Insurers have reported a growth in breast-lump disclosure on application forms but these are often benign. Anne Llewellyn explains the underwriting implications of breast disease
Breast cancer is the UK's most common cancer and accounts for nearly a third of all cancers in women. Some 46,000 are diagnosed with breast cancer each year and more than 1,000 die of the disease each month. These are frightening statistics and it is not surprising that awareness has increased through pink ribbon campaigns, media coverage and high-profile charity promotions.
In 1986, the Forrest Report recommended a national breast-screening programme to detect and remove tumours before they grew to larger and more lethal sizes and before spreading to the lymph nodes. It was estimated that if 70% of eligible women attended screening there would be a 25% reduction in mortality rates. In 1998, 110,700 women were invited for screening; the first national programme of its kind in the world. Over 2 million women now attend and the take up rate is 75%. There is no doubt that the introduction and widespread use of mammography for the purpose of early detection is one of the most important recent achievements in the control of cancer.
With the increase in awareness and self-examination, there has been a vast increase in the number of disclosures of breast lumps on application forms and cancers that have been detected a lot earlier through the screening programme. About 20% of findings are at a stage called 'carcinoma in situ' where cancerous changes have already taken place within the cells but they are still confined to the ducts and have not infiltrated the surrounding cells. No lump can be felt so a 'carcinoma in situ' is only detected through screening.
It is useful to think of the progression of change as the breast disease continuum (see image one overleaf).
As ductal carcinoma in situ (DCIS) is a malignant condition, it goes without saying that critical illness (CI) benefit will be declined or cover for cancer excluded.
What does this mean for clients? Underwriting invasive breast cancer is relatively simple but there is a whole range of benign and premalignant conditions that were unknown 20 years ago. Risk assessment, too, is likely to become even harder due to increasingly sophisticated screening techniques. It poses a whole different issue for claims too. It is not an easy task to explain to a client who has just undergone a mastectomy that her CI claim is not valid because she only had 'carcinoma in situ'. The majority of CI policies will only cover invasive cancer and the difference, at least in the client's eyes, is minimal.
There are two types of benign breast disease. The first type is known as 'non-proliferative', meaning that there is little change in the cells over time. This category includes cysts and papillomas, among others. There is little risk of malignancy so it is important to establish whether a breast lump falls into this category. The second type is characterised by an abnormal increase in cell growth and is called proliferative disease or hyperplasia. This falls into two groups: typical hyperplasia where the cells are normal and there is just an increase in numbers, and atypical hyperplasia, or dysplasia, where the cells are starting to change. Typical hyperplasia has a 50% increased risk of cancer; atypical hyperplasia, depending on where it is found, has an increased risk of up to 250%.
The two most common benign breast lumps are cysts and fibroadenomas. These are usually found by the client as they present as a discrete lump. The doctor will make an initial examination and then make a referral to a specialist. There are indications on examination as to whether the lump is suspicious or not: whether it is hard or rubbery; mobile or tethered. Usually, a mammogram will be carried out that will confirm the presence of a solid lump. Sometimes no lump is found; this is not unusual because normal hormonal changes can cause temporary lumps, and breast tissue is normally quite lumpy and uneven.
Examination and diagnosis
Mammograms are not accurate enough to make a diagnosis since cysts, fibroadenomas and malignant tumours can appear to be similar so, once a lesion is found, further investigations are required. If a cyst is suspicious, an ultrasound scan is carried out that will show whether the lump is solid or hollow (see image two).
The hollow lump will be filled with fluid and, once drained, it will collapse and disappear. An ultrasound confirms whether a lesion is benign in 99% of cases and, if the lump collapses after being drained, it is determined to be a cyst. If this happens, all benefits including CI can be accepted at standard rates.
Solid lumps are more difficult, particularly when the client has been told the lump is benign and then CI is accepted on special terms. The most common finding is fibroadenoma. The lump is distinctively rubbery and highly mobile, sometimes referred to as a breast mouse. The ultrasound scan will confirm whether the lesion is solid but a biopsy is needed to make the diagnosis. Quite often they will not be removed, although they will be followed up on a regular basis. There is little associated risk of malignancy with a simple fibroadenoma but, where it is complicated by a cyst or becomes large or irregular, there is a 3% risk of carcinoma occurring within the adenoma. For this reason, an extra premium will usually be charged for CI. Even where the adenoma has been removed and confirmed benign, there is still an increased risk of further adenomas.
In view of the growing number of applications containing disclosures of breast lumps, it is imperative that the correct underwriting approach is adhered to. Obtaining all the relevant information is paramount and will enable the underwriter to make the quickest and fairest decision for the customer.
Anne Llewellyn is underwriting training and development manager at PruProtect
Cancer Research UK
The New England Journal of Medicine
Office for National Statistics
- Mammograms carried out before the age of 50 are unreliable because of breast density pre menopause. National screening starts at age 50 so if a mammogram was carried out at a younger age the insurer will need to know why. Some private health schemes carry out screening mammograms at an earlier age but will usually be because of this increased risk of cancer where, for example, there is a family history of early breast cancer or because a lump or other abnormality has been found.
- The insurer will need to know what happened after the mammogram. If no further tests were requested and no follow up was carried out, the mammogram was probably negative and no further action is required.
- Was another test carried out after the mammogram? An ultrasound scan would normally be requested to determine whether the lump is a cyst or solid.
- Was a different type of test requested, for example, an MRI scan? This would normally be requested for women in a high-risk group such as carrying a cancer gene mutation. MRIs are more sensitive but are not used routinely because they have a high risk of false positive results.
- What happened after the ultrasound? Was a biopsy carried out? What was the result?
- After the biopsy, was the patient discharged or was further treatment carried out?
- What is the frequency of follow up and were any further investigations carried out?
- While the client may not know the exact diagnosis or biopsy results, it is often possible to tell from their story whether they had a breast lump that was considered benign. It is therefore important to get as much detail as possible from the client. Telemedical interviewing is very effective in getting the optimum information from the client.
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