Breast cancer is the most common cancer to affect women and underwriting clients with this condition can be complex. Neal Chapman explains
Breast cancer is by far the most common cancer affecting women in the UK with 41,000 new cases being diagnosed in 1999. To put that in perspective, the second most common cancer affecting women in the UK is bowel cancer with around 16,800 cases diagnosed per annum. However, where the five-year survival rate for bowel cancer is in the region of 42%, the survival rates for breast cancer over the same period are in excess of 70%. With so many new cases and improving survival rates, breast cancer is a condition which financial advisers and underwriters can expect to encounter more frequently.
The disease
Breast tissue is made up of ducts and lobules where milk is made, stored and carried through to the nipple during breastfeeding. Breast cancer starts when a single cell in the breast begins to divide and grow in an abnormal way.
There are several different types of cancer that can affect the breast:
Ductal carcinoma in situ or DCIS is an early form of tumour where the abnormal cell division has occurred within the duct cells of the breast and has not yet spread out with these cells.
Invasive cancer occurs when cancer cells spread beyond the cell membrane, which covers the underlying connective tissue in the breast. This tissue is rich in blood vessels and lymphatic channels that are capable of carrying cancer cells beyond the breast.
Infiltrating ductal carcinoma is invasive breast cancer that penetrates the wall of a duct. It comprises between 70% and 80% of all breast cancer cases.
Infiltrating lobular carcinoma is an invasive tumour that has arisen in the lobules of the breast and spread beyond the cell wall. It accounts for between 10% and 15% of all breast cancers. It may appear in both breasts and sometimes in several separate locations.
Treatment
Treatment of breast cancer depends on the type and extent of the tumour. For low risk tumours such as DCIS, simple local excision may suffice. For more serious invasive tumours, full mastectomy may be carried out. In addition to surgical intervention, chemotherapy and radiotherapy may be used, particularly with more advanced tumours.
Hormone therapies such as Tamoxifen are also common. The female hormone oestrogen is a major factor for the growth of many breast cancers. Hormone therapy lowers the amount of oestrogen in the blood, or blocks oestrogen from stimulating the cancer to grow. Improvements in treatment are, in part, responsible for increasing survival rates.
The single most important factor in the development of breast cancer is age. At age 25 the risk is one case in 15,000, by age 50 this has increased to one case in 50 and overall lifetime risk is approximately one case in nine.
From an underwriting point of view, this risk is factored into the basic premiums and we are looking for any other additional factors which may indicate a higher than average risk of developing breast cancer. A family history of breast cancer increases the risk of the disease with 5%-10% of all cases being associated with a genetic predisposition.
Risk factors
Where a strong family history exists, there is the possibility of the presence of a 'faulty' gene or genes, some of these have been identified and can be tested for, such as BRCA1 and BRCA2. However, as genetic testing is not a viable source of information for underwriting, decisions are based purely on the applicant's family history. When underwriting an applicant with a strong family history, it is likely that either an extra premium or a specific breast cancer exclusion will be applied to critical illness (CI) cover.
Another significant risk factor in the development of breast cancer is a previous history of benign breast disease. Around nine out of 10 breast lumps reported are not cancerous but represent either natural changes in the breast, cyst formations or benign fibrous growths. Women who have a history of such conditions can be at up to four times the average risk of developing breast cancer in the future. As a result, applicants who have had a history of benign breast conditions may attract an additional premium or exclusion on any application for CI cover.
In addition, having children late in life or not at all, late onset menopause, smoking, diet, obesity and alcohol may also contribute to an increased risk of breast cancer.
Neal Chapman is a senior life & disability underwriter with Scottish Equitable Protect
