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Tumor Markers: Issues from an Insurance Perspective

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Tumor Markers: Issues from an Insurance Perspective VOLUME 25, NO. 2 SUMMER ~993 TUMO~ MA~KERS TUMOR MARKERS: ISSUES FROM AN INSURANCE PERSPECTIVE Robert J. Pokorski, MD, FACP Trends in Cancer Mortality later in pancreatic cancer. Human chorionic gonadot- ropin (I-ICG) and serum acid phosphatase were identi- Two important trends in cancer mortality are being fied in the 1930s, followed by the discovery of alkaline reported world-wide. First, changing mortality due to phosphatase, vanillylmandelic acid (VMA), and lactic certain cancers is being observed. In a study of trends dehydrogenase CLDH). But it was not until the isolation in 15 industrialized cotmtries,~ increases in cancer mor-of carcinoembryonic antigen (CEA) in 1965 that tumor tality were reported for lung, breast and prostate can- marker measurements became an important part of cers in most age groups, while a substantial decline in oncology and laboratory medicine.7 stomach cancer mortality was noted. Intestinal cancer mortality varied by age and region of the world. Such Tumor markers may be bound to tissues or circulate patterns should always be interpreted in the context of freely in body fluids. Those that are tissue bound, such other changes that may have been taking place during as estrogen and progesterone receptors in breast cancer, the time of the study. For example, significant improve- can only be obtained via biopsy Circulating tumor ments in the accessibility and quality of health care may markers are found in body fluids such as blood or urine. have occurred over the years, or changes in cancer These are the markers that are commonly used in clini- mortality may be due largely to better statistics2~3 or cal medicine: prostate-specific antigen, carcinoem- earlier diagnosis due to cancer screening.4 bryonic antigen, alpha-fetoprotein, etc. Only circulating tumor markers will be discussed in this review. The second trend is much more significant: proportion- ate mortality due to cancer - relative mortality caused Circulating tumor markers may be either organ-specific by malignant diseases compared to mortality from all or general. Organ-specific tumor markers are primarily other causes -- is increasing dramatically. In the last associated with certai~ types of cancer. They are catego- sixty years, the proportion of deaths due to cancer has rized as hormones, oncofetal antigens (proteins or anti- increased progressively in many developed countries, gens that are present during fetal development, occur from one in eight to one in four and, in middle-aged in low concentrations ir~ adults, and become elevated in women, to more than one in two deaths.2 This patte~’n some malignancies), enzymes, mucins and other glyco- is related to enhanced prevention of non-malignant proteins, and specific proteins. Many of these markers disease, better treatment for specific diseases other than are commonly used in clinical practice at the present cancer, and changes in demographics. The latter factor time. General tumor markers are in theory associated is particularly important. More and more people are with a wide variety of cancers. None of the general living to older ages. In the United States, for example, markers are currently used by the medical community within the next 10 or 20 years almost half of all deaths except in research protocols, because studies to date will occur after age 80 if present trends continue.3 Since have involved very few patients and have not been the causes of death at these older ages differ from those reproduced by other researchers. in younger populations, overall proportionate mortal- ity becomes more and more weighted by diseases affect- Some of the more common tumor markers are listed in ing the elderly unless age-specific data are analyzed. Table 1. Tumor Markers in Clinical Medicine Tumor markers are used in clinical medicine for cancer diagnosis and management. They may also be used for Tumor markers are substances that can be measured in screening purposes in selected high-risk populations. tissue or body fluids to identify the presence of cancer. The existence of some of these markers has been known Diagnosis for decades or, in a few instances, more than a century.5’6 The first marker discovered, the Bence-Jones prote/n, Tumor markers sometimes aid in confirmation and was identified in 1846 in patients with multiple staging of cancer. This use is limited because most cur- myeloma. Urinary amylase was described several years rent markers are not specific for only one type of cancer. Vice President, Medica/Research, Swiss Reinsurance Group. 124 JOURNAL OF INSURANCE MEDICINE VOLUME 25, No. 2 SUMMER 1993 Management This is the most significant and accepted use of tumor Most tumor markers developed to date have not been markers. Information is provided regarding prognosis, useful, cost-effective or approved for population response to treatment, and detection of residual dis- screening because the underlying likelihood of disease is too low. The few instances of successful screening programs have involved populations at very high risk 1. Prognosis before treatment. Example- Pre-operative of cancer. In China, for example, individuals with CEA levels correlate with survival rates in colorectal chronic viral hepatitis are screened for hepatocellular cancer. carcinoma with serum alpha-fetoprotein levels. The ef- fectiveness of this program has been documented by a 2. Likely response to treatment. Example: HCG levels decrease in tumor size and an increase in resectability in testicular cancer predict the success or failure of a and survival over the past 20 years.8 drug regimen. 3. Detection of residual disease. Example- In ovarian Tumor Markers in Insurance cancer, residual disease is likely if CA 125 levels re- main elevated after treatment. The increasing proportion of mortality due to cancer in the general population has attracted the attention of Table 1 insurers. There is interest in knowing if cancer is becom- Categories of Circulating Tumor Markers ing a more common cause of mortality among insured lives, if this trend is likely to continue, which ages are at Category Cancer(s) Detected particular risk, and what steps can be taken to limit exposure. It is this last point that causes the greatest I. Organ-specific Tumor Markers uncertainty: how can insurers respond to increasing Hormones cancer mortality if medical underwriters lack the neces- Human Chorionic sary tools to detect increased risk of death from cancer? Gonadotropin (HCG) Placenta, Testis Whereas it is possible to screen for heart disease with an Calcitonin Thyroid electrocardiogram or for diabetes with a blood sugar Catecholamines Pheochromocytoma test, underwriters concerned with the possibility of can- Oncofetal Antigens cer have to rely on nonspecific findings such as weight Carcinoembryonic loss, anemia, or unexplained fatigue, findings that gen- Antigen (CEA) Colon, Breast, Lung erally occur only with advanced disease. Alpha-Fetoprotein (AFP) Liver, Testis Enzymes Increasing cancer mortality is particularly important to Prostate Prostate-Specific Antigen (PSA) companies who are insuring greater numbers of indi- Prostatic Add Phosphatase (PAP) Prostate viduals aged 55 or older, prime ages for the develop- Neuron-Specific Enolase Neuroblastoma, ment of cancer. Many of these individuals chose not to Lung purchase insurance in the preceding decades when the Mucins and Other Glycoproteins ability to obtain coverage at low rates was almost cer- CA125 Ovar~ Breast, tain. By the time they recognize the importance of in- Colon surance, the mortality rate for their age group may have CA 19-9 Pancreas, Stomach, become very high, or their health may have deterio- Liver rated. For companies interested in this market, identifi- CA 15-3 Breast, Ovar~ cation of those at greatest risk for early cancer mortality Colon may be one way to increase the affordability of coverage Specific Proteins for these individuals. Immunoglobulins Multiple Myeloma Finall~ expertise in risk selection has been a traditional II. General Tumor Markers strength of many insurers and a significant contributor Cancer Pro-Coagulant Multiple Types to profitability. Although the role of underwriting di- Tumor-Associated minished over the last ten to fifteen years in some Antigen (TAA) Multiple Types markets as premium volume and investment return Anti-Mali~in Antibody Multiple Types became more important sources of revenue, this trend is now reversing due to decreased profit margins and poorer investment results. Companies that maintained 125 VOLUME 2~, NO. 2 SUMMER 1993 TUMOR MARKERS strong underwriting departments during the last dec- cause cancer instills fear into everyone and people want ade are now positioned to take advantage of the re- to prepare themselves for the remote possibility of such newed importance of underwriting. New underwriting a diagnosis. A few applicants might even refuse the test tools that would enable a company to identify those at because they don’t want to learn about unfavorable greatest risk of cancer would have appeal because of results. their expected beneficial effect on mortality results. The extent of pre-notice may depend on the type of With this introduction, the issues associated with use of tumor marker tests developed in the future. If a marker tumor markers in an insurance context will be dis- identified early cancers that were usually curable, ap- cussed. plicants would probably receive this information with concern but relief that a cure was likel~ However, if the Underwriting Issues tumor marker primarily identified
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