Issue: November 2018 Dr. Sara Kannampuzha, Life/Health Associate
Underwriter, Cologne
Some people may wonder
about the association between personalised medicine and insurance. One point is
clear: If the insurance industry is informed about medical advancements, a huge
advantage arises for future underwriting with regards to calculating ratings
for specific diseases and also creating digital application forms with
simplified underwriting. Generally, every six months we hear about improvements
in the medical field, such as new genetic tests, simple blood tests for cancer
diagnoses and highly efficient medical devices. What are the new diagnostic
methods in medicine and what actually is personalised medicine? And why is this
so important for the insurance industry?
The traditional medical
approach is to give the same treatment to all patients who have the same
diagnosis (usually called “one-size-fits-all” treatment). Personalised
medicine, however, goes a step further and bases therapy on a person’s unique
genetic profile. Medical care is tailored to the characteristics of an
individual patient. But personalised medicine is not only about individually
tailored medicine or genetics; it is also about preventive care, about
detecting health conditions or potentially malignant diseases at an early stage
and treating them effectively.1,2,3
Personalised medicine
exclusively targets the diseased cells without harming the “healthy” part of
the body. This increased efficiency goes along with limited side effects.
Interestingly, 20% of the treatments approved by the U. S. Food and Drug
Administration (FDA) in 2017 were different types of personalised
medicine, including molecular therapies, gene therapies, and genetic tests to
examine specific health conditions.4
Blood tests – Old or
gold?
Early detection of a
disease enables a more accurate personalised medicine treatment and hence a
more efficient treatment. Many people undergo regular routine examinations to
obtain an overall picture of their well-being. With the help of different tests,
the health of main organs and the blood can be examined. A deviation in certain
values will show a higher risk for specific diseases. For instance, a high
serum creatinine value indicates kidney dysfunction, or high blood sugar levels
may be due to an impaired insulin production. But with advances in medicine,
things have changed; new blood tests are able to detect the presence of more
and more diseases, e. g. different types of cancer at an early stage,
foetus abnormalities or Alzheimer’s disease.
Blood tests for cancer
Scientists discovered
that with the help of simple blood tests, free-circulating DNA from advanced
prostate cancer cells were detected in different individuals, who then were
selected to be treated with personalised medical treatment; for example, by
inhibiting a specific gene. Moreover, according to recent research results, a
new blood test promises early detection of eight different cancer types.5 This
test, called cancerSEEK, is able to scan for early stages of cancer by
screening for circulating DNA or proteins that are a part of cancer cells. In
contrast to potentially painful biopsies, cancerSEEK is non-invasive and can be
done during a routine checkup. The study implied that different cancer types,
such as ovarian, liver, stomach, pancreatic, oesophageal, lung, bowel or breast
cancer can be detected by cancerSEEK.6Unfortunately, this blood test
is not currently available at medical health centers but could be in the
future.
How should insurers work
with this kind of information? When different cancer types can be detected in
their early stages followed by quick treatment, survival rates will increase
and subsequently Life insurance and even Disability cover can be offered to
more people. On the other hand, fast detection of cancer can be accompanied
with misuse and anti-selection for some insurance products, such as Dread
Disease cover. Dread Disease policies covering cancer typically require the
finding of malignant cells with uncontrolled growth, invasion of cells and
histopathological evidence. But should blood tests become the gold standard for
cancer diagnosis, disease definitions need to be reviewed. Early detection of
cancer showing only a minimum amount of cancer DNA could result in a claim
without the client actually having developed a life-threatening disease. These
new advances in blood testing can therefore have a big up- and down-side for
insurance companies.
Maternal blood tests
Amniocentesis is a
prenatal screening test to find chromosomal abnormalities in a foetus. A small
amount of amniotic fluid is withdrawn with a needle for testing. It is now
possible to replace this traditional invasive procedure by non-invasive
maternal blood tests. If the genes of the foetus can be determined with the
help of simple blood tests reducing the health risks associated with invasive
procedures, more women will agree to be tested for the health of their unborn
child (e. g. early detection of potential Down’s syndrome). The accuracy
of the test is up to 99.5%.7 Next to the major ethical issues that
are raised by these developments, this topic also carries huge implications for
insurance companies. Newborn baby life insurance products are offered starting
at age six months. For a foetus, early detection of abnormalities that go along
with higher mortality rates can again lead to anti-selection and increased life
insurance applications. Therefore, it is necessary that insurance companies are
aware of such tests.
Alzheimer’s disease
Another interesting
topic is that of a simple blood test to detect Alzheimer’s disease. Again,
identifying minimally invasive and cost-effective blood-based biomarkers for
Alzheimer’s would be a major step in diagnostics. The main diagnostic factor
that Alzheimer’s tests look for in the blood is the presence of amyloid beta
deposits. A study showed that in approximately 300 patients from Japan and
Australia, 90% of the cases showed an amyloid beta concentration in the blood
with associated abnormalities in the brain.8 What does that
mean for the insurance industry? Similar to cancer, existing disease
definitions in some insurance products (e. g. Dread Disease) should be
checked for adequacy as claims can be made for diseases that may never actually
become a problem to the person. Also someone who tested positive for an increased
risk for Alzheimer’s disease can specifically look for that kind of product. Or
a person who already knows about increased risk due to a diseased first degree
relative, might buy coverage before undergoing the Alzheimer’s blood test.
Cancer – How much
personalisation is possible?
Cancer is one of the
leading causes of death worldwide. Thousands of researchers conduct research
and publish studies with the aim to defeat cancer. As different cancers have
different causes and factors that influence the disease, one wonder pill for
elimination will never be likely.
Another problem is that
cancer is often over-treated – mainly via chemotherapy and radiation. These
treatments are rather unpleasant and painful and even associated with
developing other cancers. Additionally, chemotherapy and radiation do not only
kill the cancer cells but also healthy cells. Here, Multianalyte Assays with
Algorithmic Analyses (MAAA) might solve the problem. This is a new trend
in personalised medicine where algorithms help choose the right course of
treatment for a particular person with cancer or other severe diseases. In the
case of breast cancer, the prognostic factors according to the American Joint
Committee on Cancer (AJCC)9 are tumor size, metastasis to
lymph nodes, absence or presence of specific biomarkers – such as estrogen
receptor, progesterone receptor, and human epidermal growth
factor 2 (HER2). But these clinical factors can be misleading when
estimating the prognosis and predicting the response to chemotherapy. A study
showed that with the help of MAAA, it would be possible to decide whether
chemotherapy has more benefits than harm for the treatment of breast cancer.10 In
this way, chemotherapy can be added or left out of the treatment plan. This
also improves the prognosis.
“Different cancers need
different treatments”
Additionally,
personalised medicine is used for the treatment of colorectal cancer. Studies
showed that epidermal growth factor receptors (EGFR) are more highly
expressed in some colorectal cancer cells compared to other patients with this
disease. In this way, targeted inhibition of EGFR helps to shrink the cancer
cells without using aggressive treatment that damages healthy cells.11
The higher stages
(stages III to V) of skin cancer generally have a poor outcome. Most
of these skin cancers show mutations in the BRAF gene. A drug named Vemurafenib
is able to target the skin cancer cells and inhibit the mutated gene. This
leads to a decreased development of the cancer in 63% of patients with stage III
to IV skin cancer and hence to increased survival rates.12
In the future, it might
be possible that some cancer types can be cured even in advanced stages. For
insurance companies, it would be helpful to know which cancer types can be
treated in a personalised way and according to that, analyse the long-term
outcomes in the future. In underwriting, it is very difficult to accept clients
with advanced stage cancer. In the future, if personalised medicine can
increase survival rates even for those with advanced cancers (stages IV
or V) in individual cases, better ratings can be offered.
Personalised medicine
– Our future?
These days we have high
expectations that personalised medicine will be able to completely cure many
different diseases. In contrast to the past, tailored individual medicine is
becoming common and targeted therapies are getting approved by the FDA almost every
six months. The National Health Service (NHS) in England describes a
vision for 2020 where major changes within medicine will have taken place.
We’ll see better diagnostic options for cancer as well as rare diseases and
will use data combined analyses to visualise the complete picture of a
patient’s data. By 2025 a new taxonomy of medicine based on underlying cause
and personal response is expected.13 We can say for sure that
personalised medicine is not just a hype that will pass but the future
of medicine.
According to the British
Pharmaceutical Industry, there are great advantages in increased personalised
medicine, e. g. patients showing better results as less time intensive
“trial and error” treatment is needed.14 Additionally,
personalised medicine is able to target only the harmful cells, therefore
reducing side effects and increasing treatment efficacy.15 It
may be difficult to change the entire underwriting process based on the newest
developments of precision medicine. First, personalised medicine is currently
more expensive as compared to traditional treatments, and second, in some
countries this kind of treatment is not readily accessible.
“Personalised medicine is not
just a hype”
On one hand, in the
future it might not be possible to avoid accepting simple blood tests from
clients that show negative results for different cancer types; on the other
hand, it is important to prevent misuse/anti-selection because of fast and
sometimes very sensitive results. One thing is certain though: We need to take
these new advancements into account when introducing changes to underwriting
processes.
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