At some point in life, most people will have come across a mole that has caused them to worry. Often, these are harmless but what are the effects of a malignant melanoma? Anne Llewellyn explains
Moles are common - most adults have approximately 40 which will have been present since infancy. The disclosure of one on an application form can mean anything from normal blemishes, growths or 'beauty spots' that almost everyone has, to malignant melanoma, the most serious form of skin cancer.
There are two types of risk to be underwritten. Firstly, if a client has had a melanoma, the insurer will assess the risk of recurrence, and secondly, where there is a 'mole', the probability of malignancy developing in the future is particularly relevant for critical illness (CI) cover.
Melanomas usually arise on the skin but can also appear in the eye, under the nails and in the gastrointestinal tract, however, these are much rarer.
A melanoma is a malignant tumour that originates in the melanocytes, the cells that produce the pigment that colours a person's hair, eyes and skin. The melanocytes start to grow and divide more quickly than normal and, over months, they spread into the surrounding skin. If recognised and treated early, a melanoma is curable but if left untreated it grows down into the deeper layers of the skin which contain tiny blood vessels. Melanocytes drop into these blood vessels and spread to other parts of the body and form secondary cancers which are usually fatal. In fact, although melanoma is not the most common skin cancer, it causes the most deaths. Anyone can develop a melanoma, but increased risk is associated with the following:
- Exposure to the sun especially in childhood. Blistering sunburn and cumulative exposure to the sun or sunbeds are contributing factors.
- Certain type of moles known as dysplastic naevi, and multiple moles of any type - anyone who has more than 50 moles is at greater risk, and the melanoma does not necessarily arise from an existing mole.
- Fair skin which does not have natural protection from the sun through pigmentation.
- Family history. Some families are prone to melanoma and studies have shown that people with one first degree relative with melanoma have a 50% greater chance of developing it themselves. A mutation in the BRAF gene may also play a part in this.
- Once you have had a melanoma, there is an increased chance of recurrence.
- If the immune system is weakened through diseases like HIV or Aids, or compromised by chemotherapy or organ transplant, the risk of melanoma increases. Of course there are other underwriting implications for people who fall into this group.
Distinctive features
Melanomas have features that set them apart from harmless blemishes, known as the ABCDEs of melanoma:
- Asymmetry - benign moles tend to have a symmetrical shape whereas melanomas are irregular.
- Border - the borders of melanomas are uneven, often described as scalloped or notched.
- Colour - benign moles are uniform in colour whereas individual melanomas have a variety of colours, usually shades or blotches of black or brown but they can also be red, purple, blue, white or even skin colour.
- Diameter - melanomas are usually larger than benign moles. Any mole larger than 6mm is suspicious.
- Evolving - any change in size, shape, colour or new symptoms such as itching or bleeding is suggestive of malignant changes.
If a melanoma is suspected, the first course of action is to remove it. This is often done in the GP's surgery or as a hospital outpatient under local anaesthetic. The piece of tissue is sent away for a biopsy and if it is found to be malignant the patient is usually admitted to hospital for a wider excision of the site to ensure the entire tumour has been removed. The melanoma will also be classified according to its degree of severity, known as staging. The stage refers to the thickness, depth of penetration into the skin and the degree of spread into lymph nodes or other organs.
The best prognosis is with melanoma-in-situ where the melanocytes have not penetrated beyond the top skin layer, and very thin melanomas less than 1mm thick. Further treatment is not required although the patient will return to the doctor for periodic check ups.
Stage two and three melanomas are thicker and may have spread to the local lymph nodes. The patient will undergo much more extensive testing after removal of the melanoma but there is no standard adjuvant treatment - radiotherapy or chemotherapy - that has been proved to be effective.
Follow up
Over the following three years the patient will have three-monthly follow up visits to their specialist for observation, reducing to six-monthly visits after that. After five years, follow up will be less frequent as the chance of recurrence decreases.
The worst prognosis is with advanced disease - stage four - which has spread to other parts of the body like the brain, liver and lungs and more lymph nodes than would be found in stage two. At this point adjuvant treatment will be given and although it does not lead to a cure, it can control the cancer and improve symptoms and quality of life. The survival rates after five years are less than 50% so a choice has to be made between the benefits of adjuvant treatment against its side effects.
What can advisers do to help? If a customer discloses a history of a mole or melanoma the most important facts to gather are the date of diagnosis, removal, treatment and follow up. If in doubt, it is always advisable to put through a pre-sales enquiry.
Anne Llewellyn is underwriting training and development manager at PruProtect
Sources
Hannover-re.com
British Medical Journal
British Journal of Dermatology
Cancerbackup.org
Cancerresearchuk.org
Hankgeorgeinc.com
Underwriting implications
Once a client has had melanoma, the underwriter will try to establish the likelihood of recurrence. Many melanomas will recur within two years, and over time the risk diminishes so knowing the date of removal is essential in the risk assessment process. Since the prognosis also depends on the thickness of the melanoma, the insurer will also need to know the staging. The lower the stage, the lighter the rating. It is highly unlikely the patient will be aware of the staging of their melanoma so this information is obtained from the customer's GP.
Once the information from the GP has been obtained, it is fairly straightforward to assess the risk attached to melanoma. The survival rate for melanoma-in-situ is almost 100% therefore it is often possible to accept life cover at standard rates. For stage one and stage two melanomas, terms can be offered immediately with an extra premium being imposed for the first few years of the policy. Because the prognosis for stage three and above is much worse, there will be a postponement period of at least three years and if there is no recurrence in that time an extra premium, again for the first few years of the policy, will be charged. Anyone who has had this malignant tumour will either have a melanoma or general cancer exclusion imposed on CI or serious illness cover.
Assessing the risk associated with other moles is more problematic for the underwriter.
It would be impractical to obtain a GP report whenever there is a disclosure of a mole. Insurers therefore try and obtain as much information as possible from the client to ascertain how serious it may be, and tele-medical interviewing is invaluable in this regard.
The initial visit to the GP may be prompted by a number of factors, either the customer is worried about a mole, or it may be unsightly and they want it removed for cosmetic reasons or because it catches on clothes. Moles are rarely removed for cosmetic reasons after the age of 50 so it follows that a mole removed after the age of 50 would prompt the need for further medical evidence.
Another important point is the frequency of follow-up once a mole has been removed. Often customers will be told a mole is benign and sometimes it will not be removed, this does not mean it can be dismissed particularly when they have applied for CI. Dysplastic naevi or atypical moles are of particular concern.
Atypical moles can be mistaken for melanomas because they share some features such as asymmetry, size and variation of colour. Unlike common moles they continue to appear throughout adulthood. If a mole is strongly suggestive of melanoma, it can be removed and the biopsy will confirm the diagnosis of melanoma or dysplastic naevus. Not all naevi are removed; some are monitored though baseline photography and if there are any changes from the original photograph or drawing they will be removed. When assessing life cover, if a customer is undergoing monitoring this is a good prognosis since any malignant changes will be dealt with at an early stage so the mortality risk is reduced and most cases are accepted at standard rates. For CI, not only is there a risk of malignancy in the existing naevus, the presence of dysplastic naevus in itself means the patient is at increased risk of developing melanoma elsewhere, therefore the most likely outcome is a malignant melanoma exclusion being imposed.
