Julie Hopkins considers the case for adding partial benefit payment for DCIS treated with mastectomy and asks whether coverage could be extended to all DCIS diagnoses resulting in surgery
With the discussions on total permanent disability, and with comparison sites now focusing on weighting the value of the conditions covered before awarding scores, critical illness is well and truly back in the spotlight.
At the time of writing at least six providers offer partial payments for mastectomy following a diagnosis of Ductal Carcinoma in Situ (DCIS). Such payments don't yet score highly with the comparison sites because the number of claims paid so far is low - however, it can only be a matter of time before this changes.
So, what is Ductal Carcinoma in Situ? DCIS is the most common form of non-invasive breast cancer. Ductal indicates that the cancer originates in the milk ducts and is non-invasive because it has not spread into surrounding breast tissue. Carcinoma refers to cancer that begins in the skin or tissues that cover or line the internal organs. In Situ means ‘in its original place'.
The three grades
There are three grades of DCIS: low (Grade I), moderate (Grade II) and high (Grade III). Individuals with lower grade DCIS are at increased risk of developing invasive breast cancer after five years compared with those who have never had it.
With high grade DCIS, there is an increased risk of cancer - either at the time of diagnosis or in the future - as well as an increased risk of the cancer coming back earlier (within the first five years).
UK data shows around 4,000 cases of DCIS are diagnosed each year. This accounts for roughly one in eleven of all new breast cancer cases and one in five of those found by screening.
Generally, DCIS shows no signs or symptoms. According to the US National Cancer Institute, about 80% of all DCIS cases are found by mammography. In the UK, 69% of screen-detected DCIS cases are high grade. There is evidence that our screening programme has resulted in an increase in the incidence of DCIS detected at an early age.
What is interesting is that the cytonuclear grade of DCIS detected seems to have remained constant over recent years (see Figure 1). This suggests that the type of DCIS found has not drifted towards the lower grades as refined imaging techniques have improved the screening process.
Before mammographic screening began in the late 80s, DCIS was sometimes diagnosed when women had existing symptoms - and without treatment about one in three women with biopsy evidence of such lesions went on to develop invasive breast cancer in the same breast within 10 to 20 years.
Current evidence on screen-detected DCIS increasingly suggests it is an important precursor lesion for invasive disease. The epidemiological risk factors for DCIS are broadly similar to those for invasive disease, suggesting similar causes. The treatment of DCIS with local excision is associated with a substantially increased risk of developing invasive breast cancer in the same breast.
In a European treatment trial, 8% of women who had local treatment alone for DCIS developed invasive breast cancer within four years.
In other treatment trials, supplementing breast-conserving therapy with radiotherapy and/or tamoxifen treatment has been shown to reduce the subsequent incidence of recurrent DCIS or invasive breast cancer. This again suggests that many screen-detected DCIS lesions do not have a benign natural history. Invasive breast cancer is more likely to develop following high-grade than low-grade DCIS lesions.
Some have argued that if DCIS lesions were left untreated, few of those affected would go on to die from breast cancer. However, the probability of death from breast cancer among DCIS patients treated by lumpectomy (local excision) alone is around 2% in the next 10 years, i.e. two-to-four times the death rate from breast cancer among women in the general population in their 50s and 60s.
The World Health Organisation's International Agency for Research on Cancer (IARC) has concluded that mammography screening for breast cancer reduces mortality. An IARC working group comprising 24 experts from 11 countries evaluated all the available evidence on breast screening and determined that it reduces mortality from breast cancer among women aged 50-69 by 35%. So, for every 500 women screened, one life will be saved.
Treatment for DCIS
Guidelines produced by the National Institute for Clinical Excellence (NICE) in March 2007 recommend the following:
Surgery to the breast and axilla
Surgery is the primary treatment for DCIS and early invasive breast cancer, preferably with breast conservation when possible.
After breast conserving surgery for DCIS a minimum radial margin of excision of two millimetres is recommended, with pathological examination in line with the reporting standards of the NHS breast screening programme. If the margin is less than two millimetres consider re-excision after discussing the risks and benefits with the patient. Enter patients with screen-detected DCIS into the Sloane Project (the UK prospective audit of screen-detected non-invasive carcinomas of the breast). Breast units should audit their recurrence rates.
Adjuvant radiotherapy
Recommend breast radiotherapy after breast conservation surgery in patients with invasive disease, and consider it after surgery for DCIS.
Lumpectomy with radiotherapy and mastectomy remains the recommended treatment going forward.
While DCIS is clearly not invasive breast cancer, it is a serious condition and is often a precursor to invasive breast cancer. Its treatment can certainly have a significant impact on the patient's quality of life.
Due to the increased risk of malignant tumours developing, treatment for DCIS is based on the same prescribed clinical guidelines as for early invasive breast cancer.
Interestingly, it was claims specialists within the insurance industry who first put DCIS under the spotlight. Although the condition was not covered, those affected would have undergone the same treatment and follow-up as those with malignant tumours.
Support for partial payments for DCIS treated with mastectomy is growing as many believe this approach to be fair. Payment would usually be structured as a ‘rider' benefit that does not draw down from the headline critical illness cover and around a third of DCIS cases will be treated with mastectomy.
If one third is treated with mastectomy, then clearly two thirds are not - and are therefore not eligible for even a partial payment.
The Sloane Project is a UK-wide prospective audit of screen-detected non-invasive and atypical hyperplasias of the breast. This shows the average percentage of mastectomies performed following detection of DCIS at UK breast screening units at 30.1, but the precise percentage for different screening units varies widely, between 10% and 69%.
Contributing factors
A number of factors may contribute to the wide variation in mastectomy incidence from unit to unit, for example: the age of the patients seen, the grade and distribution of DCIS and the preferences of the treating surgeons.
From an actuarial and pricing perspective, care must be taken to ensure that all the relevant information has been considered.
Firstly, the incidence of DCIS is increasing sharply, as shown in Figure 2. This is broadly in line, however, with the rising numbers of women undergoing first and subsequent screenings.
Secondly, the number of women undergoing mastectomy is not increasing proportionately. This percentage has remained more or less constant over the years. In other words, the steepest increase has been among those who have had other surgical interventions such as lumpectomy.
Including cover for all surgical treatment of DCIS would certainly be a more costly option. The increased cost could, however, be mitigated through product design, e.g. by paying a partial benefit - and perhaps considering whether this should draw down from the main critical illness cover.
Summary
In December 2007, the Department of Health's Cancer Reform Strategy announced that from 2012 the NHS Breast Screening Programme would be extended to cover women between the ages of 47 and 73. This will be phased in across England over a three-year period, with full coverage in place from 2012.
This means all women will get two extra screening invitations during their lifetime. It also means they will all get their first screening invitation before their 50th birthday.
Another interesting fact to emerge from the 2002/3 data is that 29% of women in whom DCIS is detected at screening will have a mastectomy. This compares with 27% of those in whom invasive breast cancer is detected at screening.
The trend data suggests there will be more women diagnosed with both invasive breast cancer and DCIS in the years to come.
With the rising trend in DCIS incidence, coupled with impact of the extended screening programme, Hannover Life Re (UK) recommends that partial payments for DCIS with mastectomy and/or for all surgical treatment should be added to all critical illness (CI) policies to avoid turning down an increasing number of claims.
Julie Hopkins, Head of Underwriting & Claims Strategy, Hannover Life Re (UK)
