Family history of breast cancer and cost of life assurance: a test case comparison of current UK industry practice
1 London IDEAS Genetics Knowledge Park, Institute of Child Health, London WC1N 1EH,2 Centre for Cardiovascular Genetics, BHF Laboratories, London WC1E 6JF
Introduction
Under the current recently extended moratorium, applicants for life assurance need not disclose the results of predictive genetic tests.1 The exception is for policies exceeding certain values, when insurers may seek results of tests approved by the government's Genetics and Insurance Committee. The committee expects to receive applications for the use of adverse results from tests for the BRCA1 and BRCA2 genes. Currently, insurers may, and often do, seek family histories. Substantial epidemiological data describe the relative risks of developing breast cancer depending on family history and age.2 Preventive action for women at risk can include early enrolment on surveillance programmes and prophylactic surgery. Evidence is emerging for the benefits of the former,3 and evidence is strong for risk reduction by the latter.4 5
, 百拇医药
Participants, methods, and results
We surveyed 21 companies representing 100% of the reinsurance market and 68% of the life and pensions market in the United Kingdom. We asked the companies to assess a fictional proposal for a 20 year policy (paying benefit only on death) by applying an excess mortality rating, defined as the percentage increase over the assumed rate of mortality. The applicant (scenario 1) was a 35 year old woman with unremarkable personal and family histories, except for breast cancer in the mother diagnosed at age 35. In line with standard insurance application forms, only first degree family history was given. In scenario 2, the same applicant had enrolled on a mammographic surveillance programme with no adverse results reported. In scenario 3, the same applicant had undergone prophylactic double mastectomy and oophorectomy (figure).
, 百拇医药
Percentage excess mortality ratings applied by life insurance and reinsurance companies in 2004-5. All companies gave one rating for the full product term, except for one that did not specify the rating or duration and is not shown
Sixteen companies responded. The responding and non-responding groups included a similar variety of company profiles (for example, global operations and size). Nine would not increase premiums under any of the scenarios. Six would increase premiums under scenario 1 (rating +50% or +75%), and of these, four would not load under scenario 3, and two would not load under either scenario 2 or 3. One small UK company would not raise premiums under scenario 1 or 2, but would apply an unspecified increase under scenario 3.
, 百拇医药
Comment
Most life insurance companies that responded to the survey would offer a standard premium in scenario 1 (unremarkable except breast cancer in the mother diagnosed at age 35). The lifetime relative risk of developing breast cancer for the applicant in scenario 1 is 5.7 (2.7 to 11.8).2 Using life tables developed at the Cambridge Genetics Knowledge Park (A Butterworth, personal communication, 2005) this translates into a 20 year breast cancer mortality risk (from age 35) of 1.95%, compared with 0.6% for the general population—that is, three times higher.
, 百拇医药
It is reassuring that not only did all companies that rated under scenario 1 remove the rating after prophylactic surgery, but that two companies also gave credit for enrolment on a mammographic surveillance programme. Another company reported that this will be part of a review of policy, and in future it may also credit mammographic surveillance. The variation in the industry's responses show that women with a family history who are offered a high rating by one company may receive a lower rating if they approach a second company.
, http://www.100md.com
No respondent said that they would request further family history to see if second degree relatives were affected. Disclosure of more cases of cancer in second degree relatives could considerably increase the assessed risk. The artificial nature of the survey might have implied, however, that no further family history existed to be disclosed, so we cannot comment on whether second degree relative information would be requested in reality. How access to adverse test results for BRCA1 or BRCA2 would influence the response to a similar survey in the future remains to be seen.
, http://www.100md.com
What is already known on this topic
Insurers currently do not use adverse predictive test results for BRCA1 and BRCA2 genes, but this could change and could affect an increasing number of women because of the National Institute for Health and Clinical Excellence's 2004 guidelines recommending genetic testing for certain women at high risk
Applicants must disclose family history to inform risk assessment, but they can also disclose other relevant medical information, such as preventive surveillance or surgery that they may have taken
, 百拇医药
What this study adds
Reassuringly, the UK insurance industry currently makes an appropriate assessment of women with a family history of breast cancer, including how preventive action affects risk
We thank the life insurance companies for participating in the study, and Adam Butterworth, Cambridge Genetics Knowledge Park, and Alan Tyler, independent insurance and health consultant, for advice and review of the manuscript.
, http://www.100md.com
Contributors: AH designed the study with advice from SEH, and did the survey. AH wrote the paper. Both authors critically revised the paper. SEH is guarantor.
Funding: London IDEAS Genetics Knowledge Park grant, funded by the Departments of Health, and Trade and Industry.
Competing interests: None declared.
Ethics approval: Not needed.
References
, http://www.100md.com
Department of Health, Association of British Insurers. Concordat and moratorium on genetics and insurance. London: Department of Health, 2005.
Collaborative Group on Hormonal Factors in Breast Cancer. Familial breast cancer: collaborative reanalysis of individual data from 52 epidemiological studies including 58,209 women with breast cancer and 101,986 women without the disease. Lancet 2001;358:: 1389-99.
Tabar L, Yen MF, Vitak B, Chen HH, Smith RA, Duffy SW. Mammography service screening and mortality in breast cancer patients: 20-year follow up before and after introduction of screening. Lancet 2003;361: 1405-10.
, 百拇医药
National Institute for Clinical Excellence. Clinical guidelines for the classification and care of women at risk of familial breast cancer. London: NICE, 2004.
Rebbeck TR, Friebel T, Lynch HT, Neuhausen SL, van't Veer L, Garber JE, et al. Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and BRCA2 mutation carriers: the PROSE study group. J Clin Onc 2004;22: 1055-62., 百拇医药(A Hunter, S E Humphries)
Introduction
Under the current recently extended moratorium, applicants for life assurance need not disclose the results of predictive genetic tests.1 The exception is for policies exceeding certain values, when insurers may seek results of tests approved by the government's Genetics and Insurance Committee. The committee expects to receive applications for the use of adverse results from tests for the BRCA1 and BRCA2 genes. Currently, insurers may, and often do, seek family histories. Substantial epidemiological data describe the relative risks of developing breast cancer depending on family history and age.2 Preventive action for women at risk can include early enrolment on surveillance programmes and prophylactic surgery. Evidence is emerging for the benefits of the former,3 and evidence is strong for risk reduction by the latter.4 5
, 百拇医药
Participants, methods, and results
We surveyed 21 companies representing 100% of the reinsurance market and 68% of the life and pensions market in the United Kingdom. We asked the companies to assess a fictional proposal for a 20 year policy (paying benefit only on death) by applying an excess mortality rating, defined as the percentage increase over the assumed rate of mortality. The applicant (scenario 1) was a 35 year old woman with unremarkable personal and family histories, except for breast cancer in the mother diagnosed at age 35. In line with standard insurance application forms, only first degree family history was given. In scenario 2, the same applicant had enrolled on a mammographic surveillance programme with no adverse results reported. In scenario 3, the same applicant had undergone prophylactic double mastectomy and oophorectomy (figure).
, 百拇医药
Percentage excess mortality ratings applied by life insurance and reinsurance companies in 2004-5. All companies gave one rating for the full product term, except for one that did not specify the rating or duration and is not shown
Sixteen companies responded. The responding and non-responding groups included a similar variety of company profiles (for example, global operations and size). Nine would not increase premiums under any of the scenarios. Six would increase premiums under scenario 1 (rating +50% or +75%), and of these, four would not load under scenario 3, and two would not load under either scenario 2 or 3. One small UK company would not raise premiums under scenario 1 or 2, but would apply an unspecified increase under scenario 3.
, 百拇医药
Comment
Most life insurance companies that responded to the survey would offer a standard premium in scenario 1 (unremarkable except breast cancer in the mother diagnosed at age 35). The lifetime relative risk of developing breast cancer for the applicant in scenario 1 is 5.7 (2.7 to 11.8).2 Using life tables developed at the Cambridge Genetics Knowledge Park (A Butterworth, personal communication, 2005) this translates into a 20 year breast cancer mortality risk (from age 35) of 1.95%, compared with 0.6% for the general population—that is, three times higher.
, 百拇医药
It is reassuring that not only did all companies that rated under scenario 1 remove the rating after prophylactic surgery, but that two companies also gave credit for enrolment on a mammographic surveillance programme. Another company reported that this will be part of a review of policy, and in future it may also credit mammographic surveillance. The variation in the industry's responses show that women with a family history who are offered a high rating by one company may receive a lower rating if they approach a second company.
, http://www.100md.com
No respondent said that they would request further family history to see if second degree relatives were affected. Disclosure of more cases of cancer in second degree relatives could considerably increase the assessed risk. The artificial nature of the survey might have implied, however, that no further family history existed to be disclosed, so we cannot comment on whether second degree relative information would be requested in reality. How access to adverse test results for BRCA1 or BRCA2 would influence the response to a similar survey in the future remains to be seen.
, http://www.100md.com
What is already known on this topic
Insurers currently do not use adverse predictive test results for BRCA1 and BRCA2 genes, but this could change and could affect an increasing number of women because of the National Institute for Health and Clinical Excellence's 2004 guidelines recommending genetic testing for certain women at high risk
Applicants must disclose family history to inform risk assessment, but they can also disclose other relevant medical information, such as preventive surveillance or surgery that they may have taken
, 百拇医药
What this study adds
Reassuringly, the UK insurance industry currently makes an appropriate assessment of women with a family history of breast cancer, including how preventive action affects risk
We thank the life insurance companies for participating in the study, and Adam Butterworth, Cambridge Genetics Knowledge Park, and Alan Tyler, independent insurance and health consultant, for advice and review of the manuscript.
, http://www.100md.com
Contributors: AH designed the study with advice from SEH, and did the survey. AH wrote the paper. Both authors critically revised the paper. SEH is guarantor.
Funding: London IDEAS Genetics Knowledge Park grant, funded by the Departments of Health, and Trade and Industry.
Competing interests: None declared.
Ethics approval: Not needed.
References
, http://www.100md.com
Department of Health, Association of British Insurers. Concordat and moratorium on genetics and insurance. London: Department of Health, 2005.
Collaborative Group on Hormonal Factors in Breast Cancer. Familial breast cancer: collaborative reanalysis of individual data from 52 epidemiological studies including 58,209 women with breast cancer and 101,986 women without the disease. Lancet 2001;358:: 1389-99.
Tabar L, Yen MF, Vitak B, Chen HH, Smith RA, Duffy SW. Mammography service screening and mortality in breast cancer patients: 20-year follow up before and after introduction of screening. Lancet 2003;361: 1405-10.
, 百拇医药
National Institute for Clinical Excellence. Clinical guidelines for the classification and care of women at risk of familial breast cancer. London: NICE, 2004.
Rebbeck TR, Friebel T, Lynch HT, Neuhausen SL, van't Veer L, Garber JE, et al. Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and BRCA2 mutation carriers: the PROSE study group. J Clin Onc 2004;22: 1055-62., 百拇医药(A Hunter, S E Humphries)