The 2004 Healthcare Conference

26-27 April 2004

Scarman House, The University of Warwick

Session B1 / D3

Richard Morris, Hamish Galloway, Sue Elliott

Critical Illness Trends Research Group

Trends in Critical Illness Risk CostsFurther Lessons from Population DataAn update from the Critical Illness Trends Research Group

What impact might screening for bowel cancer have ?Richard Morris

The interaction between trends in CABG, angioplasty, angina and

heart attacks The importance of trends in non-CI deaths

Hamish Galloway

Pulling it all together - a framework for assessing the outlook on CI risk costsSue Elliott

Critical Illness Trends Research Group

Our Aims :

To examine underlying trends in the factors influencing UK Insured Critical Illness claim rates, and from these, to assess : The historic trend in incidence and death rates for the major

CI’s Any pointers for future trends in Standalone CI, Mortality and

hence Accelerated CI.

Formed in March 2001

Group Members and our Current Focus

Heart Attack MS, TPD,Cancer & Stroke non-CI morty

& overall proj’n Actuaries

Azim Dinani Scott Reid Sue ElliottRichard Morris Joanne Wells Hamish GallowayNeil Robjohns (Chair) Scott Reid

Medical ExpertsProfessor Rubens Richard CroxsonConsultant Oncologist Consultant Cardiologist

Links : Actuaries Panel on Medical Advances CMIB CI experience investigation ABI CI definitions group

The Impact of Screen for Bowel Cancer - Richard Morris

The Actuarial Profession

making financial sense of the future

Screening for Colo-rectal Cancer

• (Prostate - quick update)• Background on the disease• Plans for screening• Trends to date• Modelling screening

Prostate Cancer Screening Update

• PSA Test:– Not specific enough - false positives– Not sensitive enough - false negatives– Not standardised

• No evidence that screening reduces mortality• Cancer Research UK briefing to MPs (Sep 03):

“Population screening of men displaying no symptoms is not recommended.”

Colorectal cancer

Statistics• 3rd most common cancer in men• 2nd most common cancer in women• Over 35,500 new cases per annum• Male incidence (ages 40-59) increasing at 1%

p.a.• Female incidence trend is level• 90% of cases occur over age 50

Risk FactorsUnclear but could include:• High-fat diet• Lack of dietary fibre• Sedentary lifestyle• Obesity• Alcohol• Family history• Age• History of bowel disease (inflammation, Crohn’s disease, …)• Lack of melatonin (night-shift workers)

Histology• Normal cells• Abnormal gland cells in the lining of the bowel wall• Adenomatous Polyp

– (20-25% prevalence at age 50)

• Cancer localised within the bowel wall (Duke’s Stage A)• Cancer which penetrates the bowel (Duke’s Stage B)• Cancer spread to lymph nodes (Duke’s Stage C)• Cancer with distant metastases (Duke’s Stage D / Stage

4)

Histology• Normal cells• Abnormal cells• Adenomatous Polyp

– (20-25% prevalence at age 50)

• Cancer localised within the bowel wall (Duke’s Stage A)• Cancer which penetrates the bowel (Duke’s Stage B)• Cancer spread to lymph nodes (Duke’s Stage C)• Cancer with distant metastases (Duke’s Stage D / Stage

4)

DETECTION?

Screening Methods• Faecal Occult Blood Test (FOBT)• Double Contrast Barium Enema• Flexible sigmoidoscopy• Colonoscopy• CT Colonography• DNA in stools

Plans for screening• UK clinical trials: population screening over age 50

using FOBT:– 15% reduction in mortality.

• Two pilots (Coventry and Fife) set up in spring 2000 for a 2-year period.– 50-69 year olds invited for FOBT screen.

• Evaluated by National Screening Committee and DofH• Second round of screening in pilot sites.• Separate UK trial of flexible sigmoidoscopy screening.

Screening Pilot Conclusions• “Our recommendation to the Department of Health

is that FOBT screening should be part of new national strategies targeting colorectal cancer.”

• “Findings … suggest that population-based FOBT screening is feasible.”

• “adverse effects of screening … were low”• “The UK Pilot has demonstrated that mortality

reductions demonstrated in randomised studies of FOBT screening can be repeated in the models of screening used in the UK pilot.”

Past Trends

Colo-rectal Cancer Trends Ages 40-59

0.00.51.01.52.02.53.03.54.04.5

1971 1975 1979 1983 1987 1991 1995 1999

Rat

e p

er 1

0,00

0

Male Incidence

Female Incidence

Male Mortality

Female Mortality

See Legend BreastEngland & Wales

Rates per 10,000

See LegendWomen

Cancer Trends 1971 - 2000

Country Sex Event Cancer Site Age Band

Q_65-69Q_60-64Q_30-34 Q_35-39 Q_40-44 Q_45-49 Q_50-54 Q_55-59

I_50-54 I_55-59 I_60-64 I_65-69I_30-34 I_35-39 I_40-44 I_45-49

-

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Past Trends: Breast Cancer

See Legend ProstateUSA

Rates per 10,000

See LegendMen

Cancer Trends 1971 - 1998

Country Sex Event Cancer Site Age Band

Not in UseQ_75-79Q_50-54 Q_55-59 Q_60-64 Q_65-69 Not in Use Q_70-74

Not in Use I_70-74 I_75-79 Not in UseI_50-54 I_55-59 I_60-64 I_65-69

-

20.0

40.0

60.0

80.0

100.0

120.0

140.0

160.0

180.0

200.0

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

Past Trends: Prostate Cancer

H

ULRP

UHRP

LCA

DHRP

DCA DCB DCC DCD

CuredFrom Cancer

DeadFrom Cancer

LCB LCC LCD

DLRP

Cancer Screening Model

Screening Studies

• National Screening Committee UK– Pilot study data

• “Cost-effectiveness of screening for colorectal cancer in the general population” - Frazier et al (Journal of the American Medical Association – October 2000)

– : “One of the most robust modelling studies reported to date.” National Screening Committee report

• Both focus on mortality reduction.

Model AssumptionsMedical data

Transition rates:• Low-risk polyp to high-risk polyp• High-risk polyp to cancer (stage A)• Transition between cancer stages

Population data

• Cancer incidence rate• Incidence rate by Duke’s stage

Unknown• Risk of developing low-risk polyp

Cancer Incidence: Modelled Incidence

Colo-rectal Cancer Incidence: Year 1

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

45-49 50-54 55-59 60-64 65-69 70-74

Rat

e p

er 1

0,00

0

Actual

Model

Cancer Incidence: No polyp detection

0

5

10

15

20

25

30

35

40

45

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Year

Reg

istr

ati

on

s p

er

10,0

00

40-44

45-49

50-54

55-59

60-64

65-69

70-74

Cancer Incidence: Duke’s Stage

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

D

C

B

A

Cancer Incidence: Up to 10% Polyp detection

0

5

10

15

20

25

30

35

40

45

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Year

Reg

istr

ati

on

s p

er

10,0

00

40-44

45-49

50-54

55-59

60-64

65-69

70-74

Cancer Incidence: Indexed

0

20

40

60

80

100

120

140

160

180

200

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Year

Reg

istr

ati

on

s In

dex %

v Y

ear

1

40-44

45-49

50-54

55-59

60-64

65-69

70-74

Screening: Conclusions for Insurers

We’re all doomed!

Don’t panic!

Interaction in Trends between Heart Attack, CABG and Angioplasty- Hamish Galloway

The Actuarial Profession

making financial sense of the future

Should Trends in Heart Conditions be Modelled Together?

Drivers of trends

Risk factors

Medical intervention

Review of trends in incidence

heart attack, coronary artery bypass, angioplasty 2+

Correlation

by age

by calendar year

Risk Factors for Coronary Heart Disease

Source: Britton and McPherson (2000). National Heart Forum

Medical Intervention

Drug treatments

Surgical intervention (e.g. CABS and Angioplasty)

Limited by resource

could also be driven by resource

Trends in Population Incidence RatesHeart Attack (First and Subsequent) Age 35-64

60%

65%

70%

75%

80%

85%

90%

95%

100%

105%

89/89 90 /89 91 /89 92 /89 93 /89 94 /89 95 /89 96 /89 97 /89 98 /89 99 /89 00 /89

F em ale

M ale

Trends in Population Incidence RatesCoronary Artery Bypass Graft Age 35-64

60%

80%

100%

120%

140%

160%

180%

200%

89/89 90/89 91/89 92/89 93/89 94/89 95/89 96/89 97/89 98/89 99/89 00/89

Fem ale

M ale

Trends in Population Incidence RatesAngioplasty 2+Vessels Age 35-64

6 0%

11 0%

16 0%

21 0%

26 0%

31 0%

36 0%

41 0%

46 0%

8 9 /89 9 0 /8 9 91 /8 9 92 /89 93 /89 9 4 /89 9 5 /8 9 96 /8 9 97 /89 98 /89 9 9 /8 9 0 0 /8 9

F em a le

M ale

Percentage Change p.a. in Incidence Rates1989-2000 Non-smoker model

HA, CABG and Angioplasty 2+ Males

-6.00%

-4.00%

-2.00%

0.00%

2.00%

4.00%

6.00%

8.00%

25

_2

9

30

_3

4

35

_3

9

40

_4

4

45

_4

9

50

_5

4

55

_5

9

60

_6

4

65

_6

9

70

_7

4

75

_7

9

80

_8

4

85

_8

9

p.a % change

LCI

UCI

Percentage Change p.a. in Incidence Rates1989-2000 Non-smoker model

HA, CABG and Angioplasty 2+ Females

-6.00%

-4.00%

-2.00%

0.00%

2.00%

4.00%

6.00%

8.00%

30_34

35_39

40_44

45_49

50_54

55_59

60_64

65_69

70_74

75_79

80_84

85_89

p.a % change

LCI

UCI

Summary Trends Heart Related Conditions

Heart attack incidence is no longer reducing at historical rates Potentially explained by the use of troponin to assist in the diagnosis

of heart attacks Full impact of troponin not yet in data

Operations CABG

stabilising/reducing less 60 increasing over 60

Angioplasty operations increasing at all ages

Combined effect Flat incidence at younger ages Increases in incidence at older ages Before troponin and other medical advances

Heart procedure rates versus 1st ever heart attack rates35 up to age 65. 1996-2000 data combined.

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

0.00 2.00 4.00 6.00

1st Ha per '000

CA

BG

per

'000

CABG

r = 0.997

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.00 2.00 4.00 6.00

1st Ha per '000

An

gio

2+

per

'000

Angio 2+

r = 0.996

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

0.00 2.00 4.00 6.00

1st Ha per '000A

ng

ina p

er

'000

Angina

r = 0.999

Age

Age Age

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00 10.00 15.00

1st Ha per '000

CA

BG

per

'000

CABG

r = - 0.983

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

5.00 10.00 15.00

1st Ha per '000

An

gio

2+

per

'000

Angio 2+

r = - 0.982

20.00

25.00

30.00

35.00

40.00

45.00

5.00 10.00 15.00

1st Ha per '000A

ng

ina

per

'000

Angina

r = 0.903

Heart procedure rates versus 1st ever heart attack rates.From age 65. 1996-2000 data combined.

Age

AgeAge

0.60

0.70

0.80

0.90

1.00

1.10

1.20

1.30

1.40

2.00 2.50 3.00

All Ha per '000

CA

BG

per

'000

CABG

r = - 0.759

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

2.00 2.50 3.00

All Ha per '000

An

gio

2+

per

'000

Angio 2+

r = - 0.799

2.00

3.00

4.00

5.00

6.00

7.00

8.00

2.00 2.50 3.00

All Ha per '000A

ng

ina

per

'000

Angina

r = - 0.929

Years

Heart procedure rates versus all heart attacks rates By HES year 1989 to 2000. Ages 35-64 combined

YearsYears

Effectiveness of CABS and Angioplasty

Randomised controlled trials of revascularisation against medical treatment show:

for CABS a reduction in mortality no reduction in the subsequent risk of non fatal vascular

events

For angioplasty improved symptoms in patients with angina no improvements in survival no prevention of subsequent myocardial infarction

Heart procedure rates versus angina ratesby HES year 1989 to 2000. Ages 35-64 combined

0.60

0.70

0.80

0.90

1.00

1.10

1.20

1.30

1.40

2.00 4.00 6.00 8.00

Angina per '000

CA

BG

per

'000

CABG

r = 0.612

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.00 5.00 10.00

Angina per '000

An

gio

2+

per

'000

Angio 2+

r = 0.832

2.00

2.10

2.20

2.30

2.40

2.50

2.60

2.70

2.80

2.90

3.00

0.00 5.00 10.00

Angina per '000A

ll H

a p

er '0

00

All HA

r = - 0.929

YearsYears Years

Ratio of heart procedures to first ever heart attack by calendar year for England and Wales, Ages 35-64 combined

52%

53%

54%

55%

56%

57%

58%

59%

60%

61%

62%

95/96 96/97 97/98 98/99 99/00 00/01

CABG / HA 1st

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

95/96 96/97 97/98 98/99 99/00 00/01

Angio 2+ / HA 1st

0%

50%

100%

150%

200%

250%

300%

350%

400%

95/96 96/97 97/98 98/99 99/00 00/01

Angina / HA 1st

Ratio of heart procedures to angina rates by calendar year for England and Wales, Ages 35-64 combined

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

95/96 96/97 97/98 98/99 99/00 00/01

HA 1st / Angina

0%

5%

10%

15%

20%

25%

95/96 96/97 97/98 98/99 99/00 00/01

CABG / Angina

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

95/96 96/97 97/98 98/99 99/00 00/01

Angio 2+ / Angina

0%

20%

40%

60%

80%

100%

1990 1992 1994 1996 1998 2000

US CABG/All HA - Ages 45+US Angio 1+/All HA - Ages 45+

0%

20%

40%

60%

80%

100%

1993 1995 1997 1999

Australia CABG/All HA - All AgesAustralia Angio 1+/All HA - All ages

0%

20%

40%

60%

80%

100%

1994 1996 1998 2000

Scotland CABG / All HA - All ages

Scotland Angio 1+ / HA - All ages

International data on the ratio of heart procedures to all heart attacks

0%

20%

40%

60%

80%

100%

1989 1991 1993 1995 1997 1999

England & Wales CABG / All HA - All ages

England & Wales Angio 1+ /All HA - All ages

Summary on Correlation

Trends in diet and smoking will impact all of HA, CABS, and angioplasty as well as angina but…

the impact does not appear to be the same due to medical intervention

Correlation by calendar year of CABS and angioplasty is stronger with angina than heart attack

Increases in the number of CABS and angioplasty are not acting to reduce the rate of heart attack

Greatest potential for increase in operations is at ages over 65 International comparisons show considerable scope for the rate of

angioplasty operations to increase. Heart attack, needs to be modelled separately from CABS and

angioplasty.

Trends in non-CI Mortality

- Hamish Galloway

The Actuarial Profession

making financial sense of the future

Importance of Non CI Mortality

Accelerated CI Incidence Rate Formula ix + (1-kx)qx or ix + q’x where q’x represents non-CI related

mortality Non CI Mortality as a %age of CIBT93

Age 25 Age 55Male 54.7% 24.6%Female 27.4% 13.4%

Biggest Single Component of Male ACI to Age 502nd Biggest Single Component of Female ACI throughout

Comparison of Trends in All and in Non CI Deaths

Improvement p.a. in male death rates

-1.5%

-1.0%

-0.5%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85plu

sImp

rove

men

t p

er a

nn

um

All 79-2000

All 89-2000

Non CI 79-2000

Non CI 89-2000

Comparison of Trends in All and in Non CI Deaths

Improvement p.a. in female death rates

-3.0%

-2.0%

-1.0%

0.0%

1.0%

2.0%

3.0%

4.0%

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85plu

s

Imp

rove

men

t p

er a

nn

um

All 79-2000

All 89-2000

Non CI 79-2000

Non CI 89-2000

Interim Conclusions

Non CI Mortality improvement is worse than all cause improvement almost everywhere

For key insurance ages Non CI Mortality is deteriorating

Trend in the 90’s worse than the 80’s Particularly for females

Evidence of Ageing of Mortality Improvement

Deaths by Cause, Males 15-39

0

0.5

1

1.5

2

2.5

3

3.5

4

De

ath

Ra

te p

er

10

,00

0

AccidentsVehicular AccidentsCancer (CI)Cardio (Non-CI)Heart Attack CIMental / NervousEverything else

Cause of Death by Gender and Age Group

Cause of Death by Gender and Age Group

Non CI Deaths by Cause, Males 15-39 Excluding Accidents

00.10.20.30.40.50.60.70.80.9

1

De

ath

Ra

te p

er

10

,00

0

Cardio (Non-CI)

Mental Nervous

Respiratory

Drugs and Alcohol

Infections

Chronic Liver

All Else

Deaths by Cause - Female ages 15-39

0

0.5

1

1.5

2

2.5

3

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

Dea

th R

ate

per

10,

000 Cancer (CI)

Accidents

Vehicular Accidents

Mental Nervous

Respiratory

Cardio (Non-CI)

Stroke CI

Everything Else

Cause of Death by Gender and Age Group

Cause of Death by Gender and Age Group

Non CI Deaths by Cause, Females 15-39 Excluding Accidents

0

0.2

0.4

0.6

0.8

1

1.2

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

De

ath

Ra

te p

er

10

,00

0

Mental Nervous

Respiratory

Cardio (Non-CI)

Infections

Chronic Liver

Digestive

Drugs and Alcohol

All Else

Further Conclusions - deterioration in non CI deaths at young ages due to

Accident Drug/Alcohol Chronic Liver Infection “Everything Else”

Offset at young ages by improvements in

Vehicular Accidents

Deaths by Cause - Males 40-64

0

0.5

1

1.5

2

2.5

3

3.5

Dea

th R

ate

per

1,0

00 Cancer (CI)

Heart Attack CI

Cardio (Non-CI)

Respiratory

Stroke CI

Accidents

Everything Else

Cause of Death by Gender and Age Group

Cause of Death by Gender and Age Group

Non CI Deaths by Cause, Males 40-64

02468

1012141618

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

De

ath

Ra

te p

er

10

,00

0 Cardio (Non-CI)

Respiratory

Accidents

Chronic Liver

Digestive

Mental Nervous

Vehicular Accidents

Infections

All Else

Death by Cause - Females 40-64

0

0.5

1

1.5

2

2.5

3

Dea

th R

ate

per

1,0

00

Cancer (CI)

Cardio (Non-CI)

Heart Attack CI

Stroke CI

Respiratory

Everything Else

Cause of Death by Gender and Age Group

Cause of Death by Gender and Age Group

Non CI Deaths by Cause, Females 40-64

012345678

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

De

ath

Ra

te p

er

10

,00

0

Cardio (Non-CI)

Respiratory

Accidents

Mental Nervous

Digestive

Chronic Liver

Vehicular Accidents

All Else

Further Conclusions - deterioration in non CI deaths at middle ages due to

Respiratory Chronic Liver Accident (F) Cardio non CI (F < 54)

Offset at middle ages by improvements in

Cardio non CI (ages 55+)

Deaths by Cause - Males 65+

02468

101214161820

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

Dea

th R

ate

per

1,0

00

Cancer (CI)

Cardio (Non-CI)

Heart Attack CI

Respiratory

Stroke CI

Everything Else

Cause of Death by Gender and Age Group

Cause of Death by Gender and Age Group

Non-CI Deaths by Cause, Males 65+

020406080

100120140160180200

De

ath

Ra

te p

er

10

,00

0

Cardio (Non-CI)

Respiratory

Digestive

Mental Nervous

Accidents

Kidney

All Else

Death by Cause - Females 65+

0123456789

10

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

De

ath

Ra

te p

er

1,0

00

Cardio (Non-CI)Cancer (CI)RespiratoryStroke CIHeart Attack CIEverything Else

Cause of Death by Gender and Age Group

Cause of Death by Gender and Age Group

Non CI Deaths by Cause, Females 65+

0102030405060708090

100

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

De

ath

Ra

te p

er

10

,00

0

Cardio (Non-CI)

Respiratory

Digestive

Mental Nervous

Accidents

Kidney

Cancer (non CI)

All Else

Further Conclusions - deterioration in non CI deaths at old ages due to

Respiratory (F)

Offset at old ages by improvements in

Cardio non CI (M, F<75)

Further Work and Application to Insured Lives

Need to understand cardio non-CI

CMI cause of Death survey discontinued 1994

Link to deprivation codes

Distortion due to ICD coding

Pulling it all together – a framework for assessing the outlook on CI risk costs - Sue Elliott

The Actuarial Profession

making financial sense of the future

Pulling it all together – a framework for assessing the outlook on CI risk costs

Populations trends 1989-2000

Simplistic extrapolations (based on population data)

Potential scenarios for future

Conditions considered

Cardiovascular Split by heart attack, angioplasty, CABG, stroke, etc Data available 1989-2000 (HES)

Cancer Modelled as one condition Data available 1971-2000 (Cancer registration statistics)

Non CI deaths Modelled as one condition Data available 1979-2000 (OPCS cause of death statistics)

The rest No change projected at this time

Health warnings

Smoker/non-smoker Obesity Health/wealth Base data at 1993 may be incorrect

e.g. “fudge” for angioplasty Large trends in small conditions can distort big picture

Angioplasty again

Cardiovascular trends - males

Trends by Age by Cardiovascular Condition - Males

-0.1

-0.08

-0.06

-0.04

-0.02

0

0.02

0.04

0.06

0.08

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85-8

9

90 p

lus

Imp

rov

em

en

t p

er

an

nu

m 8

9-2

00

0

Heart Attack

Stroke

Angio 1+

Angio 2+

CABG

HA CABG Angio 1+

HA CABG Angio 2+

Cardiovascular trends - females

Trends by Age for Cardiovascular Condition - Females

-0.1

-0.08

-0.06

-0.04

-0.02

0

0.02

0.04

0.06

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85-8

9

90 p

lus

Imp

rov

em

en

t p

er

an

nu

m 8

9-2

00

0

Heart Attack

Stroke

Angio 1+

Angio 2+

CABG

HA CABG Angio 1+

HA CABG Angio 2+

Cancer trends

Cancer Trends by Age, Sex and Historical Period

-2.5%

-2.0%

-1.5%

-1.0%

-0.5%

0.0%

0.5%

1.0%

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85plu

s

Imp

rov

em

en

t P

er

An

nu

m

Male 71-00

Male 89-00

Female71-00

Female89-00

Non CI death trends

Trends in Non CI Deaths by Age, Sex and Historical Period

-3.0%

-2.0%

-1.0%

0.0%

1.0%

2.0%

3.0%

4.0%

Imp

rove

men

t P

er A

nn

um

Male 79-2000

Male 89-2000

Female 79-2000

Female 89-2000

Simplistic extrapolations – issues to consider

What period of past data to use as a base trend?

Project 5 year age bands or impose an age-related pattern?

What level of subdivision of CI’s (eg all cancer or by key cancer site?)

Simplistic extrapolation 1 (for illustration only)

Trends from 1989-2000 only Some smoothing applied

Trends run to zero with half life 10 years Heart attack, CABG, angioplasty 2+ modelled

together CIBT 93 (with angioplasty 2+) applies at 1993 Trends in 1994-2000 are actual population trends 2001 et al projected off trended average of 1989-

2000

Simplistic extrapolation 1 (for illustration only)

Males - Projected CI Incidence Rates per 10,000 Age 1993 1998 2003 2008 2013 2018 2023 2028

22 13.2 13.5 13.4 13.4 13.4 13.4 13.4 13.427 14.2 15.4 15.0 15.1 15.3 15.3 15.4 15.432 18.4 19.6 19.1 19.3 19.5 19.6 19.7 19.737 28.6 27.6 27.5 27.3 27.3 27.3 27.2 27.242 48.1 46.5 46.3 46.2 46.2 46.2 46.3 46.347 74.0 75.7 73.8 73.3 73.0 72.9 72.7 72.752 124.3 115.5 113.7 111.5 110.1 109.1 108.5 108.057 200.5 197.7 192.7 191.7 191.1 190.7 190.5 190.462 312.4 306.9 309.2 311.0 312.5 313.6 314.4 315.167 437.3 418.9 431.8 437.7 442.4 446.0 448.6 450.672 628.1 630.0 638.7 649.7 658.3 664.9 669.7 673.277 892.3 859.0 868.4 873.9 878.3 881.6 884.0 885.8

Females - Projected CI Incidence Rates per 10,000

Age 1993 1998 2003 2008 2013 2018 2023 202822 8.0 8.9 8.5 8.7 8.8 8.9 8.9 9.027 10.6 11.1 11.3 11.6 11.8 12.0 12.1 12.232 16.2 17.0 17.1 17.5 17.8 18.1 18.2 18.337 25.4 25.1 26.0 26.3 26.5 26.7 26.8 26.942 38.2 39.9 40.1 40.8 41.3 41.6 41.8 42.047 58.4 59.7 62.1 63.5 64.6 65.4 66.0 66.452 88.7 91.6 92.9 94.4 95.6 96.4 97.0 97.457 129.7 132.9 132.4 133.8 134.9 135.8 136.4 136.862 197.0 195.7 197.2 198.5 199.5 200.2 200.8 201.267 247.8 245.1 249.7 252.6 254.8 256.4 257.6 258.572 358.1 373.1 373.8 381.8 387.7 392.0 395.1 397.477 517.7 519.3 534.5 546.5 555.3 561.7 566.3 569.6

Simplistic extrapolation 1 (for illustration only)

Males - Projected CI Incidence Rates as %age of 1993Age 1993 1998 2003 2008 2013 2018 2023 2028

22 100.0% 102.1% 101.6% 101.4% 101.3% 101.3% 101.3% 101.4%27 100.0% 108.2% 105.6% 106.7% 107.5% 108.0% 108.4% 108.7%32 100.0% 106.6% 104.0% 105.0% 105.8% 106.4% 106.8% 107.1%37 100.0% 96.5% 96.0% 95.5% 95.3% 95.2% 95.2% 95.2%42 100.0% 96.7% 96.2% 96.1% 96.1% 96.1% 96.2% 96.2%47 100.0% 102.3% 99.7% 99.1% 98.7% 98.4% 98.3% 98.2%52 100.0% 92.9% 91.5% 89.7% 88.6% 87.8% 87.3% 86.9%57 100.0% 98.6% 96.1% 95.6% 95.3% 95.1% 95.0% 94.9%62 100.0% 98.2% 99.0% 99.5% 100.0% 100.4% 100.6% 100.9%67 100.0% 95.8% 98.7% 100.1% 101.2% 102.0% 102.6% 103.0%72 100.0% 100.3% 101.7% 103.4% 104.8% 105.8% 106.6% 107.2%77 100.0% 96.3% 97.3% 97.9% 98.4% 98.8% 99.1% 99.3%

Females - Projected CI Incidence Rates as %age of 1993

Age 1993 1998 2003 2008 2013 2018 2023 202822 100.0% 111.1% 106.8% 108.5% 109.8% 110.8% 111.5% 112.0%27 100.0% 104.4% 106.3% 109.3% 111.5% 113.0% 114.2% 115.0%32 100.0% 105.0% 105.8% 108.3% 110.1% 111.5% 112.4% 113.1%37 100.0% 98.7% 102.1% 103.4% 104.3% 104.9% 105.4% 105.7%42 100.0% 104.5% 105.2% 106.9% 108.1% 109.0% 109.7% 110.1%47 100.0% 102.3% 106.3% 108.8% 110.7% 112.1% 113.0% 113.7%52 100.0% 103.3% 104.8% 106.5% 107.7% 108.7% 109.4% 109.9%57 100.0% 102.4% 102.1% 103.2% 104.0% 104.7% 105.2% 105.5%62 100.0% 99.3% 100.1% 100.8% 101.3% 101.7% 102.0% 102.2%67 100.0% 98.9% 100.8% 102.0% 102.8% 103.5% 104.0% 104.3%72 100.0% 104.2% 104.4% 106.6% 108.3% 109.5% 110.3% 111.0%77 100.0% 100.3% 103.2% 105.6% 107.3% 108.5% 109.4% 110.0%

Simplistic extrapolation 2 (for illustration only)

Trends from 1989-2000 only Some smoothing applied

Trends run to zero with half life 10 years All cardio vascular modelled separately CIBT 93 (with angioplasty 2+) applies at 1993 Trends in 1994-2000 are actual population trends 2001 et al projected off trended average of 1989-2000

Simplistic extrapolation 2 (for illustration only)

Males - Projected CI Incidence Rates per 10,000 Age 1993 1998 2003 2008 2013 2018 2023 2028

22 13.2 13.5 13.4 13.4 13.4 13.4 13.4 13.427 14.2 15.3 15.0 15.1 15.2 15.3 15.4 15.432 18.4 19.7 19.2 19.4 19.5 19.7 19.7 19.837 28.6 28.3 28.3 28.4 28.5 28.6 28.7 28.842 48.1 46.8 46.5 46.6 46.7 46.8 46.8 46.947 74.0 75.9 73.8 73.3 73.0 72.9 72.8 72.752 124.3 115.4 113.4 111.4 110.2 109.4 108.9 108.657 200.5 196.4 191.2 190.7 190.8 191.1 191.4 191.762 312.4 304.2 307.6 312.5 317.6 322.1 326.0 329.067 437.3 416.1 438.2 460.7 486.0 510.9 533.0 551.572 628.1 633.1 671.2 737.4 819.1 905.3 986.5 1057.077 892.3 859.3 898.4 966.0 1061.7 1173.1 1285.7 1388.6

Females - Projected CI Incidence Rates per 10,000

Age 1993 1998 2003 2008 2013 2018 2023 202822 8.0 8.9 8.5 8.7 8.8 8.9 8.9 9.027 10.6 11.1 11.3 11.6 11.8 12.0 12.1 12.232 16.2 17.0 17.1 17.5 17.8 18.0 18.2 18.337 25.4 25.1 25.9 26.3 26.5 26.7 26.8 26.942 38.2 40.2 40.5 41.3 41.9 42.4 42.7 43.047 58.4 59.8 62.1 63.5 64.6 65.5 66.0 66.552 88.7 91.6 93.0 94.6 95.9 96.8 97.5 98.057 129.7 132.6 132.1 133.6 134.9 135.9 136.6 137.262 197.0 195.2 197.1 199.2 201.3 203.1 204.5 205.767 247.8 244.3 250.7 257.0 263.3 268.9 273.6 277.472 358.1 373.9 383.8 408.0 434.8 461.5 485.8 506.477 517.7 518.3 538.3 561.9 588.0 614.9 640.5 663.0

Simplistic extrapolation 2 (for illustration only)

Males - Projected CI Incidence Rates as %age of 1993Age 1993 1998 2003 2008 2013 2018 2023 2028

22 100.0% 101.9% 101.5% 101.3% 101.3% 101.3% 101.3% 101.3%27 100.0% 108.0% 105.5% 106.6% 107.4% 107.9% 108.3% 108.6%32 100.0% 107.0% 104.3% 105.4% 106.2% 106.9% 107.3% 107.6%37 100.0% 98.9% 98.8% 99.1% 99.5% 99.9% 100.2% 100.5%42 100.0% 97.4% 96.7% 96.8% 97.0% 97.2% 97.4% 97.5%47 100.0% 102.5% 99.7% 99.1% 98.7% 98.4% 98.3% 98.2%52 100.0% 92.9% 91.3% 89.6% 88.6% 88.0% 87.6% 87.4%57 100.0% 98.0% 95.4% 95.1% 95.1% 95.3% 95.5% 95.6%62 100.0% 97.4% 98.5% 100.0% 101.6% 103.1% 104.3% 105.3%67 100.0% 95.2% 100.2% 105.3% 111.1% 116.8% 121.9% 126.1%72 100.0% 100.8% 106.9% 117.4% 130.4% 144.1% 157.1% 168.3%77 100.0% 96.3% 100.7% 108.3% 119.0% 131.5% 144.1% 155.6%

Females - Projected CI Incidence Rates as %age of 1993

Age 1993 1998 2003 2008 2013 2018 2023 202822 100.0% 111.1% 106.8% 108.5% 109.8% 110.8% 111.5% 112.0%27 100.0% 104.3% 106.3% 109.3% 111.4% 113.0% 114.2% 115.0%32 100.0% 104.8% 105.5% 108.0% 109.8% 111.1% 112.1% 112.7%37 100.0% 98.6% 102.0% 103.2% 104.1% 104.8% 105.3% 105.6%42 100.0% 105.4% 106.2% 108.3% 109.9% 111.1% 112.0% 112.6%47 100.0% 102.4% 106.3% 108.9% 110.7% 112.1% 113.1% 113.9%52 100.0% 103.3% 104.8% 106.7% 108.1% 109.1% 109.9% 110.4%57 100.0% 102.2% 101.8% 103.0% 104.0% 104.8% 105.4% 105.8%62 100.0% 99.1% 100.0% 101.1% 102.2% 103.1% 103.8% 104.4%67 100.0% 98.6% 101.2% 103.7% 106.3% 108.5% 110.4% 112.0%72 100.0% 104.4% 107.2% 113.9% 121.4% 128.9% 135.7% 141.4%77 100.0% 100.1% 104.0% 108.5% 113.6% 118.8% 123.7% 128.1%

Potential scenarios for the future

A range of outcomes are possible Need to consider:

Medical advances Prevention Diagnosis Treatment

Health awareness Social change Economic change

Potential scenarios for the future

No change – current and “known” future trends run their course and are not replaced

Adverse lifestyles continue – obesity, smoking, drug/alcohol abuse, etc

“Prevention” campaigns – have best effect that can be reasonably considered

Improved detection: cancer screening (eg breast, prostate, bowel) – create a spike? impact of troponins? overall – improved detection could increase or decrease CI claim

incidence Improved treatment – prevent a CI condition from becoming a CI

claim