We have made great progress in the battle against breast cancer: improved screening and treatment have produced a 30% reduction in mortality over the last two decades. Better still, continued advances in genomics are opening entirely new possibilities that hold the promise of not only improved outcomes, but an eventual cure. For life and health insurers, it is time to reexamine how we underwrite applicants with a history of breast cancer.
A better understanding of risk factors, including genetic indicators such as BRCA-1 or BRCA-2 mutations, and improved screening processes have transformed cancer detection and diagnosis. Screening decisions are now based upon risk stratification and weighing potential benefits and harms. This has reduced overscreening, overdiagnosis, and the high morbidity resulting from overly aggressive treatments.
Mortality outcomes meanwhile have benefited from advances in our understanding of predictive factors and prognosticators. Predictive factors indicate the likelihood of response to specific treatment, whereas prognosticators determine the chance of survival and recurrence rate in patients with a history of breast cancer. Some predictive factors are also prognostic factors, since treatment can alter prognosis.
Prognosticators range from a patient’s age to her estrogen and progesterone receptor (ER and PR) status, and include those factors used in staging. The TNM staging system identifies cancer stages based on tumor size (T), regional lymph nodes (N), and Metastasis (M). New technology, such as immunohistochemical staining (IHC), has allowed doctors to develop new staging categories based on much smaller tumor cells and recommend treatment (or lack thereof) accordingly.
The new generation of prognosticators go beyond staging to apply genomic testing. Microarray studies opened the genomics frontier by molecularly dividing breast cancers into four subtypes to aid in treatment planning. Oncotype DX®, currently widely used in the U.S., followed. Oncotype DX examines the expression of 21 genes in breast tissue to determine an FDA-validated recurrence score (RS), aiding in the treatment decision process. MammaPrint, a genomic test currently more widespread in Europe, takes a similar approach to Oncotype DX but tests for 70 genes.
Cancer genome sequencing, first introduced in 2009, promises to drive breast cancer prognostication forward. Genome sequencing compares DNA from breast cancer tissue to the patient’s healthy breast tissue to identify areas of chromosomal rearrangement and mutations or deletions of individual genes. Physicians can then target treatment of those genetic defects or determine if treatment is even necessary.
What does this mean for life and health underwriters? Moving forward, insurers will be able to underwrite more and more applicants with a history of breast cancer.
On the health side, we know the debilitating effects of chemotherapy, surgical complications, radiation therapy, and related conditions. Current treatments have improved in this area, but continue to produce notable side effects. We should see even greater progress over the next 10 years as oncologists apply insights gained through genomics. Individualized, targeted approaches will reduce excessively aggressive treatment programs.
Similar progress will continue to improve mortality outcomes. Through better screening practices, most breast cancer is now detected at an earlier stage, with only 5% of tumors having evidence of metastatic disease. From there, genomics has helped delay recurrence by stratifying breast cancer subtypes and subsequently allowing physicians to select appropriate patient populations for targeted therapy. The next generation of genome sequencing promises to produce transformative new therapies and further reduce mortality for breast and other cancers.
The science of genomics is changing the game in breast cancer treatment and in the medical field in general. Life and health insurers will need to adapt to keep pace.