How CanCer becomes critical in the claims

How CanCer becomes critical in the claims arena Cancer is a disease in which cells in your body grow in an uncontrolled way and form a lump called a tumour. In a healthy individual cells grow and reproduce in a regular and orderly manner, but cancer develops when these cells grow abnormally. However, cancer cells don't stop dividing and reproducing. They carry on growing in an uncontrolled way to form a lump called a tumour. Tumours can be Benign Malignant Benign Tumours Not Cancerous Tend to be made of cells that are either normal or only mildly abnormal Grow quite slowly Don t spread to other parts of the Body Malignant Tumours Made up of abnormal cancerous cells Grow faster than benign tumours Spread in to and destroy surrounding tissues Spread to other parts of the body through the blood stream or lymphatic system When cancer cells spread to another part of the body and form a new tumour at that site this is known as secondary cancer or metastasis. 1 P a g e

1. Types of Cancer There are over 200 different types of cancer, each classified according to the type and site of cell of origin. They are named after the types of cells that they develop from and are grouped into the categories below. 1.1 Carcinoma This type of cancer starts off in epithelial cells. These are cells that line your organs and tissues. The main forms of lung cancer, prostate cancer and breast cancer are all carcinomas. The different types of carcinoma are named after the type of epithelial cell that they develop from. There are four main types of epithelial cells, so there are four main types of carcinoma. Squamous cell carcinomas affect the cells that line your skin, mouth, airways and oesophagus (the pipe that goes from your mouth to your stomach). Adenomatous cell carcinomas affect the cells lining organs that contain glands, such as your stomach, bowel, pancreas and breasts. Transitional cell carcinomas affect the cells in your bladder and urinary tract (where your body makes, and gets rid of, urine). Basal cell carcinomas affect the cells in your skin. Carcinomas are the most common type of cancer, accounting for up to 85 in 100 diagnosed cancers. 1.2 Sarcoma This type of cancer develops from the cells of your connective tissues. These include bone, muscle, blood vessels and fat. The two main types are bone sarcomas and soft tissue sarcomas. Sarcomas are rare; less than one in 100 diagnosed cancers is this type. 2 P a g e

1.3 Leukaemia and lymphoma These are cancers of your blood and lymphatic system. Your lymphatic system is made up of your bone marrow, spleen, thymus and lymph nodes. These tissues and organs produce and store cells that fight infection and disease. Only about seven in 100 people diagnosed with cancer have leukaemia or lymphoma. Some types of leukaemia are more common in children than adults. The following terms often have prefixes that describe exactly what type of cell the cancer originated from. Adeno = Gland Hepto = Liver Lipo = Fat Lympho = White blood cell Melano = Pigment cell Myelo = Bone marrow Myo = Muscle Osteo = Bone 2. Stage of a Cancer Two main types of staging systems are used by doctors; I. Tumour, node, metastasis (TNM) system II. Numbered stages Some cancers have their own staging systems, such as Dukes staging for bowel cancer. 2.1 TNM Staging T the size of the actual tumour N the involvement of lymph nodes M whether there has been metastasis 3 P a g e

Table 01 - Principles of TNM Staging T is (in situ) Non-invasive, pre malignant, carcinoma in situ T1 Tumour superficial, small, early, usually less than 2cm diameter T2 Tumour early, but beginning to invade more deeply, 2-4 cm diameter T3 Tumour moderately advanced, invading deeply, confined to the organ T4 Locally advanced tumour, invading adjacent organs, fixed N0 No detectable spread of cancer to lymph nodes (glands) N1 Spread to immediately adjacent lymph nodes N2 M0 M1 Regional lymph nodes involved No distance metastases detected Distance metastases present Source: Life, critical illness and disability claims, Study Text (2014), Charted Insurance Institute UK. Numbered Staging Table 02 - Numbered Staging Classification Stage I Stage II Stage III Stage IV Local Disease only Spread to local lymph nodes Locally advanced Metastases present Source: Life, critical illness and disability claims, Study Text (2014), Charted Insurance Institute UK. 4 P a g e

Importance of understanding the stage of a Cancer in Critical illness claims Usually this is the most important factor for the assessment of critical illness claims, as that typically determines whether the cancer is Invasive or not. 3. Grade of a Cancer The grade of a cancer is a measure of how closely tumour cells resemble normal cells or the extent of differentiation. Table 03 Grading of Cancer Grade I Tumour cells mostly appear similar to normal healthy cells. Well differentiated. Slow growing and less likely to spread Grade II Both differentiated and undifferentiated (abnormal) cells are seen. Moderately differentiated. More likely to spread Grade III Mostly abnormal undifferentiated (anaplastic) tumour cells. Poorly differentiated. Highly likely to grow fast and spread Source: Life, critical illness and disability claims, Study Text (2014), Charted Insurance Institute UK. The importance of understanding the grade in critical illness claim The one cancer type where it is important to know the grade for critical illness is prostate cancer. 4. Cancer Treatments Treatment of Cancer Surgery Radiotherapy Chemotherapy Treatment with hormones and other 5 P a g e

4.1 Surgery The usual treatment for the majority of localized cancers is excision of the tumour and a margin of adjacent tissues to ensure complete removal, for an example, in cancers of bowel, breast and skin. Cancer that has spread to adjacent lymph nodes may be treated by surgery, though often it is necessary to give post operative radiotherapy in addition. Optimum treatment may involve combined treatment, for an example surgery, radiotherapy and chemotherapy or hormone therapy in breast cancer. 4.2 Radiotherapy This involves the use of radiation to treat cancer by damaging the DNA within the cancer cells. This will destroy the cancer cells in the area that is being treated, and can help reduce the chances of it coming back. It can be delivered by means of x rays directed from outside the body or by a radioactive material being placed within the body. Normal tissues have a greater ability to regenerate than malignant cells; therefore radiotherapy is usually given in small doses daily over four to six weeks which allows recovery of the normal cells that sits alongside the cancerous cells. This gives a high total dose to eradicate the tumour while allowing the adjacent organs to survive. 4.3 Chemotherapy This is simply means drug treatment. Cytotoxic ( cell killing ) drugs affect cells which are multiplying. This means it will damage the cancer cells but also other healthy body tissues where cells are growing and dividing. *(E.g. in the bone marrow, skin and intestine) Hair loss due to chemotherapy damaging the cells of the hair follicles is a well-recognized side effect of chemotherapy treatment. Cytotoxic chemotherapy must be given in such a way as to poison the maximum number of cancer cells while allowing the normal tissues to recover from the inevitable damage. Fortunately, normal tissues are stimulated to regenerate after chemotherapy, whereas malignant tumours lack the normal regulatory mechanisms. Therefore, drugs are usually given in pulses three to four weeks, to allow sufficient recovery of the normal cells (bone marrow in particular) Some forms of cancers which can be cured by chemotherapy Leukaemia Lymphoma Testicular teratoma Choriocarcinoma 6 P a g e

Breast, ovarian and bowel cancer are moderately sensitive, and although not curable by chemotherapy alone, the prospects of cure may be improved when combined with other treatments. Side effects of chemotherapy Tiredness, sickness, digestive disruption, and an increased susceptibility to infection 4.4 Hormone Therapy Some cancers rely on hormones that are naturally produced substances in the body in order to grow. Hormone therapy is therefore aimed at blocking the hormone from reaching the cancer cells, thereby stopping or slowing the growth of the cancer Majority of prostate cancers and breast cancers which are sensitive to the influence of hormones are treated through this therapy. Side effects include tiredness, digestive problems, muscle and bone damage, weight gain, mood swings and depression. 4.5 Palliative treatment Palliative treatment is designed to relieve symptoms, and improve quality of life, at a time when it has been acknowledged there is no longer a chance of the cancer being cured. It can be used to reduce symptoms, such as pain or sickness, and may help someone to live longer and to live more comfortably in the last months of their life. Chemotherapy, radiotherapy, hormone therapy and surgery can all be used as a palliative treatment. 5. Common Cancers Breast Cancer Colon and rectum cancer Carcinoma of the lung Carcinoma of the prostate Skin cancer Leukaemia Lymphoma 7 P a g e

5.1 Breast Cancer Investigation and Diagnosis Stage Treatment Diagnosis is made in combination of; Physical examination Mammography Ultrasound scan Biopsy Confirmed by Histological examination and follow TNM Staging system If localized breast cancer is confirmed, the tumour and surrounding breast tissue are surgically removed along with tissue from the axilla to examine whether or not lymph nodes spread has already occurred. 5.2 Cancer of the colon and rectum Investigation and Diagnosis Stage Treatment Blood Tests, Physical Examination Initially performed Sigmoidoscopy or Colonoscopy Internal examination of the Bowel Virtual Colonoscopy (CT Scan) Dukes A The cancer is confined to the innermost lining of the colon or rectum or slightly growing in to the muscle layer Dukes Lettered System Dukes B Dukes C Dukes D The cancer has grown through the muscle layer of the colon or rectum The cancer has spread to at least one lymph node in the area close to the bowel The cancer has spread to somewhere else in the body such as the liver or lung. This is more commonly referred to as stage 4, or advanced bowel cancer, rather than Dukes stage D. Surgery In order to remove the tumour and adjacent lymph nodes Chemotherapy Used to shrink the tumour prior to surgery and destroy any remaining cancer cells that may 8 P a g e

be present after tumour has been removed Radiotherapy May be used in combination with curative surgery for rectal cancer or as a palliative measure in advanced cases. 5.3 Carcinoma of the lung Smoking is the biggest cause of lung cancer and a history of smoking should always be considered when assessing any claim for lung cancer. Other causes which cause lung cancers include; exposure to asbestos, previous lung disease and weakened immune system. The most common presenting symptom is a cough (about 70%) with dyspnea (shortness of breath), hemoptysis (coughing up blood) and chest pain also being present in nearly half of patients. Lung cancer is also frequently associated with fatigue and weight loss, which occur in over 50% at presentation. Investigation and Diagnosis When cancer is identified referred for X Ray Followed by CT Scan, Bronchoscopy with Biopsy to determine the type and spread of the cancer Stage Either follow the TNM Staging system or Numbered Staging system Only about 01 out of every 100 people(1%) diagnosed with stage 4 small cell lung cancer will live for at least five years Treatment All cancer treatments will depend on the type and extent of the cancer, and patient s state of health. There are four histological types of lung cancer as follows; Squamous cell carcinoma 9 P a g e

Large cell carcinoma Adenocarcinoma and other variants Small cell carcinoma Small cell cancers Chemotherapy Non-small cell carcinomas Surgical resection with chemotherapy, radiotherapy, or a combination of these depending on the individual circumstances. 5.4 Carcinoma of the prostate Investigation and Diagnosis Investigations for Prostate Cancer Prostate specific antigen(psa) blood test Digital rectal examination(dre) Biopsy Ultrasound CT,MRI and bone scans Stage and Grade Usually follow the TNM Staging system Clinical Staging - estimate the extent of the disease and is based on the results of physical examination and test results Pathological Staging this is given after surgery and examination of the removed tissue, is more accurate than clinical staging. Treatment Treatement of early (T1 or T2), localized prostate cancer may be by surgery or radiotherapy Small tumours prostatectomy or keyhole surgery Local radiotherapy Advanced recurrent or metastastatic prostate cancer - hormone therapy 10 P a g e

5.5 Skin Cancer There are three main types of skin cancer as follows; Basal cell carcinoma Non Melanoma skin cancer Squamous cell carcinoma Melanomas arise in the melanin producing cells and are the most malignant of the three. Grow quickly and spread throughout the body. Investigation and Diagnosis Stage If lesion has any suspicious features referral to a dermatologist Tests Skin biopsy to remove the lesion Sample of cells may be taken from the nearest lymph nodes An x-ray, ultrasound, CT Scan or MRI Scan arrange to determine if there has been any spread to other sites in the body Staging System for Skin Cancer Stage TNM Breslow Description thickness 0 Tis NO MO In situ Clark level 1 1A T1a NO MO < 1.0 mm No ulceration. Clark level 1B 2A 2B T1b NO MO T2a NO MO T2b NO MO T3b NO MO T3b NO MO T4a NO MO < 1.0 mm 1.01 2.0 mm 1.01 2.0mm 2.01 4.0mm 2.01 4.0mm > 4.0 mm II/III With ulceration. Clark level IV/V No ulceration With ulceration No ulceration With ulceration No ulceration 2C T4b NO MO > 4.0 mm With ulceration 3 T(any) N1-3 MO Regional node metastases 4 T(any) N (any) M1 Distant metastases 11 P a g e

Treatment Surgery Early stage melanomas and non-melanoma skin cancers Regular surveillance and self-checking of any new moles and lesions For more advance cases wide local excision removes tissue around the site of the melanoma, and accompanied by lymph node removal, radiotherapy and chemotherapy 5.6 Leukaemia Can be divided by the type of white blood cells Chronic myeloid (CML) Chronic lymphocytic (CLL) Acute myeloid (AML) Acute lymphoblastic (ALL) Investigation and Diagnosis Patients with suspected leukaemia referred to Haematologist Blood tests will be taken looking deficiencies of normal blood and presence of abnormal white blood cells Depending on results of the above tests, further tests will be recommended as follows; Bone marrow biopsy Chromosome and DNA analysis CT, MRI, X ray or ultrasound scans to look for enlarged lymph nodes, spleen or tumour Treatment Acute leukaemias usually arise in childhood chemotherapy has greatly improved the chance and duration of remission Bone marrow transplants if the match is available 12 P a g e

5.7 Lymphoma Lymphomas are cancers of the lymphatic system. They are classified in to two main groups as follows; Lymphoma Hodgkin s Lymphoma Non-Hodgkin s Lymphoma Investigation and Diagnosis Initial manifestation of the disease painless enlargement of a lymph node (in neck, armpit or groin) Other symptoms intermittent high temperature, night sweats, persistent cough, general malaise, anaemia and weight loss Diagnosed made by histological examination of a biopsied lymph node According to the each subtype of Hodgkin s lymphoma various histological groupings are as follows; Hodgkin s lymphoma Lymphocyte predominant Nodular Sclerosing Mixed Cellularity Lymphocyte depleted Outlook Best Intermediate Worst In non-hodgkin s group only one type of cell is involved and the malignant process is graded according to the microscopical appearance of this single cell type Non Hodgkin s Outlook lymphoma Low grade(indolent) Best malignancy Intermediate grade Intermediate 13 P a g e

malignancy High grade Worst (aggressive malignancy) Stage Stage 1 One group of lymph nodes affected or lymphoma just in one organ of the body Stage 2 Two or more groups of lymph nodes affected, on the same side of your diaphragm Stage 3 Lymph nodes affected on both sides of the diaphragm Stage 4 Lymphoma has spread outside the lymph nodes, for example to the liver bones Treatment Hodgkin s lymphoma Chemotherapy and radiotherapy Non Hodgkin s lymphoma Chemotherapy, radiotherapy and monocional antibody therapy 6. Critical illness claim considerations 6.1 Risk Factors Smoking History Close family members who have had cancer, usually before the age of 60 or 65 Previous diagnosis of cancer Lumps or moles that have changed in size, bled etc. Tests and investigations for other considerations, or unexplained symptoms When considering cancer claim the claims handling officer should consider whether the proposal form disclosures are consistent with what is being stated within the claim correspondence, or whether more detailed inquiry in to the relevant risk factors is warranted. 14 P a g e

7. Cancer definition of AAI Cancer A disease manifested by the presence of a malignant tumour characterized by the uncontrolled growth and spread of malignant cells, and the invasion of tissue. Diagnosis has to be confirmed by a specialist and evidenced by definite histology. The term cancer also includes leukaemia and malignant diseases of the lymphatic system such as Hodgkin s disease. Excluded are; - Any CIN stage (cervical intraepithelial neoplasia) - Any pre- malignant tumour - Any non invasive cancer (cancer in situ) - Prostate cancer stage I (TI a, I b, I c) - Basal cell carcinoma and squamous cell carcinoma - Malignant melanoma stage IA (TI a NO MO) - Any Malignant tumour in the presence of any Human Immunodeficiency Virus 7.1 Documents require when considering the critical illness claim for cancer Histology report Details of this report confirms the invasion of malignant cells. Diagnosis Ticket All connected Medical Reports Claim Form and Hospital Treatment Certificate The key piece of information for all cancer critical illness claims will be to determine the stage given via the histology. Where there is any doubt as to extent and nature of the disease, all histology reports and medical reports should be referred to an oncologist chief medical officer for opinion. By: Mr. Charitha Jayasanka Boteju Manger Life Claims, Asian Alliance Insurance PLC. 15 P a g e

References Life, critical illness and disability claims, Study Text (2014), Charted Insurance Institute UK www.bupa.co.uk http://info.cancerresearchuk.org 16 P a g e