But some forms of discharge may be signs of cancer. If discharge is bloody or from only 1 nipple, further evaluation is recommended. Women are advised to conduct monthly breast self-examinations.

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10 Lumps in the testicles: Most men (90%) with cancer of the testicle have a painless or uncomfortable lump on a testicle. Some men have an enlarged testicle. Other conditions, such as infections and swollen veins, can also cause changes in the testicles, but a medical professional should evaluate any lump. Men are advised to conduct monthly testicular self-examinations. A change in urination: Urinary symptoms can include frequent urination, small amounts of urine, and slow urine flow. These symptoms can be caused by urinary infections or, in men, by an enlarged prostate gland. Most men will suffer from harmless prostate enlargement as they age, and will often have these urinary symptoms. But these symptoms may signal prostate cancer. Men experiencing urinary symptoms require investigation, probably including a specific blood test called a PSA (Prostate Specific Antigen) and a digital rectal exam. Cancer of the bladder and pelvic tumours can also cause irritation of the bladder and urinary frequency in both men and women. Blood in the urine: Haematuria or blood in the urine can be caused by urinary infection, kidney stones, or other causes. For some people, it is a symptom of cancer of the bladder or kidney. Any episode of blood in the urine should be investigated. Hoarseness: Hoarseness not caused by a respiratory infection or that lasts longer than 3-4 weeks should be referred to a GP. Hoarseness can be caused by simple allergy or by vocal cord polyps, but it can also be the first sign of cancer of the throat. Persistent lumps or swollen glands: Lumps most frequently represent harmless conditions. But a doctor should examine any new lump or a persistent lump. Lumps may represent cancer or a swollen lymph gland related to cancer. Lymph nodes swell from infection and other causes and may take weeks to shrink again. A lump or gland that remains swollen for 3-4 weeks should be evaluated. Obvious change in a wart or a mole: Multicoloured moles that have irregular edges or bleed may be cancerous. Removing a mole is usually a simple and straightforward procedure. A GP will usually refer any suspicious mole for removal, after which the tissue will be sent for examination under a microscope for evidence of skin cancer. 8

11 Indigestion or difficulty swallowing: Most people with chronic heartburn do not have serious problems. People who suffer from chronic or lasting symptoms despite using over-thecounter antacids may need to have an upper GI (Gastrointestinal) endoscopy. A condition called Barrett oesophagus, which may lead to cancer of the oesophagus, can be treated with medication and then monitored by a doctor. Difficulty swallowing is a common problem, especially in elderly people, and has many causes. Swallowing problems need to be investigated, because nutrition is always important and difficulty swallowing solids can be seen with cancer of the oesophagus. Unusual vaginal bleeding or discharge: Unusual vaginal bleeding or bloody discharge may be an early sign of cancer of the uterus. Women should seek the opinion of their GP if they have bleeding after intercourse or bleeding between periods, bleeding that lasts 2 or more days longer than expected, or that is heavier than usual also merits medical examination. Postmenopausal bleeding, unless expected on HRT (Hormone Replacement Therapy) should also be evaluated by a medical professional. Usually, the evaluation will include an endometrial biopsy, in which a doctor takes a small tissue sample from inside the uterus for testing. Non-healing sores: Sores generally heal quickly. If an area fails to heal, it may be indicative of cancer and a doctors opinion should be sought. Non-healing sores in the mouth or persistent white or red patches on the gums, tongue, or tonsils should also raise concerns. Headaches: Headaches have many causes, but cancer is not a common one. A severe unrelenting headache that feels different from usual can be a sign of cancer. If your headache fails to improve with over-thecounter medications, see a doctor promptly. Back pain, pelvic pain, bloating, or indigestion: These are common symptoms of daily life. But they also can be seen in ovarian cancer. This cancer is particularly difficult to treat, because it is frequently diagnosed late in the course of the disease. To counter this, cancer research bodies have been trying to make both patients and physicians more aware and consider this possible diagnosis if the classic symptoms are present. 9

12 General & Medical regularly see claims for the treatment of many different forms of cancer. For the patient it is a worrying diagnosis and some treatments for cancer can themselves be traumatic often with unpleasant side-effects. However, the results of modern treatment, impressively, are routinely good, giving the patient an excellent chance of a cure and a return to their previous state of health. Providing our member has purchased a level of cover, which includes benefit for the treatment of cancer General & Medical will make benefit available for the treatment of the disease to effect a cure and return the patient (our member) to their normal state. Occasionally there are episodes of care that are unable to achieve a full recovery from cancer and the patient is diagnosed as incurable. Sometimes a patient succumbs to their symptoms quite quickly but frequently, with the assistance of modern medicines, aids and therapies, the patient is able to lead a near normal and fulfilled life for some considerable time, in some cases for years. An incurable cancer is usually referred to as terminal and once diagnosed as, long-term, chronic, incurable or terminal (see summary) cover for that condition will only be available at our discretion and then for a very limited period only. It is important to note that like other private healthcare insurers there are certain elements that General & Medical do not cover. General & Medical provide cover for acute and curable conditions but do not provide cover for temporary relief of symptoms, or for the ongoing management, or monitoring, of a condition which has become long-term, chronic, incurable or terminal. In addition, we do not cover preventative treatment or therapies. To summarize the above, General & Medical will provide benefit for the treatment of cancer within the scope of the cover purchased where there is reasonable expectation of a cure. Once a cancer is diagnosed as long-term, chronic, incurable or terminal, cover will cease. General & Medical will not provide benefit for treatment which is preventative or palliative. 10 3

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14 Using a diagnosis of Breast Cancer, here is an illustration of how General & Medical handle a claim for cancer. This example will demonstrate our commitment to our member in helping them get the treatment they need as quickly as the private healthcare system will allow. Breast Cancer Carole develops a lump in her left breast, which is diagnosed as breast cancer. Her specialist recommends that she has a mastectomy (breast removal) followed by a course of chemotherapy and radiotherapy. We will establish Carole s symptoms are not an undisclosed pre-existing condition or subject to an additional exclusion, then providing Carole s cover includes benefit for treatment of cancer, we will cover Carole s mastectomy and breast reconstruction, we will also cover Carole s chemotherapy and radiotherapy aimed at curing the condition. Once her primary treatment has been completed we will, with Carole s permission, request a progress report from her attending consultant. If a cure cannot be achieved we will liase with Carole s consultant in order to give Carole reasonable notice of cessation of benefit in a sympathetic manner. Once Carole s course of treatment has been completed, her specialist recommends that she has regular check-ups to ensure that she remains free from recurrence of the disease. Providing Carole s cover includes Out-Patient benefit and sufficient benefit is available where monetary limits apply, following her all clear and discharge from care, we will cover Carole for her regular check ups, until she has been symptom free for thirty six months, however we will not pay for the cost of Out-Patient drugs or for the cost of ongoing or continuing treatment aimed at maintenance or prevention. Should a recurrence occur or Carole develops secondary cancer we will pay for further surgery, chemotherapy or radiotherapy aimed at curing Carole. We would require a treatment plan from Carole s consultant at the outset and we would obtain reports from her consultant in order to assess the progress of the cure. If a cure cannot be achieved we will liaise with Carole s consultant in order to give Carole reasonable notice of cessation of benefit in a sympathetic manner. 12 3

15 Prosthesis: Sometimes the treatment of breast cancer or testicular cancer involves the removal of the breast (Mastectomy) or the testicle (Orchiectomy). In order to restore a natural appearance following a mastectomy or orchiectomy, in most circumstances the surgeon is able to perform a reconstruction of the breast or testicle using an implant, this is called a prosthesis. Providing our member has followed our claims procedure and their claim is eligible General & Medical will pay for a surgical operation to restore their appearance after, or as a result of surgery for cancer, if this is part of the original treatment for the cancer and takes place during continuous membership of our scheme with our written consent. It is important to note that a prosthesis which is anything other than a surgical implant (for example a specially padded brassiere) is not eligible for cover under any General & Medical healthcare schemes. Speech Therapy: Providing our member has followed our claims procedure and their claim is eligible General & Medical may pay for treatment to restore the ability to speak after, or as a result of surgery for cancer if this is part of the original treatment for the cancer and takes place during continuous membership of our scheme with our written consent. 13

16 General & Medical do not pay for treatment which in our reasonable opinion is experimental or unproved, based on established medical practice in the UK (such as drugs used outside the terms of their license). We only pay for treatment that is endorsed and recommended by the National Institute of Clinical Excellence (N.I.C.E.) in accordance with our members purchased level of cover. In addition, in order to fall within the scope of our cover all treatment administered either surgically or by drug therapy must be undertaken in order to achieve a cure in the short-term and not to alleviate long-term symptoms nor to be administered as preventative treatment. There has been a considerable amount of press coverage regarding the high cost drug Herceptin, and the beneficial effects in preventing secondary cancer where administered when only primary cancer breast cancer is present. Much mention has been made of the cost of Herceptin to the NHS, in the region of 25-30,000. In the private sector these costs rise considerably and can be nearer 40-50,000. Although Herceptin is not the only drug of this type we have used Herceptin as an illustration of how General & Medical view the administration of this drug therapy. Example: Herceptin. There are now drugs available which are able to treat cancer in a way which differs from conventional chemotherapy. One of these is Herceptin (Trastuzumab) which is used to treat breast cancer. In some cases of breast cancer a cancer-causing gene called an oncogene may be present. This oncogene called HER2. Herceptin is called a monoclonal antibody and it utilises the natural immune system to kill tumour cells. Herceptin binds to the HER2 (receptors) on the tumour cell surface and this stops the receptor signalling the cell to grow and divide. Certain immune system cells, called natural killer (NK) cells, attach to Herceptin when it is bound to the tumour cells. The NK cells then detect an abnormality, and kill the tumour cell. Herceptin and chemotherapy work in different ways, but when given together, the two drugs can form a partnership (synergy) so kill tumour cells more effectively than either Herceptin or chemotherapy when given alone. When given with chemotherapy most of the side effects relate to the chemotherapy drugs and Herceptin generally does not make these worse. Herceptin does have some mild side effects on its own (such as chills and fever) which may occur in addition to those caused by chemotherapy. However, it is important to note that late side effects may occur for some time after receiving Herceptin. The most important of these is heart damage (including congestive heart failure), although this is rare 14 3

17 (in clinical trials around 4%). To ensure patients receiving Herceptin do not experience any damage to the heart it is usual for all patients to have a test for heart function before starting treatment and at regular intervals (usually every few months) after starting Herceptin. Herceptin cannot be taken orally as it would be destroyed by the stomach. It is, therefore, given as a drip into a vein usually over 90 minutes followed by a period of observation. The drug needs to be administered monthly usually for at least a year (although such a prolonged period of any drug therapy, or regime, would fall outside the scope of General & Medical cover). Herceptin has been shown to be effective in reducing the risk of recurrence of disease in patients with HER2 positive tumours, however although it is very effective in controlling secondary breast cancers it is not a cure. All General & Medical insurance schemes are designed to treat illnesses, not prevent them. Therefore in the event a member of one of our schemes is recommended, by their attending medical professional, to undertake a course of Herceptin, providing the member has sufficient benefit available and has followed our claims procedure, we will require a medical report from their consultant prior to the treatment taking place this is to establish the stage of the breast cancer and the medical report must confirm the treatment plan and prognosis. Where Herceptin is recommended as a preventative measure in early stage breast cancer, to reduce the risk of the disease spreading it falls outside the scope of our cover. Members with early stage breast cancer can continue to receive active treatment of their disease in keeping with 15

18 the level of cover they have purchased; this may include surgery, radiotherapy and chemotherapy. Where Herceptin is to be used to treat secondary cancer General & Medical will offer cover for a limited period only, in keeping with the level of cover purchased by our member and described in the policy documents issued to the member. Where treatment for cancer is included in the members policy General & Medical will accept a claim, relating to secondary cancer, for high cost drug therapy (such as Herceptin) for a maximum period of 90 days in any 36 month period of continuous membership, as any condition requiring treatment or drug therapy which lasts longer than 90 days is recognised by General & Medical as prolonged and this, as described in our policy wording falls outside the criteria of eligibility. In addition a medical report will be required from the attendant physician confirming the treatment plan as a whole and the prognosis, which must indicate there is a reasonable expectation of a cure. It is important to note that although we have used the example Herceptin our rules apply to all drug therapies/regimes Summary To summarise, General & Medical do not cover high cost drugs (for example: Herceptin) where administered in the treatment of primary cancers as this is preventative treatment and falls outside the scope of our covers. General & Medical may cover high cost drugs (for example: Herceptin) where administered in the treatment of secondary cancers but cover is limited to a period of 90 consecutive days in any 36 month period of continuous membership of a General & Medical policy, subject to provision of medical reports from attendant medical professionals indicating there is reasonable expectation of a cure and within the scope of the cover purchased. 16

19 During the treatment of cancer, under a General & Medical scheme, we will periodically request reports from attending medical professionals to monitor the progress of our member s treatment. Occasionally it becomes apparent from a medical report that a cure cannot be achieved and the cancer has become incurable, terminal, chronic, or long-term. When this happens we will liaise with the attending consultant in order to give reasonable notice of cessation of benefit in a sympathetic manner. In these circumstances a minimum of 30 days notice will be given, in writing, to our Member or their next of kin, that benefit is ceasing. For reasons of sensitivity we may use the word chronic to avoid using the word terminal when dealing with such situations. Our definition of a Chronic Condition A Chronic condition is a disease, illness or injury (including a mental or addictive condition) that has at least one of the following characteristics: (a) (b) (c) (d) (e) (f) (g) is of gradual onset has no known cure, or recurs leads to permanent disability is caused by changes in the body which cannot be reversed requires special training or rehabilitation needs long-term supervision monitoring and/or treatment requires a prolonged course of drug therapy/treatment. 17

20 A Acute Lymphoblastic Leukemia Acute Myeloid Leukemia Adrenocortical Carcinoma Anal Cancer Astrocytoma, Cerebellar Astrocytoma, Cerebral B Basal Cell Carcinoma Bile Duct Cancer, Extrahepatic Bladder Cancer Bone Cancer, Osteosarcoma/Malignant Fibrous Histiocytoma Brain Stem Glioma Brain Tumour Breast Cancer Bronchial Adenomas/Carcinoids Burkitt s Lymphoma C Carcinoid Tumour Carcinoid Tumour, Gastrointestinal Carcinoma of Unknown Primary Central Nervous System Lymphoma, Primary Cerebellar Astrocytoma Cerebral Astrocytoma/Malignant Glioma Cervical Cancer Chronic Lymphocytic Leukemia Chronic Myelogenous Leukemia Chronic Myeloproliferative Disorders Colon Cancer Colorectal Cancer Cutaneous T-Cell Lymphoma E Endometrial Cancer Ependymoma, Childhood Esophageal Cancer Esophageal Cancer Ewing s Family of Tumours Extracranial Germ Cell Tumour Extragonadal Germ Cell Tumour Extrahepatic Bile Duct Cancer Eye Cancer, Intraocular Melanoma Eye Cancer, Retinoblastoma G Gallbladder Cancer Gastric (Stomach) Cancer Gastrointestinal Carcinoid Tumour Gastrointestinal Stromal Tumour (GIST) Germ Cell Tumour, Extracranial Germ Cell Tumour, Extragonadal Germ Cell Tumour, Ovarian Gestational Trophoblastic Tumour Glioma Glioma, Brain Stem Glioma, Cerebral Astrocytoma Glioma, Visual Pathway and Hypothalamic H Hairy Cell Leukemia Head and Neck Cancer 21

21 Hepatocellular (Liver) Cancer (Primary) Hodgkin s Lymphoma Hypopharyngeal Cancer Hypothalamic and Visual Pathway Glioma I Intraocular Melanoma Islet Cell Carcinoma (Endocrine Pancreas) K Kaposi s Sarcoma Kidney (Renal Cell) Cancer Kidney Cancer L Laryngeal Cancer Laryngeal Cancer, Childhood Lip and Oral Cavity Cancer Liver Cancer, Adult (Primary) Liver Cancer, Childhood (Primary) Lung Cancer, Non-Small Cell Lung Cancer, Small Cell M Malignant Fibrous Histiocytoma of Bone/ Osteosarcoma Medulloblastoma, Childhood Melanoma Melanoma, Intraocular (Eye) Merkel Cell Carcinoma Mesothelioma, Adult Malignant Mesothelioma, Childhood Metastatic Squamous Neck Cancer with Occult Primary Multiple Endocrine Neoplasia Syndrome, Childhood Multiple Myeloma/Plasma Cell Neoplasm Mycosis Fungoides Myelodysplastic Syndromes Myelodysplastic/Myeloproliferative Diseases Myelogenous Leukemia, Chronic Myeloid Leukemia, Adult Acute Myeloid Leukemia, Childhood Acute Myeloma, Multiple Myeloproliferative Disorders, Chronic N Nasal Cavity and Paranasal Sinus Cancer Nasopharyngeal Cancer Nasopharyngeal Cancer, Childhood Neuroblastoma Non-Hodgkin s Lymphoma O Oral Cancer, Childhood Oral Cavity Cancer, Lip and Oropharyngeal Cancer Osteosarcoma/Malignant Fibrous Histiocytoma of Bone Ovarian Cancer, Childhood Ovarian Epithelial Cancer Ovarian Germ Cell Tumour Ovarian Low Malignant Potential Tumour 22

22 P Pancreatic Cancer Pancreatic Cancer, Childhood Pancreatic Cancer, Islet Cell Paranasal Sinus and Nasal Cavity Cancer Parathyroid Cancer Penile Cancer Pheochromocytoma Pineoblastoma and Supratentorial Primitive Neuroectodermal Tumours, Childhood Pituitary Tumour Plasma Cell Neoplasm/Multiple Myeloma Pleuropulmonary Blastoma Primary Central Nervous System Lymphoma Prostate Cancer R Rectal Cancer Renal Cell (Kidney) Cancer Renal Pelvis and Ureter, Transitional Cell Cancer Retinoblastoma S Salivary Gland Cancer Sarcoma, Ewing s Family of Tumours Sarcoma, Kaposi s Sarcoma, Soft Tissue Sarcoma, Uterine Sezary Syndrome Skin Cancer (non-melanoma) Skin Cancer (Melanoma) Skin Carcinoma, Merkel Cell Small Intestine Cancer Squamous Neck Cancer with Occult Primary, Metastatic Supratentorial Primitive Neuroectodermal Tumours T T-Cell Lymphoma Testicular Cancer Thymoma and Thymic Carcinoma Thyroid Cancer Trophoblastic Tumour, Gestational U Urethral Cancer Uterine Cancer, Endometrial Uterine Sarcoma V Vaginal Cancer Visual Pathway and Hypothalamic Glioma Vulvar Cancer W Waldenström s Macroglobulinemia Wilms Tumour Women s Cancers 23

23 We hope that the information provided in this booklet has provided answers to questions about how General & Medical treat claims relating to Cancer. If there are any further questions please contact one of our Client Relations Co-ordinators who will be pleased to help.

24 General & Medical Insurance Ltd Registered in Guernsey No Normandie House, Rue a Chiens St Sampson s, Guernsey GY2 4AE General & Medical Insurance Ltd are authorised and regulated by The Guernsey Financial Services Commission Administered by General & Medical Healthcare General & Medical House, Napier Place, Peterborough PE2 6XN General & Medical Healthcare, a division of General & Medical Finance Ltd Registered in England No General & Medical Finance Ltd are authorised and regulated by the Financial Conduct Authority - FCA No which can be checked by visiting General & Medical comply with the guidelines set by the Association of British Insurers for Health Insurance General & Medical Securities Ltd has a beneficial interest in General & Medical Insurance Ltd D-1009-V1.10