According to the American Cancer Society, breast cancer is the most common cancer seen in American women, except for skin cancer, and is the second leading cause of cancer death in women after lung cancer. About one in eight women in the United States will eventually develop breast cancer.
Risk factors for breast cancer include female gender; advancing age; inherited genetic mutations (such as BRCA 1 and BRCA 2); having a family history of breast cancer; a history of certain noncancerous breast lesions, including atypical hyperplasia and lobular carcinoma
in situ; early menarche and late menopause, which may be related to increased exposure to estrogen and progesterone; use of combined postmenopausal estrogen and progesterone hormone therapy; a history of chest irradiation; having dense breast tissue; and alcohol use.
Screening mammography has been shown to reduce breast cancer mortality. Mammography is less sensitive for the diagnosis of breast cancer in women under age50, which increases the risk of missing a cancer. MRI, which might be offered to people at increased risk of breast cancer, is more sensitive and thus might detect breast cancers not identified on mammography. MRI can be associated with more false positive results, however.
Ultrasonography, which can help distinguish solid masses from cysts, may be performed to help clarify abnormalities detected on mammography.
Breast cancer is a heterogeneous disease and there are several subtypes. Infiltrating ductal carcinoma is the most common type of breast cancer seen. Ductal carcinoma in situ is a premalignant lesion that can become invasive.
Staging of breast cancer is based upon the TNM system, where T represents the tumor size, N represents regional lymph node involvement and M represents distal metastasis.
The most important prognostic factors in breast cancer are lymph node status, tumor size and grade. The more lymph nodes involved, the larger the tumor, and the more abnormal or higher the grade of the tumor cells, the worse the prognosis. Breast cancers can also be categorized into different patterns based upon the presence or absence of estrogen and progesterone receptors, which are also called hormone receptors, and whether or not there are elevated levels of a marker called HER2.
The presence of hormone receptors suggests a favorable response to hormonal therapy, but also predicts an increased risk of late recurrence more than a decade after treatment completion. Tumors with elevated HER2 levels tend to be aggressive, although specific treatments are available that have been found to improve outcomes. Tumors that contain neither hormone receptors nor elevated HER2 levels are termed “triple negative” and tend to have unfavorable outcomes and limited treatment options.
Other tests can be performed on breast tumors in order to help assess prognosis and guide treatment, including molecular testing that evaluates the cancer’s genetic material.
The treatment of breast cancer needs to be individualized based upon the specific details of the case. Treatment can be categorized as localized or systemic.
Localized treatment modalities, which include surgery and radiation therapy, only treat cancer cells included within the field of treatment. Systemic therapy, which includes chemotherapy, hormonal therapy, and biologic therapy, can treat cancer cells throughout the body, including those not detected during staging.
Surgical therapy includes breast conservation therapy, such as with lumpectomy, or mastectomy with removal of the entire breast. Lumpectomy is often followed by radiation therapy, and this treatment regimen has equivalent survival to mastectomy when the breast cancer is localized.
When surgery is performed the axillary lymph nodes are often evaluated to see if they contain cancer. This might be accomplished with a sentinel lymph node biopsy, in which the first lymph node that would likely contain cancer cells is identified and removed for examination. If the sentinel lymph node does not contain cancer then it is unlikely that other lymph nodes will. If the doctors feel that a more intensive lymph node examination is indicated, that could be accomplished with an axillary lymph node dissection.
Hormonal therapy, which opposes the action of estrogen, is often used as part of the treatment regimen when estrogen receptors are positive. Medications used for hormonal therapy include tamoxifen and the aromatase inhibitors. It is important to be cognizant of potential complications from breast cancer therapies, some of which might not become apparent until many years after the completion of treatment. For example, chemotherapy can result in cardiomyopathy and hematologic malignancies and radiation therapy can increase the risk of coronary artery disease.
When underwriting an applicant with a breast cancer history, it is important to review the pathology reports and staging information, treatments that were given, any possible adverse effects related to treatment, and follow up.
APPLICANT 1 is a 55 year old female who who underwent mastectomy three years ago for lobular carcinoma in situ. She has had regular favorable follow up. This can be Standard Plus.
APPLICANT 2 is a 65 year old female who had a high grade 2.5 cm infiltrating ductal breast cancer positive for hormone receptors and no evidence of lymph node involvement or metastatic disease. Chemotherapy was given with primary treatment completed four years ago, hormonal therapy is currently being taken, and there has been regular favorable follow up. This applicant will have a flat extra of $15 per $1000 for five years off Standard.
APPLICANT 3 is a 70 year old who had a low grade 0.5 cm infiltrating ductal breast cancer positive for hormone receptors with no evidence of lymph node involvement or metastatic disease. Treatment consisted of lumpectomy and hormonal therapy and was completed ten years ago. There has been regular follow up with no evidence of recurrence. This can be Standard Plus.