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© General Reinsurance AG
Ian Cox
CMO Gen Re
Cancer: early detection or ‘Big C to little c’
© General Reinsurance AG
Brief
> Early Detection> Diagnostic techniques and prevention – less invasive ways of diagnosing
Screening programmes & impact on claimsGeographical factors & impact. Environmental factors
> Claims have requested:> Screening programmes: we are aware of breast, cervical, bowel, prostate, are there
others planned?> How effective are the programmes (bearing in mind recent publicity re false
positives, and number of people receiving possibly unnecessary treatment) Does more screening = more claims queries?
> What impact might the following factors have: age, family history, geography?
> UW have requested:> Prostate cancers - They are aware of recent developments in treatment; including
genetic testing and hormone treatments that aren't covered by the manuals. An update on these developments would be very useful as would help on establishing stagings
> Family history - A family history of 2 or more family members with cancer is an area not fully covered by the manuals. Instruction here would be useful as would details of any familial links that we should know about.
2Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Cancer risk Scotland
> More than 1 in 3 people in Scotland will develop some form of cancer during their lifetime
> Around 1 in 9 males and 1 in 7 females will develop some form of cancer before the age of 65
3Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Cancer survival
4Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
Survival rates in UK are still lagging behind other countries
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Age-standardised five-year relative survival trends, by cancer and by country
5Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Why is early diagnosis important?
Gen Re LifeHealth – Presentation for FOCUS 19 June 20126
> Principle that earlier diagnosis will mean:
• More diagnosed at earlier stage
• Easier to treat
• Surgery possible
• Less mortality
• Less morbidity
• Lower cost
• ‘Lives saved’
Cancer type
Stage %yrs Survival
Colorectal Stage A 93
Stage B 77
Stage C 47
Stage D 7
Breast Stage I 90
Stage II 70
Stage III 50
Stage IV 13
Lung Stage I 42
Stage II 23
Stage III 10
Stage IV 2
• 90% of cancers present with symptoms
• Many at an advanced stage
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Stage at presentation/diagnosis 2009 East England
7Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
Cancer site Stage 1 Stage 2 Stage 3 Stage 4 Stage not
known
Oesophagus 5.5 10.9 18.5 26.6 38.5
Colon 13.8 30.7 25.5 18.4 11.7
Lung 11.1 5.8 28.3 39 15.7
Melanoma 62.1 18.7 13.5 1.5 4.2
Breast 38.3 41.7 8.8 4.9 6.2
Cervix 68 9.9 9.5 7.4 5.3
Ovary 33.6 3.3 42.7 10.7 9.8
Prostate 1.1 68.3 11 14.3 5.4
Kidney 33.4 10.9 17.8 28.3 9.5
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Delays to diagnosis
8Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Delay in referral with symptoms - Scotland
9Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
Delayed diagnosis of cancer; Thematic review Data from the first Scottish Primary Care Group report showing the average number of days delay in cancer diagnosis in primary care.
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Percentage saying that they would contact the doctor in <2 weeks for each warning sign by socio-economic group
Gen Re LifeHealth – Presentation for FOCUS 19 June 201210
Delay seeking help
British Journal of Cancer (2009) 101(S2), S18 – S23
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Improving early detection
Gen Re LifeHealth – Presentation for FOCUS 19 June 201211
> Faster referral to hospital
> Faster appointment times– ‘2 week rule’ for suspected cancer
> Faster investigation
> 18 weeks treatment target
> Public education re symptoms
> Screening
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Lead time or increase in life expectancy
Gen Re LifeHealth – Presentation for FOCUS 19 June 201212
Time
Symptoms DeathDetectable by screening
Cancer starts
Apparent increase in survival
Survival after diagnosis from symptoms
Survival after diagnosis from screening
Prolonged survival or Cure
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Cancer Screening UK
Gen Re LifeHealth – Presentation for FOCUS 19 June 201213
> Breast 1988 - Mammography every 3 years from age 47 to 73
> Cervical 1989 - Smears from age 25 every 3 years, from age 50 every 5 years
> Colorectal 2006 - Faecal Occult blood test every 2 years 60-68
> Prostate No screening in place
> Lung cancer Watch this space!
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Cervical Screening
> Established screening programme in1989
> Smears from age 25 every 3 years
> from age 50 every 5 years
> Changed to liquid based cytology
14Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Cervical Cancer screening
15Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
Percentage with severe dyskaryosis or worse
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Outcomes of referral for abnormal smear
17Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
Persistent ‘non-negative’ test result
Single occurrence of potentially significantabnormality
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Cervical screening turnaround times - Scotland
Gen Re LifeHealth – Presentation for FOCUS 19 June 201218
http://www.isdscotland.org/Health-Topics/Cancer/Cervical-Screening/
2007 - 2011
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Time from screening to availability of report (%)
19Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
Changes in time from screening to availability of smear report England
2006/7 2007/8 2008/9 2009/10 2010/11
Up to 2 weeks 11 21 45 82.8
Up to 4 weeks 48 60 65 72 97.4
4-6 weeks 26 23 21 14 1.8
6-8 weeks 14 9 8 7 0.5
8-10 weeks 7 4 4 5 0.1
10-12 weeks 4 2 1 2 0.1
>12 weeks 2 1 0 0.6 0.1
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Breast Cancer screening
> Mammography every 3 years from age 47 to 73
> Attendance rate 74%
> 2,133,189 women screened
> 17,013 cancers detected
– 13,672 (80%) invasive
– 3,196 (19%) non-invasive
– 137 (1%) micro-invasive
Gen Re LifeHealth – Presentation for FOCUS 19 June 201220
http://news.bbcimg.co.uk/media/images/59720000/gif/_59720340_c0027305-mammography_examin.gif
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Size screen detected Breast cancers
Gen Re LifeHealth – Presentation for FOCUS 19 June 201221
Cancer detection rate•Overall 8.0 per 1,000 women screened•Invasive 6.4 per 1,000 women screened•Non/micro-invasive 1.6 per 1,000 women
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15 year survival trend with screen detected breast cancer
22Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Overdiagnosis cancer and screening
> Diagnosis of a cancer that would not have been diagnosed without screening
> Previously thought that all cancers would progress inevitably
> Between 15 and 30% could be ‘overdiagnosed’
Gen Re LifeHealth – Presentation for FOCUS 19 June 201223
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Diagnosis, symptoms, screening and overdiagnosis
Gen Re LifeHealth – Presentation for FOCUS 19 June 201224
Screening
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Breast Cancer Overdiagnosis
Gen Re LifeHealth – Presentation for FOCUS 19 June 201225
http://www.bmj.com/highwire/filestream/423608/field_highwire_fragment_image_l/0.jpg
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Incidence breast cancer Fife
27Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Nordic Cochrane report for patients
> If 2000 women are screened regularly for 10 years
> One will benefit from the screening, as she will avoid dying from breast cancer.
> At the same time, 10 healthy women will become ‘cancer patients’ and will be treated unnecessarily.
• These women will have either a part of their breast or the whole breast removed, and they will often receive radiotherapy, and sometimes chemotherapy.
> Furthermore, about 200 healthy women will experience a false alarm.
• The psychological strain until one knows whether or not it was cancer, and even afterwards, can be severe.
Gen Re LifeHealth – Presentation for FOCUS 19 June 201228
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British review
> The absolute benefits were estimated as 5.7 breast cancer deaths prevented per1000 women screened for 20 years starting at age 50
> The corresponding estimated numbers of cases overdiagnosed per 1000 women screened for 20 years were 2.3 per 1000.
Gen Re LifeHealth – Presentation for FOCUS 19 June 201229
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Rates of new diagnosis and death for five types of cancer in the US, 1975-2005.
Moynihan R et al. BMJ 2012;344:bmj.e3502
©2012 by British Medical Journal Publishing Group
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Breast Cancer Mortality Scotland
31Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Overdiagnosis and claims
How much overdiagnosis is present?
How much is carcinoma-in-situ?
How much is already in our claims portfolio?
May be more important for newer screening programmes
We cannot distinguish those cancers that are overdiagnosed from those that would have been diagnosed eventually
Gen Re LifeHealth – Presentation for FOCUS 19 June 201232
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Bowel cancer & screening
> Faecal Occult blood testing offered to all aged 60-69 every 2 years
> Extending to all up to age 75 – depends on area but can request
> In Scotland age 50-75
Gen Re LifeHealth – Presentation for FOCUS 19 June 201233
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Results Bowel cancer screening Scotland
Gen Re LifeHealth – Presentation for FOCUS 19 June 201234
Uptake Positive test
Adenoma rate
Cancer detection
rate
% Dukes A
% Dukes B
Males 50% 3.0 1.05 0.19 29 22.5
Females 57.2% 1.8 0.41 0.09 25.3 26.9
Overall 53.7% 2.3 0.71 0.14 27.7(8.7%)
24.1(24.2%)
Positive Predictive Value
Cancer Adenoma
Males 8.0 44.0
Females 6.3 29.6
Overall 7.3 36.1
http://www.isdscotland.org/Health-Topics/Cancer/Publications/2011-08-30/KPI_report.pdf
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Duke’s stage of bowel cancers detected after first million people screened in England
35Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
http://gut.bmj.com/content/early/2011/11/22/gutjnl-2011-300843.full.pdf+html
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Prostate cancer screening UK
Conclusions from NHS cancer screening committee:
• The harms from prostate cancer screening using PSA are currently likely to outweigh the benefits.
• In this circumstance screening for prostate cancer cannot be justified on the current evidence.
Gen Re LifeHealth – Presentation for FOCUS 19 June 201236
•PSA is a poor test for prostate cancer and a more specific and sensitive test is needed
•Currently unable to correctly identity those cancers which will progress and those which are indolent and may be safely watched
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Prostate cancer screening - US latest
37Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Prostate Cancer staging
38Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Family History
Question: A Family History of 2 or more family members with cancer is an area not fully covered by the manuals
Life cover –
Interventions may reduce the risk considerably
Critical illness -
Need to understand the percentage of claims from that particular cancer
Overall need to use information carefully
39Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Risk Colon cancer by family history
40Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
http://delgadomd.com/colon-cancer-screening/
% risk of developing cancer by age 79 4 8 9 15 16
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Breast cancer and family history
41Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
Probability % women developing breast cancer by age 50
Number first degree relatives affected
Current age None One Two
20 1.7 3.7 8.0
30 1.7 3.5 7.4
40 1.3 2.5 5.2
Probability % women developing breast cancer by age 80
Number first degree relatives affected
Current age None One Two
20 7.8 13.3 21.1
30 7.7 13.0 20.7
40 7.3 12.0 18.9
50 6.1 9.8 14.7
60 4.5 7.1 10.4
70 2.5 4.2 5.7
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Breast Cancer & FH by age
42Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Prostate cancer and family History
43Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
http://www.cancer.gov/cancertopics/pdq/genetics/prostate/HealthProfessional#Section_13
Family history Relative risks
Brother with Prostate cancer 3.4
Father with Prostate cancer 2.2
One First Degree Relative (FDR) at any age 2.6
One Second Degree Relative at any age 1.7
FDR diagnosed <65 yrs 3.3
FDR diagnosed >65 yrs 2.4
2 or more FDRs diagnosed at any age 5.1
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Changes in Family History with time/age
44Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
JAMA, July 13, 2011—Vol 306, No. 2
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Lung Cancer Screening
45Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Cumulative Numbers of Lung Cancers and of Deaths from Lung Cancer.
The National Lung Screening Trial Research Team . N Engl J Med 2011;365:395-409.
Lung Cancer screening with CT scans Vs CXR
> 53,000 current and former smokers ages 55 to 74
> Low dose spiral CT Vs CXR
> 20% relative reduction death from lung cancer
> 7% overall mortality fall
> 24% positive results
96% were false positive results
46Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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EarlyCDT
48Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Lung Cancer screening Scotland 2012
49Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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EarlyCDT Lung cancer screening
> With a Pre-test likelihood of 4% risk for age and smoking history group a positive result indicates:
> 1 out of 14.3 people who test positive from a CT diagnostic imaging scan will truly have the presence of lung cancer
> 1 out of 7 people with positive results from the EarlyCDT™-Lung test will truly have the presence of lung cancer
> 1 out of 4.3 people who test positive from both the EarlyCDT™-Lung test and a CT scan will truly have the presence of lung cancer
50Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
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Gen Re LifeHealth – Presentation for FOCUS 19 June 201251
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Disclaimer
Gen Re LifeHealth – Presentation for FOCUS 19 June 2012
This presentation is protected by copyright. All the information contained in it has been very carefully researched and compiled to the best of our knowledge. Nevertheless, no responsibility is accepted for its accuracy, completeness or currency. In particular, this information does not constitute legal advice and cannot serve as a substitute for such advice. It may not be duplicated or forwarded without the prior consent of the Gen Re.
Diese Präsentation ist urheberrechtlich geschützt. Alle hierin enthaltenen Informationen sind sehr sorgfältig recherchiert und nach unserem besten Wissen zusammengestellt. Dennoch können wir keine Haftung hinsichtlich ihrer Genauigkeit, Vollständigkeit oder Aktualität übernehmen. Insbesondere stellen diese Informationen keine Rechtsberatung dar und können auch nicht als Ersatz für eine solche Beratung dienen. Eine Vervielfältigung oder Weiterleitung ist nur mit vorheriger Zustimmung der Gen Re gestattet.
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© General Reinsurance AG
Gen Re LifeHealth – Presentation for FOCUS 19 June 201253