Breast cancer gene testing and prophylactic mastectomies

First, a good CI product must balance meeting the true needs of the target customer and being an attractive offering that customers can relate to and understand. Customers have many needs, and the art in CI is about distilling what is a ‘must-have’ feature as opposed to a ‘nice to have’ one and responding accordingly in product design.

 

Second, a good CI product must be innovative and relevant, as consumers and their advisers compare products prior to making a purchase.

 

Third, CI products must be affordable. There is a limit beyond which each customer will not go, so it is important that the product is not priced beyond what the targeted consumer is willing to pay or can afford to pay for CI cover, as assessed by his or her financial adviser. Of course, any good CI product must be financially viable.

The fourth and last consideration is that a good CI product must have a solid value proposition to the shareholder and be sustainable over the long term.

 

CI is about identifying those conditions or illnesses that are common enough to be relevant to the consumer, but that are also catastrophic enough to disrupt the consumer’s day-to-day life.

The condition must also be easy to underwrite, with clear means to differentiate those that can be offered CI cover. When the offer is made, there is a price attached to it that is derived from what we know about the incidence, prevalence, progression, screening, treatments, morbidity and mortality of the individual conditions as well as each insurer’s experience.

Each condition that is covered must have clear claim triggers that are well defined and in keeping with the current body of knowledge about disease presentation, diagnostics and implications for outcomes. The conditions covered must be resilient to medical advances, as the policy is issued with current medical knowledge for a claim event that will occur sometime in the future.

 

Insurance medicine usually follows clinical medicine, and in the case of cover for prophylactic mastectomies insurers seem to have made a call on this procedure before it has been vetted by clinicians both locally and internationally. There is currently no consensus among clinicians on how to respond to gene-testing results that show an increased risk of breast cancer. The National Cancer Institute suggests that prophylactic mastectomy is indicated if there is:

• A positive BRCA gene test

• Contralateral breast cancer/ previous cancer diagnosis

• Nodular breast tissue

• Personal choice based on family history

• Radiation therapy

• Fear of breast cancer

Some clinicians prefer close monitoring as opposed to active treatment with prophylactic mastectomy, particularly in the younger ages where the risk of cancer is less. There is also no consensus on the timing of the prophylactic mastectomy, as the theoretical risk exists at all ages.

 

When it comes to gene testing we can safely say that we do not know who has access and what the consequences of this access are. The decision to have a prophylactic mastectomy depends to a very large extent on discussions between the attending doctor and the woman with the risk of breast cancer.

 

Nobody knows which patients will actually manifest the breast cancer and which patients will not. Gene testing estimates the risk but is not actually diagnostic of breast cancer itself. BRCA1 and BRCA2 chromosome abnormalities also indicate increased risk of breast cancer, ovarian cancer and pancreatic cancer. Why recognize breast cancer only? What about the other cancers? Where does one draw the line?