– Hereditary Cancer Syndrome

By now you’ve probably heard the exciting news that some companies will no longer consider family cancer histories as an adverse underwriting factor that would prevent applicants from consideration for preferred classes unless there are features of the family history that suggest a hereditary cancer syndrome may be present.

While all cancers are believed to have a genetic component, in only a small percentage of cases is a hereditary cancer syndrome likely to be present. Some clues suggesting such a syndrome include the development of cancer at ages under 50, multiple family members with a cancer history and/or multiple cancers in the same family member (grandparents, parents, aunts, uncles, siblings, half-siblings and children).

Some well known hereditary cancer syndromes include:

Familial Adenomatous Polyposis (FAP) is autosomal dominant and associated with multiple colon polyps (possibly hundreds to thousands), colorectal cancer, and other tumors.

BRCA1 and BRCA2 are both autosomal dominant, meaning you only need to get the gene from one parent in order for you to inherit the disease. Affected families have an increased risk of breast, ovarian, prostate, pancreatic, and other types of cancer. Prophylactic removal of the breasts and ovaries has been found to decrease the cancer risk in afflicted females.

Lynch Syndrome, also known as Hereditary Non-Polyposis Colorectal Cancer (HNPCC) is autosomal dominant and associated with an increased risk of colorectal, endometrial, urinary tract, other gastrointestinal, and other types of cancer

UNDERWRITING HEREDITARY CANCER SYNDROME: IF THE APPLICANT IS UNDER AGE 70 AND THE REPORTED FAMILY HISTORY IS SUSPICIOUS FOR A HEREDITARY CANCER SYNDROME THE UNDERWRITER MAY ORDER AN APS TO OBTAIN MORE INFORMATION.

What makes up a family? Our definitions are:

Relatives = grandparents, parents, aunts, uncles, siblings, half-siblings and children.

Relatives from the same side of the family = grandparents, parents, aunts, uncles (all on mother’s side or all on father’s side), siblings, halfsiblings and children.

First-degree relatives = parents, siblings, half-siblings and children.

First-degree male relatives = father, brother and son.

Initial Screening

When initial screening suggests the possible existence of a hereditary cancer syndrome, a multistep underwriting process is undertaken.

Suspicious family history criteria that initiate this process may include:

• Three or more first-degree relatives with a cancer history, excluding non-melanoma skin cancer and cervical cancer.

• Two or more relatives from the same side of the family with a cancer history with at least one occurring before age 50, excluding nonmelanoma skin cancer and cervical cancer.

• A first-degree male relative with breast cancer.

• Two or more cancers in the same first-degree relative, excluding nonmelanoma skin cancer and cervical cancer. • Three or more relatives from the same side of the family with cancer.

• Two or more relatives with the same type of cancer.

• A suspected or diagnosed hereditary cancer syndrome in an applicant under age 70, or in any relative.

• An applicant under age 70 advised to have genetic testing for a hereditary cancer syndrome.

If at least one of the above criteria is present, medical records will be obtained in order to better assess the risk.

Once all of the information has been obtained, the risk will be referred to the medical director for review, with an underwriting decision rendered based upon the family history details developed.

A responsible underwriting decision:

Even though the prevalence of hereditary cancer syndromes is very low in the general population, the mortality risk among these relatively few people is very high. We cannot offer insurance to individuals with a documented history of a hereditary cancer syndrome or a history that is very worrisome for a hereditary cancer syndrome without limiting class or rating. In some cases we may even need to decline these risks.

Primary factors taken into consideration include:

• The age of the applicant

• The types of cancers and age of onset in the family members

• Whether the family history appears consistent with a known hereditary cancer syndrome

• Whether any genetic testing has been recommended; the results of any genetic testing that has been performed

• Whether any cancer screening has been performed and the results of such testing

• Whether any other prophylactic measures have been taken to reduce future cancer risk

Each case is unique and underwritten on an individualized basis. The client can facilitate by providing full and complete details of his or her family history of cancer, at the time of the application- eliminating the need for any further questioning.

Case Studies

Applicant 1 is a 35 year old female. Her mother died at age 40 from ovarian cancer and her sister was diagnosed with breast cancer at age 32. Review of the medical records revealed she had no other impairments. This family history is suggestive of a hereditary breastovarian cancer syndrome, therefore this case would be rated.

Applicant 2 is a 45 year old male nonsmoker whose father was a smoker who died at age 47 from lung cancer and whose mother had lymphoma and is alive at age 72. This family history is not suggestive of a hereditary cancer syndrome and this case would be Preferred Plus.

Applicant 3 is a 55 year old female whose father and sister both had Lynch Syndrome and died from colorectal cancer in their 40s. The applicant has had three negative screening colonoscopies, most recently one year prior to application. Although she is still at risk for a hereditary colon cancer syndrome, because of her recent normal colonoscopy, this case would be Standard. Applicant 4 is 40 year old male whose mother was diagnosed with breast cancer at age 70, father was diagnosed with prostate cancer at age 65, and sister had childhood leukemia. This history is not suggestive of a hereditary cancer syndrome and this case would be Preferred Plus.

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