Disease of the month: Colorectal cancer screening

Colorectal cancer is the third most common cancer worldwide and the second highest cause of death from cancer in the UK, yet if diagnosed early it is treatable. Anne Llewellyn explains the insurance ramifications

An article has just been published in The Lancet medical journal which showed that a certain type of screening between the ages of 55 and 64 can substantially reduce colorectal cancer incidence and mortality, and this is likely to be added to the existing UK colorectal cancer screening programme. April 2010 was also bowel cancer awareness month. Could this mean a rise in the detection of colorectal cancer, and what could this mean for underwriting and claims?

The bowel is divided into two distinct parts which have a different structure and function; the small bowel (small intestine) and the large bowel (colon and rectum). Cancer of the small bowel is rare with only just over 700 people diagnosed in the UK each year. Nearly all bowel cancers develop in the large bowel – two-thirds of these are in the colon and one-third in the rectum. Cancer in the large bowel is also referred to as colorectal or colon cancer. Every year more than 37,500 men and women are diagnosed with bowel cancer in the UK, and more than 16,000 people die.

Cancers are grouped according to how far they have spread, known as the stage. Colorectal cancer is usually staged according to the Dukes system.

• Dukes A – the cancer is only affecting the innermost lining of the colon or rectum or is slightly growing into the muscle layer but not through it
• Dukes B – the cancer has grown through the muscle layer.
• Dukes C – the cancer has spread to at least one lymph node in the area.
• Dukes D - the cancer has spread to other organs in the body.

The survival rate for those with a Dukes A tumour is 90%, but only 9% of people with colorectal cancer are diagnosed at this early stage. This is because at first colorectal cancer is usually painless, and symptoms such as blood in the faeces, changes to bowel habit (going to the toilet more frequently), unexplained weight loss and persistent tiredness are often put down to other causes. By the time the patient consults their GP the disease has usually progressed to a more advanced stage, which is much more difficult to treat and has a much lower survival rate.

Bowel cancer screening was started in the UK in 2006 in an attempt to detect the disease at the crucial earlier stages. 97% of all diagnoses are in people over the age of 50. In England, Wales and Northern Ireland everyone aged berween 60 and 69 is screened every two years; in Scotland the screening is carried out from the age of 50 to 74. Above these ages screening is carried out on request.

A testing kit is sent in the post so it can be carried out in the privacy of the patient’s home. A small sample of faeces is smeared onto the kit which is then posted for testing.

The test is known as the Faecal Occult Blood or FOB test, and is checking for hidden blood in the faeces, an early sign of bowel cancer which would not normally be noticed. About 2% of FOB tests are positive although a positive result is not always caused by cancer.

In England, for every 1,000 people who have the FOB test, around 20 will have an abnormal result and may be asked to do the test again. Around 16 of those people will have a colonoscopy where the colon is inspected by a camera to ascertain the cause of the bleeding. Of those 16 about eight people will have nothing abnormal detected at colonoscopy, around six will have polyps and two will have cancer. Through screening and detecting these cancers early, there has been a 16% overall reduction in bowel cancer deaths.

A large UK clinical trial has looked into another way of screening healthy people for bowel cancer. The trial followed more than 170,000 people over 11 years to see who developed bowel cancer. More than 40,000 of those people had a test called flexible sigmoidoscopy between the ages of 55 to 64. It is easier to carry out than a colonoscopy, and involves having a thin, bendy tube put into the rectum and lower bowel to look at the inside wall of the bowel. Bowel cancers usually develop very slowly from polyps called adenomas, which are easily found, and the doctor (or specialist nurse) may remove any polyps that they find.

The results of the study were reported in April 2010 in The Lancet. The researchers found the people who had screening with flexible sigmoidoscopy reduced their risk of developing bowel cancer by a third because any polyps were removed at an early stage – this could mean 3,000 lives a year would be saved. Currently The UK government and the UK cancer screening programme are looking at the possibility of adding the sigmoidoscopy test to the UK bowel screening programme.

Some people are at higher risk of bowel cancer and may also be offered regular screening at an earlier age. This is highly relevant to underwriting and you may find you have had clients who have been offered substandard terms due to one of these increased risks.

Family history

There are two inherited bowel conditions which have a strong link with bowel cancer. Familial Adenomatous Polyposis (FAP) is a rare condition which causes hundreds of polyps to grow in the bowel. It is so strongly linked with cancer that people who inherit the condition are recommended to have their bowel removed (colectomy) by the age of 25. Screening for this condition begins at an early age.

Hereditary non-polyposis colorectal cancer (HNPCC) is another inherited condition which makes bowel cancer more likely. Screening usually starts at the age of 25.

Finally, screening may be carried out if there is a strong family history of bowel cancer which is not known to be FAP or HNPCC. A strong family history is where there is bowel cancer in one first degree relative (parent, sibling or child) before the age of 45, or in two first degree relatives at any age. A colonoscopy is likely to be carried out at the age of 35-45, and if this is negative further screening will not take place until the age of 55. This is because polyps take a long time to develop so it is not necessary to carry out colonoscopies frequently.

Inflammatory bowel Disease

Ulcerative colitis and Crohn’s disease are chronic diseases of the bowel which cause inflammation and ulceration, and which are linked to an increased risk of colorectal cancer. Depending on the extent of the condition and how long it has been present, regular colonoscopies are recommended every one to three years.

Polyps

Virtually all colon cancers arise from adenomatous polyps in the bowel. Not all polyps become cancerous, but the chance of cancer developing in the future increases with the number, size and type of polyp found. If someone has had a polyp removed they will undergo regular screening, and the frequency of screening depends on the type of polyp first found. If no further polyps are found over a period of years, the screening may be stopped.

Underwriting Considerations

If an applicant is being screened under the UK colorectal cancer screening programme because of their age, no investigation or rating is necessary. Just as with regular cervical cancer and breast cancer screening, we just need to know that the screening was negative.

If the client is being screened because they are at an increased risk of developing colorectal cancer, then the rating will depend on the level of risk. A family history of colorectal cancer will also usually result in a loading even if they do not fulfil the criteria for a ‘strong’ family history at the time of application, because it will be too soon to tell whether this was a sporadic case or whether there is a familial element.

The most likely outcome for critical illness is a bowel cancer exclusion.

Clients can be distressed by these decisions because they will have been told that their polyps were benign, or because they have a clear medical history themselves but a positive family history – however, the fact that they are undergoing screening, or should be, indicates that they are at risk and this predisposition cannot be ignored for protection products.

If screening in the UK does increase we will have fewer death claims, and if polyps are discovered before they become malignant, we will have fewer critical illness cancer claims too.

If a malignant tumour is discovered on screening this may lead to a slightly earlier critical illness claim, but will not increase the incidence. A good outcome not only for patients, but also for the protection industry too.

Anne Llewellyn is underwriting development manager at PruProtect