UNDERWRITING CORRELATION FOR CANCER CASES. Are we going to accept a proposed insured with known cancer?

UNDERWRITING CORRELATION FOR

CANCER CASES

Are we going to accept a Are we going to accept a proposed insured with proposed insured with

known cancer?known cancer?

IT DEPENDSIT DEPENDS

Accurate risk assessment requiresAccurate risk assessment requires Correlation with Family HistoryCorrelation with Family History Present OccupationPresent Occupation Lifestyle : diet, smoker, drinker, hobbiesLifestyle : diet, smoker, drinker, hobbies A working knowledge of the anatomyA working knowledge of the anatomy An understanding of nomenclature used in An understanding of nomenclature used in

pathology reports (staging, size of tumor, lymph pathology reports (staging, size of tumor, lymph nodes, mets)nodes, mets)

Attending physician’s statements (since when, Attending physician’s statements (since when, Dx, course of CA, treatment, other therapies, Dx, course of CA, treatment, other therapies, present status)present status)

General familiarity with current medical General familiarity with current medical treatment (surgically removed, chemo, radio, treatment (surgically removed, chemo, radio, ablation, etc.)ablation, etc.)

Co-morbiditiesCo-morbidities

For underwriting work up, the following For underwriting work up, the following requirements are suggested:requirements are suggested:

• Application FormApplication Form• Financial Adviser’s ReportFinancial Adviser’s Report• Full medical examination (FME)Full medical examination (FME)• Attending Physician StatementsAttending Physician Statements• Histopathology (biopsy) ReportHistopathology (biopsy) Report• Tumor MarkersTumor Markers

Differentiation of the characteristics of Differentiation of the characteristics of tumorstumors

BENIGNBENIGN MALIGNANTMALIGNANT

Growth patternGrowth pattern Expansion Expansion Invasion Invasion (infiltration)(infiltration)

Tendency to Tendency to recurrecur

Usually slightUsually slight CommonCommon

MetastasisMetastasis Extremely rareExtremely rare CommonCommon

Growth rateGrowth rate SlowSlow Usually rapidUsually rapid

DifferentiationDifferentiation NormalNormal Near normal to Near normal to anaplasticanaplastic

Mitosis Mitosis Few or rareFew or rare ManyMany

Effect on host Effect on host Usually Usually insignificantinsignificant

Often fatalOften fatal

TNM ClassificationTNM Classification

Tis – pre-invasive carcinoma (CIS – carcinoma in Tis – pre-invasive carcinoma (CIS – carcinoma in situ)situ)

T0 – no evidence of a primary tumorT0 – no evidence of a primary tumor T1 – small tumor confined to the organ of originT1 – small tumor confined to the organ of origin T2 – relatively large but restricted to the organ T2 – relatively large but restricted to the organ

of originof origin T3 – some invasion of adjacent tissueT3 – some invasion of adjacent tissue T4 – massive invasion of adjacent tissue &/or T4 – massive invasion of adjacent tissue &/or

organsorgans TX – unable to assess primary tumorTX – unable to assess primary tumor

TNM Classification TNM Classification N0 – no regional lymph node (LN) involvementN0 – no regional lymph node (LN) involvement N1 – evidence of involvement of movable regional LN N1 – evidence of involvement of movable regional LN N2 – evidence of involvement of fixed regional LNN2 – evidence of involvement of fixed regional LN N3 – massive LN involvementN3 – massive LN involvement N4 – involvement of juxta-regional LNN4 – involvement of juxta-regional LN N0 – unable to assess reg’l &/or juxta-reg’l LNN0 – unable to assess reg’l &/or juxta-reg’l LN

. M0 - no evidence of distant metastasis. M0 - no evidence of distant metastasis

. M1 - distant metastasis present. M1 - distant metastasis present

. MX - unable to assess distant mets. MX - unable to assess distant mets

StagingStaging System* System*

Stage 0 – Carcinoma in situ: no associated Stage 0 – Carcinoma in situ: no associated invasive (infiltrating) carcinomainvasive (infiltrating) carcinoma

Stage I - T1-2Stage I - T1-2 N0N0 M0M0 Stage II - T1-2Stage II - T1-2 N1N1 M0M0 Stage III - T1-2Stage III - T1-2 N2-3N2-3 M0M0

T3-4T3-4 N0-3N0-3 M0M0 Stage IV - Any TStage IV - Any T Any NAny N M1M1

* differences are found in different organs * differences are found in different organs

Histopathology ReportHistopathology Report

provides an indication of provides an indication of the type and the type and staging/grading of the staging/grading of the tumortumor

read carefully and read carefully and correlate with the APScorrelate with the APS

GradeGrade

Refers to the degree of differentiation of Refers to the degree of differentiation of malignant tumor :malignant tumor :

Grade 1 – Well differentiated, low grade Grade 1 – Well differentiated, low grade carcinoma carcinoma

Grade 2 – Moderately undifferentiated, Grade 2 – Moderately undifferentiated, intermediate grade carcinomaintermediate grade carcinoma

Grade 3-4 – Poorly differentiated Grade 3-4 – Poorly differentiated ( markedly undiffert’d, anaplastic), high ( markedly undiffert’d, anaplastic), high grade carcinomagrade carcinoma

Tumor MarkersTumor Markers Are by-products of tumor growth; may

be hormones, enzymes, other proteins Carcinoembryonic antigen (CEA ) for GI Carcinoembryonic antigen (CEA ) for GI

tract (colon), pancreas, lung, breast tract (colon), pancreas, lung, breast Human chorionic gonadotropin (HCG) Human chorionic gonadotropin (HCG)

for uterine choriocarcinoma, for uterine choriocarcinoma, ovarian/testicularovarian/testicular

Alpha-fetoprotein (AFP ) for liver, yolk Alpha-fetoprotein (AFP ) for liver, yolk sac remnants, testes and ovarysac remnants, testes and ovary

Prostate Specific Antigen (PSA) for Prostate Specific Antigen (PSA) for prostateprostate

Serial measurement of tumor markers Serial measurement of tumor markers will give an indication of the size and will give an indication of the size and activity of the tumor and adequacy of activity of the tumor and adequacy of

treatmenttreatment

Persistently elevated tumor marker Persistently elevated tumor marker levels mandate medical consultationlevels mandate medical consultation

Persistently elevated levels may Persistently elevated levels may indicate that there is residual tumor indicate that there is residual tumor that was not removedthat was not removed

Tumors

Endocrine CancerAdrenal Cortical Carcinoma T1 Class V, T2 Class VI, T3 DParathyroid CA localized Class VThyroid CA Anaplastic D Medullary Class VI Follicular Class III Papillary T1 - T2 Class I, T3 - T4 Class III

Gastro-intestinal CancerAnal CA T1 Class I, T2 - T3 Class VBile Duct CA DColorectal CA T1 - T2 Class I, T3 Class IV Sigmoid/rectum only T1 Class IIIGallbladder CA DGastro-intestinal Carcinoid Tumor localized less than 1 cm Class IA, 1 - 2 cm Class IIILiver CA DPancreatic CA DPeritoneal CA DSalivary Gland CA T1 Class IV, T2 - T3 Class VISmall Intestine CA T1 - T2 Class III, T3 - T4 Class VIStomach CA T1 Class V

General Genitourinary CancerBladder CA T1 Gr 1 Class I, Gr 2 Class V, Gr 3 Class VIKidney CA Renal Cell CA T1 Class IV, T2 Class VI Transitional Cell CA T1 Gr 1 Class I, Gr 2 Class V, Gr 3 Class VI

Female-specific Genitourinary CancerBreast CA Stage I Grade 1 Class I, higher Class III; Stage IIA Class VIBreast Tumors & other Breast DisordersCervix CA FIGO Stage IA Class I, Stage IB Class III, Stage IIA Class V, Stage IIB Class VIEndometrial CA AdenoCa and adenosquamous CA FIGO Stage IA Class II, Stage IB Class III, Stage II Class V, Stage III D Papillary serous CA & clear cell CA DGestational choriocarcinoma Stage I HCG normal w/in 2 years P, HCG abnormal DOvarian CA Stage I Class IV, Stage II Class VIUterine Sarcoma Stage I Class VVagina CA DVulvar CA Stage I Class II, Stage II Class IV

Male-specific Genitourinary CancerMale Breast CA Stage I Grade 1 Class I, higher Class III; Stage IIA Class VIProstate CA Stage I Class II, Stage II Class VPenile CA Stage I Std, Stage II class 1A to DTesticular CA Seminoma Stage I Class II, Stage IIA & B Class III Nonseminoma and Gonadal Stromal Tumor Stage I Class II, Stage IIA & B Class III

Hematologic CancerHodgkin's Lymphoma Stage IA Class III, Stage IB/IIA Class IV, Stage IIB/IIIA Class VLeukemia ALL - Childhood, Adult Class V/Class VI AML D CLL Table F to L CML DMultiple Myeloma DMyelodysplastic Syndrome DNon-Hodgkin's Lymphoma Stage I Class IV, Stage II Class V, Stage III Class VI

Head and Neck CancerHypopharyngeal CA T1 Class IV, T2 - T3 Class VILaryngeal CA T1 Class IV, T2 - T3 Class VINasopharyngeal CA T1 Class IV, T2 - T3 Class VIEsophageal DOral Cavity and Oropharyngeal CA T1 Class IV, T2 - T3 Class VIParanasal Sinus and Nasal Cavity T1 Class IV, T2 - T3 Class VIPrimary Intraocular Melanoma spindle cells small/medium Class I, large D non spindle cells small/medium Class VI, large DRetinoblastoma intraocular more than 10 years after treatment - consider extraocular and recurrent D

Muskuloskeletal CancerBone CA Osteosarcoma T1 Class VI Chondrosarcoma Stage I/II Class VI Ewing's Sarcoma Class VI (localized) Malignant fibrous histiocytoma Stage I/II Class VI Chordoma and Fibrosarcoma DKaposi's Sarcoma DSoft Tissue Sarcoma Arms/legs T1 Class I till Class VI Head/Neck/Trunk T1 Class V till Class VI

Neurological CancerAdult Central Nervous System Tumors

Respiratory CancerLung CA Small Cell CA D Non-small Cell CA T1 Class VILung Carcinoid Tumor resectable Class II to Class V unresectable DThymus CA Thymoma Stage I Class III, Stage II Class IV Thymic Carcinoma D

Skin CancerMelanoma Skin CA Stage IA Class I, Stage IB Class III, Stage IIA Class VNon-Melanoma Skin CA any T, NO, MO Std

any T, N1 or M1 D

NOTE: family historypresent occupationlifestyle - diet, smoker, drinks, hobbieshistopathology with staging size of tumor, lymph nodes, metastasestreatment - removed surgically, medically, chemo, radio, other therapies number of years sinceco-morbiditiesAPS from the oncologist - present situation

Risk class 1A LIFE ADB TPD/WP        

Years since completion of treatment≤ 1 5 per M x 3 yrs P P

> 1 to 2 5 per M x 2 yrs P P

> 2 to 3 5 per M x 1 yr P P

> 3 Std Std Std

Risk class I LIFE ADB TPD/WP        Years since completion of treatment≤ 1 7.5 per M x 4 yrs P P

> 1 to 2 7.5 per M x 3 yrs P P

> 2 to 3 7.5 per M x 2 yrs P P

> 4 Std Std Std

Risk class II LIFE ADB TPD/WP        Years since completion of treatment≤ 1 P P P

> 1 to 2 10 per M x 4 yrs P P

> 2 to 3 10 per M x 3 yrs P P

> 3 to 4 10 per M x 2 yrs P P

> 4 Std Std Std

Risk class III LIFE ADB TPD/WP        Years since completion of treatment

≤ 2 P P P

> 2 to 3 12 per M x 5 yrs P P

> 3 to 4 12 per M x 4 yrs P P

> 4 to 5 12 per M x 3 yrs P P

> 5 to 6 12 per M x 2 yrs P P

> 6 Std Std Std

Risk class IV LIFE ADB TPD/WP        Years since completion of treatment≤ 3 P P P

> 3 to 4 15 per M x 5 yrs P P

> 4 to 5 15 per M x 4 yrs P P

> 5 to 6 15 per M x 3 yrs P P

> 6 to 7 15 per M x 2 yrs P P

> 7 Std Std Std

Risk class V LIFE ADB TPD/WP        Years since completion of treatment≤ 4 P P P

> 4 to 5 17 per M x 5 yrs P P

> 5 to 6 17 per M x 4 yrs P P

> 6 to 7 17 per M x 3 yrs P P

> 7 to 8 17 per M x 2 yrs P P

> 8 to 9 17 per M x 1 yr P P

> 9 Std Std Std

Risk class VI LIFE ADB TPD/WP        Years since completion of treatment≤ 5 P P P

> 5 to 6 20 per M x 5 yrs P P

> 6 to 7 20 per M x 4 yrs P P

> 7 to 8 20 per M x 3 yrs P P

> 8 to 9 20 per M x 2 yrs P P

> 9 to 10 20 per M x 1 yr P P

> 10 Std Std Std

The general criteria and ratings The general criteria and ratings or the tumor rating guide or the tumor rating guide

varies from one company to varies from one company to another’s insurance manualanother’s insurance manual

“ “ Underwriting is more than Underwriting is more than a science: it is an art ”a science: it is an art ”

Thank YouThank You