© general reinsurance ag ian cox cmo gen re cancer: early detection or ‘ big c to little c ’

© General Reinsurance AG

Ian Cox

CMO Gen Re

Cancer: early detection or ‘Big C to little c’


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


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



Cancer survival


Survival rates in UK are still lagging behind other countries


Age-standardised five-year relative survival trends, by cancer and by country



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


Stage at presentation/diagnosis 2009 East England


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


Delays to diagnosis



Delay in referral with symptoms - Scotland


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.


Percentage saying that they would contact the doctor in <2 weeks for each warning sign by socio-economic group


Delay seeking help

British Journal of Cancer (2009) 101(S2), S18 – S23


Improving early detection


> Faster referral to hospital

> Faster appointment times– ‘2 week rule’ for suspected cancer

> Faster investigation

> 18 weeks treatment target

> Public education re symptoms

> Screening


Lead time or increase in life expectancy


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


Cancer Screening UK


> 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!


Cervical Screening

> Established screening programme in1989

> Smears from age 25 every 3 years

> from age 50 every 5 years

> Changed to liquid based cytology



Cervical Cancer screening


Percentage with severe dyskaryosis or worse


Outcomes of referral for abnormal smear


Persistent ‘non-negative’ test result

Single occurrence of potentially significantabnormality


Cervical screening turnaround times - Scotland


http://www.isdscotland.org/Health-Topics/Cancer/Cervical-Screening/

2007 - 2011


Time from screening to availability of report (%)


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


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


http://news.bbcimg.co.uk/media/images/59720000/gif/_59720340_c0027305-mammography_examin.gif


Size screen detected Breast cancers


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


15 year survival trend with screen detected breast cancer



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’



Diagnosis, symptoms, screening and overdiagnosis


Screening


Breast Cancer Overdiagnosis


http://www.bmj.com/highwire/filestream/423608/field_highwire_fragment_image_l/0.jpg


Incidence breast cancer Fife



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.



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.



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


Breast Cancer Mortality Scotland



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



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



Results Bowel cancer screening Scotland


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


Duke’s stage of bowel cancers detected after first million people screened in England


http://gut.bmj.com/content/early/2011/11/22/gutjnl-2011-300843.full.pdf+html


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.


•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


Prostate cancer screening - US latest



Prostate Cancer staging



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



Risk Colon cancer by family history


http://delgadomd.com/colon-cancer-screening/

% risk of developing cancer by age 79 4 8 9 15 16


Breast cancer and family history


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


Breast Cancer & FH by age



Prostate cancer and family History


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


Changes in Family History with time/age


JAMA, July 13, 2011—Vol 306, No. 2


Lung Cancer Screening



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



EarlyCDT



Lung Cancer screening Scotland 2012



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



Disclaimer


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 ian cox cmo gen re cancer: early detection or ‘ big c to little c ’

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