Breast cancer

Breast cancer is the most common cancer women suffer in this country. Each year, there are nearly 41,000 new cases in the UK. This cancer accounts for almost one in three of all cancer cases in women, and the lifetime risk for breast cancer in women is one in nine. In 2002 the disease claimed around 13,000 lives in the UK.

What exactly is breast cancer? The breast is made up of fat, connective tissue and glandular tissue, which form sections called lobules and lobes (a collection of lobules). A network of ducts connects the lobes to the nipple. The breast contains millions of cells that are constantly being renewed and replaced. Breast cancer starts in a duct or lobule, when a single cell begins to multiply out of control. Some cells break away and travel to other parts of the body, starting new tumours.

Risk factors

The strongest risk factor for breast cancer, apart from gender, is age. The older you are, the higher your risk, and the disease is rare in women under 30.

The more children a woman has, the lower her risk of breast cancer. Having children at a young age also lowers the risk, and breast-feeding helps protect against the disease. Starting periods at a younger than average age, or having a late menopause, increases the risk of breast cancer, while taking the contraceptive pill or hormone replacement therapy (HRT) also causes a small increase in risk. But the risk gradually returns to normal after stopping taking them. Being overweight after the menopause increases the possibility of breast cancer.

Women with a family history of breast cancer are at a slightly increased risk, but most women with one or two affected relatives will never develop breast cancer.

A small number of women are at an especially high risk because of faulty genes they have inherited. However, faults in known high-risk breast cancer genes such as BRCA1 and BRCA2 account for fewer than one in 20 breast cancer cases.

Regularly drinking large amounts of alcohol also slightly increases the chances of breast cancer, and mammographically dense breasts, or the pattern of a woman's breast tissue on a mammogram (x-ray of the breasts), is associated with an increased risk of disease (the more dense the mammogram, the higher the risk of breast cancer).

Certain types of benign breast lumps also increase the risk of the disease. Benign breast disease can be classified as non-proliferative, proliferative without atypia, and proliferative with atypia. The latter two increase the risk of breast cancer. Long-term exposure to radiation, or exposure at moderate to high levels, can also have an effect.

Every three years, the NHS invites all women in the UK aged between 50 and 64 to go for a mammogram. This programme includes women up to the age of 70. Mammograms can identify breast cancer early, so treatment can start as soon as possible. Women who have a strong family history of breast cancer should speak to their doctor about the possibility of screening before the age of 50.

Signs and symptoms

Breast cancer usually presents itself as a painless lump in the breast. Women should be "breast aware" through knowing what is normal for them, and looking out for the following symptoms:

- a new lump or thickening in the breast or armpit

- changes in the skin, such as dimpling, puckering or redness

- changes in the nipple, such as a change in direction of the nipple or an unusual discharge

- changes around the nipple, such as an unusual rash or sore area

- a change in the size or shape of the breast

- unusual pain or discomfort (although pain without any other symptoms is extremely unlikely to be due to cancer).

Women should report any signs to their doctor.

Breast conditions can fall into one of two categories: benign (non-cancerous) or malignant (cancerous). Nine in 10 breast lumps are not cancerous, and all of these signs may have other causes. However, it is important that breast cancer is detected early. The doctor will ask questions about a woman's medical history and about any risk factors she might have, and will also carry out an examination of the breasts, armpits and neck, looking for any lumps or suspicious changes. If necessary, a specialist may carry out further tests.

Treatment

The main treatment options for breast cancer include:

- Surgery: the two most common operations for breast cancer are breast conservation surgery and mastectomy, which is removal of the breast.

- Radiotherapy: doctors may use radiotherapy before surgery to reduce the size of the cancer. More commonly, women will receive radiotherapy two to four weeks after breast conservation surgery to destroy any cancer cells that may still be present. Some women may also have radiotherapy after mastectomy. If the cancer has spread to other parts of the body, radiotherapy may be used to relieve symptoms such as bone pain.

- Chemotherapy: doctors often treat breast cancer with a combination of chemotherapy drugs. Women may receive chemotherapy before or after breast surgery. The doctor can also use chemotherapy to treat cancer that has come back.

- Hormone therapy: 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. Tamoxifen is the most common hormone therapy used.

FACTS AND FIGURES

- More than 100 women are diagnosed with breast cancer every day. It is the second most common cause of cancer death in women in the UK, after lung cancer

- UK women have a one in nine lifetime chance of developing breast cancer

- 74% of women survive over five years after diagnosis

- Recent figures published by Cancer Research UK show breast cancer death rates have fallen by 20% over the last 10 years

- The estimated number of new cases in the US for 1999 was 175,000

- Cancer Research UK is the major supporter of breast cancer research in the UK, with annual spending of over £20m

- Government figures published in February 2004 show a marked increase in the number of breast cancers detected by screening. In 2002-03 over 13% more breast cancers were detected by screening than in the previous year. Detection rates have been steadily increasing for the last five years

- Current recommendations are that women with a strong family history of breast cancer should be screened by mammography, with screening starting at an age five to 10 years younger than that of the youngest relative to have developed the disease

- Women aged between 50 and 69, who are most likely to be diagnosed with the disease, have a better prognosis than average, with 72% surviving for 20 years. The figures for England and Wales are a vast improvement on a decade ago. Then, women overall had a 54% chance of surviving for 10 years and a 44% chance of surviving for 20 years. Almost 80% of women aged between 50 and 69 will survive at least 10 years after diagnosis, according to a recent report by Cancer Research UK

- Men can also get breast cancer, but it is rare (around 300 cases are diagnosed each year)

- Overall, almost two-thirds of women diagnosed with breast cancer are likely to survive for at least 20 years (Cancer Research UK)

UNDERWRITING IMPLICATIONS

When assessing a case where a client has had breast cancer, the underwriter will obtain a report from the client's GP together with related hospital/consultant reports. Underwriters need to identify the stage of the cancer in order to offer the most accurate terms available. The general staging system is as follows:

- Stage 0: carcinoma in situ (cancer that remains at the site of origin and has not yet spread)

- Stage 1: confined to breast, no skin involvement, no deep fixation

- Stage 2: confined to breast and ipsilateral axillary lymph nodes, no skin involvement, no deep fixation

- Stage 3: locally advanced disease, skin involvement, fixation of axillary nodes and/or involvement of supraclavicular

- Stage 4: distant metastases (the spread of a disease).

The prognostic significance of the stage is enhanced by consideration of historical type. Around 90% of invasive breast cancers are ductal, others being designated lobular, tubular, mucoid and medullary. Ductal carcinomas are graded according to their differentiation on degree of tubule formation, cell pleomorphism and mitotic activity.

The information required by an underwriter must include axillary lymph node status, histological type and grade, size of the tumour and if there is any involvement of adjacent structures (eg skin, chest wall). In addition, treatment details are required.

In certain situations underwriters may have to defer their decision depending on the date since treatment was completed and when the application is made; however, again this is dependent on the stage of the cancer. In some cases there will be temporary loading applied depending on when treatment finished, and in some circumstances there will be a loading applied throughout the term of the plan, reflecting the higher risk or recurrence due to more extensive disease.

The terms offered for life cover, critical illness (CI) or income protection (IP) cover vary. Family history is also taken into account. Between 2% and 10% of patients with breast cancer have a genetic abnormality that predisposes them to develop the disease.

It is difficult to provide an exact rating to an IFA who is making a pre-sales enquiry, as an underwriter needs to assess all the specific medical reports. In some cases, however, underwriters are unable to consider cover depending on when treatment commenced and when the application is submitted.

To illustrate: for life and IP, stage 0 tumours are likely to be acceptable more or less immediately after treatment, but a temporary extra premium is likely to be applied in the first two to three years post-treatment. This reflects the possibility of incomplete excision and therefore development into an invasive tumour. From a CI angle, we would decline any applications where a client has had a malignant breast condition.

SOURCES:

www.cancerresearch.co.uk

Swiss Re Underwriting Manual - SURE