underwriting colon cancer

1

UNDERWRITING COLON CANCER

EILEEN STEDEM

LIFE UNDERWRITING SPECIALIST

LIFEMARK ACCOUNTPRUDENTIAL

For the education of producers/brokers. Not for use with the public.

The Prudential Insurance Company of America, Newark, NJNR-12D35701 Ed. 3/12 Exp. 9/6/2013

2

GENERAL CONCEPTS AND TERMS

• Cancer is a general term used to describe any of the multiple types of malignant tumors.

• Cancer can affect any organ or tissue in the body.

• Cancer is characterized by inappropriate cell growth.

For the education of producers/brokers. Not for use with the public.

3

RELATED GI CONCERNS

• Ulcerative colitis (UC) - recurrent inflammation of the colorectum

• Crohn’s disease (Regional Enteritis) - chronic inflammatory process which may be found in any area of GI tract from lips to anus

• Familial Adenomatous Polyposis (FAP)and Gardner’s Syndrome - characterized by hundreds to thousands of polyps in the colon

• Colon Polyp - tumor of the inner lining of the colon. Adverse underwriting action is usually due to pre-malignant potential

For the education of producers/brokers. Not for use with the public.

4

BENIGN COLON POLYPS

• Hyperplastic and other non-neoplastic polyps (e.g., hamartomas, juvenile, inflammatory lymphoid aggregates) have little to no risk of progression to cancer.

• Adenomatous polyps (characterized histologically as tubular, tubulovillous and villous) can progress to cancer.Tubular polyps are likely to be small and benign. Villous polyps are more likely to be large and

contain cancer. • After one polyp is removed, there is an increased risk of

developing another polyp.

For the education of producers/brokers. Not for use with the public.

5

BENIGN COLON POLYPS

GUIDELINES

Colon polyp present, under 1 cm in size, well followed

No rating

Colon polyp present, over 1 cm in size Decline

Colon polyp removed, benign

with good follow-up No rating

with unknown follow-up, no villous elements No rating

with unknown follow-up of dysplastic or villous polyp

Table B

For the education of producers/brokers. Not for use with the public.

6

COLORECTAL CANCER ITEMS OF INTEREST

• Colorectal cancer is the third most common cancer in men and women and the second leading cause of cancer death in the United States.

• Most colorectal cancer arises slowly from an adenomatous polyp over 7 to 15 years.

• Incidence and mortality rates have been decreasing due to screening for and subsequent removal of polyps via colonoscopy.

For the education of producers/brokers. Not for use with the public.

7

RISK FACTORS

Risk factors for developing colorectal cancer include:

• family history of cancer or polyps• inherited conditions (such as familial

adenomatous polyposis and hereditary nonpolyposis)

• diet and or age • inflammatory bowel disease (such as ulcerative

colilitis or Crohn’s disease)• personal history of colorectal polyps

For the education of producers/brokers. Not for use with the public.

8

FACTORS IMPORTANT IN ASSESSING THE RISK FOR COLON CANCER:

• Type (i.e. adenocarcinoma, mucinous, signet ring cell)

• Grade

• Stage

• Time since treatment has ended

• Any recurrences or relapses

• Surveillance

For the education of producers/brokers. Not for use with the public.

9

COLORECTAL CANCER: ANATOMY

The wall of the colon consists of four layers:

• mucosa (adjacent to the lumen)

• Submucosa

• muscularis propria

• subserosa (outermost, farthest from the lumen)

For the education of producers/brokers. Not for use with the public.

10

COLORECTAL CANCER: ANATOMY

The wall of the colon consists of four layers:

• mucosa (adjacent to the lumen)

• Submucosa

• muscularis propria

• subserosa (outermost, farthest from the lumen)

For the education of producers/brokers. Not for use with the public.

11

STAGING CANCER

Stage represents the extent of tumor within the body. A commonly used classification for stage is the TNM system.

• T indicates local tumor size and its characteristics

• N indicates the spread of the tumor to the nearby lymph nodes

• M indicates spread to distant parts of the body via metastasis

For the education of producers/brokers. Not for use with the public.

12

STAGING OF COLORECTAL CANCER

TNM is preferred to the older Duke’s system.

Both are provided below for reference.

Stage TNM Duke’s Description

0 Tis, N0, M0

In-situ, tumor confined to mucosa

I T1, N0, M0 A Tumor through the mucosa into submucosa

I T2, N0, M0 A Tumor through submucosa in muscularis propria

IIA T3, N0, M0 B1 Tumor through muscularis propria and into subserosa but not into neighboring tissues

IIB T4, N0, M0 B2 Tumor into nearby tissues or organs, but nodes remain negative

IIIA T1, N1, M0T2, N1, M0

C1 T1 or T2 plus 1-3 nodes positive

IIIB T3, N1, M0T4, N1, M0

C2 T3 or T4 plus 1-3 nodes positive

IV M1 D Spread to distant sites such as liver, lung, peritoneum, ovary, etc.

For the education of producers/brokers. Not for use with the public.

13

DETERMINING THE RATING

Step 1: Refer to Rx for Success for colorectal cancer rating based upon staging and age at diagnosis.

StageRating

Age < 65 at diagnosisRating

Age > 65 at diagnosis

Carcinoma in situ, Tis No rating No rating

Stage I and Stage IIA Tumor table C Tumor table D

Stage IIB Tumor table B Tumor table C

Stage III - Best case only with ≤2 positive lymph nodes and normal CEA

0-5 years 6th year 7th year 8th year 9th year 10th year

thereafter

Decline Table B + $10x5 Table B + $10x4 Table B + $10x3 Table B + $10x2 Table B + $10x1

Table B

0-2 years 3rd year 4th year 5th year6th year 7th year

thereafter

Decline Table B + $10x5 Table B + $10x4 Table B + $10x3 Table B + $10x2 Table B + $10x1

Table B

Stage III (>2 lymph nodes positive) and Stage IV

Decline Decline

For the education of producers/brokers. Not for use with the public.

14

DETERMINING THE RATING

Step 2: Enter the Malignant Tumor Rating Schedule (found on Rx for Success Colorectal Cancer). Rating schedule applies only to those individuals who have had cancer which was presumably cured and who are no longer under treatment. Dating for entry into the tumor schedule starts with the date that treatment was completed, including any chemotherapy or radiation therapy.

A B C D

Within 1st year Decline Decline Decline $5x3

2nd year Decline Decline $7.50x5 $5x2

3rd year Decline $10x6 $7.50x4 $5x1

4th year $15x6 $10x5 $7.50x3 0

5th year $15x5 $10x4 $7.50x2 0

6th year $15x4 $10x3 $7.50x1 0

7th year $15x3 $10x2 0 0

8th year $15x2 $10x1 0 0

9th year $15x1 0 0 0

For the education of producers/brokers. Not for use with the public.

15

DETERMINING THE RATING

Step 3: Confirm:

• appropriate surveillance is being performed

• liver function tests are normal

• CEA is normal and stable

• no recurrence

• no recommended tests pending

For the education of producers/brokers. Not for use with the public.

16

CASE CLINIC # 1

• 70 Male

• Smoker

• Diagnosed with adenocarcinoma Stage I age 66

Tentative offer: Standard Smoker

For the education of producers/brokers. Not for use with the public.

17

CASE CLINIC # 2

• 71 Male

• Diagnosed with Stage I adenocarcinoma 10/2007 with treatment ending 2/1/2008.

• Serial CEA readings since diagnosis with most recent CEA increased from last year’s CEA but still below CEA at time of diagnosis and within normal range.

If CEA increase deemed significant, cannot consider.

For the education of producers/brokers. Not for use with the public.

18

CASE CLINIC # 3

• 69 Female• Non-smoker• Diagnosed with Stage IIA adenocarcinoma

8/2009 with treatment ending 1/2010

Tentative offer: Standard Non-smoker with $5 extra for 1 year.

For the education of producers/brokers. Not for use with the public.

19

CASE CLINIC # 4

• 60 Female

• Non-Smoker

• Diagnosed with carcinoma in situ with treatment completed 6 months prior to app

Tentative offer: Non-smoker Plus

For the education of producers/brokers. Not for use with the public.

For the education of producers/brokers. Not for use with the public.

20

RESOURCES

• For Quick Quotes, send an e-mail to lifemark.quickquotes@prudential.com

• To reach the RU of the Day, please call

1-888-828-4PRU (1-888-828-4778), prompt 1 and ask Account Representative for RU of the Day

21

IMPORTANT INFORMATION

Insurance issued by the Prudential Insurance Company of America, Newark, NJ. Underwriting rules are subject to change at our discretion.

For the education of producers/brokers. Not for use with the public.