UNDERWRITING COLON CANCER EILEEN STEDEM LIFE UNDERWRITING SPECIALIST LIFEMARK ACCOUNT PRUDENTIAL For the education of producers/brokers. Not for use with the public. The Prudential Insurance Company of America, Newark, NJ NR-12D35701 Ed. 3/12 Exp. 9/6/2013 1

GENERAL CONCEPTS AND TERMS Cancer is a general term used to describe any of the multiple types of malignant tumors. Cancer can affect any organ or tissue in the body. Cancer is characterized by inappropriate cell growth. For the education of producers/brokers. Not for use with the public. 2

RELATED GI CONCERNS Ulcerative colitis (UC) - recurrent inflammation of the colorectum Crohn’s disease (Regional Enteritis) - chronic inflammatory process which may be found in any area of GI tract from lips to anus Familial Adenomatous Polyposis (FAP)and Gardner’s Syndrome - characterized by hundreds to thousands of polyps in the colon Colon Polyp - tumor of the inner lining of the colon. Adverse underwriting action is usually due to pre- malignant potential For the education of producers/brokers. Not for use with the public. 3

BENIGN COLON POLYPS Hyperplastic and other non-neoplastic polyps (e.g., hamartomas, juvenile, inflammatory lymphoid aggregates) have little to no risk of progression to cancer. Adenomatous polyps (characterized histologically as tubular, tubulovillous and villous) can progress to cancer.  Tubular polyps are likely to be small and benign.  Villous polyps are more likely to be large and contain cancer. After one polyp is removed, there is an increased risk of developing another polyp. For the education of producers/brokers. Not for use with the public. 4

BENIGN COLON POLYPS GUIDELINES Colon polyp present, under 1 cm in size, well followed No rating Colon polyp present, over 1 cm in sizeDecline Colon polyp removed, benign with good follow-up No rating with unknown follow-up, no villous elementsNo rating with unknown follow-up of dysplastic or villous polyp Table B For the education of producers/brokers. Not for use with the public. 5

COLORECTAL CANCER ITEMS OF INTEREST Colorectal cancer is the third most common cancer in men and women and the second leading cause of cancer death in the United States. Most colorectal cancer arises slowly from an adenomatous polyp over 7 to 15 years. Incidence and mortality rates have been decreasing due to screening for and subsequent removal of polyps via colonoscopy. For the education of producers/brokers. Not for use with the public. 6

RISK FACTORS Risk factors for developing colorectal cancer include: family history of cancer or polyps inherited conditions (such as familial adenomatous polyposis and hereditary nonpolyposis) diet and or age inflammatory bowel disease (such as ulcerative colilitis or Crohn’s disease) personal history of colorectal polyps For the education of producers/brokers. Not for use with the public. 7

FACTORS IMPORTANT IN ASSESSING THE RISK FOR COLON CANCER: Type (i.e. adenocarcinoma, mucinous, signet ring cell) Grade Stage Time since treatment has ended Any recurrences or relapses Surveillance For the education of producers/brokers. Not for use with the public. 8

COLORECTAL CANCER: ANATOMY The wall of the colon consists of four layers: mucosa (adjacent to the lumen) Submucosa muscularis propria subserosa (outermost, farthest from the lumen) For the education of producers/brokers. Not for use with the public. 9

COLORECTAL CANCER: ANATOMY The wall of the colon consists of four layers: mucosa (adjacent to the lumen) Submucosa muscularis propria subserosa (outermost, farthest from the lumen) For the education of producers/brokers. Not for use with the public. 10

STAGING CANCER Stage represents the extent of tumor within the body. A commonly used classification for stage is the TNM system. T indicates local tumor size and its characteristics N indicates the spread of the tumor to the nearby lymph nodes M indicates spread to distant parts of the body via metastasis For the education of producers/brokers. Not for use with the public. 11

STAGING OF COLORECTAL CANCER TNM is preferred to the older Duke’s system. Both are provided below for reference. StageTNMDuke’sDescription 0Tis, N0, M0 In-situ, tumor confined to mucosa IT1, N0, M0 ATumor through the mucosa into submucosa IT2, N0, M0 ATumor through submucosa in muscularis propria IIAT3, N0, M0 B1Tumor through muscularis propria and into subserosa but not into neighboring tissues IIBT4, N0, M0 B2Tumor into nearby tissues or organs, but nodes remain negative IIIAT1, N1, M0 T2, N1, M0 C1T1 or T2 plus 1-3 nodes positive IIIBT3, N1, M0 T4, N1, M0 C2T3 or T4 plus 1-3 nodes positive IVM1DSpread to distant sites such as liver, lung, peritoneum, ovary, etc. For the education of producers/brokers. Not for use with the public. 12

DETERMINING THE RATING Step 1: Refer to Rx for Success for colorectal cancer rating based upon staging and age at diagnosis. Stage Rating Age < 65 at diagnosis Rating Age > 65 at diagnosis Carcinoma in situ, TisNo rating Stage I and Stage IIATumor table CTumor table D Stage IIBTumor table BTumor table C Stage III - Best case only with ≤2 positive lymph nodes and normal CEA 0-5 years 6th year 7th year 8th year 9th year 10th year thereafter Decline Table B + $10x5 Table B + $10x4 Table B + $10x3 Table B + $10x2 Table B + $10x1 Table B 0-2 years 3rd year 4th year 5th year 6th year 7th year thereafter Decline Table B + $10x5 Table B + $10x4 Table B + $10x3 Table B + $10x2 Table B + $10x1 Table B Stage III (>2 lymph nodes positive) and Stage IV Decline For the education of producers/brokers. Not for use with the public. 13

DETERMINING THE RATING Step 2: Enter the Malignant Tumor Rating Schedule (found on Rx for Success Colorectal Cancer). Rating schedule applies only to those individuals who have had cancer which was presumably cured and who are no longer under treatment. Dating for entry into the tumor schedule starts with the date that treatment was completed, including any chemotherapy or radiation therapy. ABCD Within 1st yearDecline $5x3 2nd yearDecline $7.50x5$5x2 3rd yearDecline$10x6$7.50x4$5x1 4th year$15x6$10x5$7.50x30 5th year$15x5$10x4$7.50x20 6th year$15x4$10x3$7.50x10 7th year$15x3$10x200 8th year$15x2$10x100 9th year$15x1000 For the education of producers/brokers. Not for use with the public. 14

DETERMINING THE RATING Step 3: Confirm: appropriate surveillance is being performed liver function tests are normal CEA is normal and stable no recurrence no recommended tests pending For the education of producers/brokers. Not for use with the public. 15

CASE CLINIC # 1 70 Male Smoker Diagnosed with adenocarcinoma Stage I age 66 Tentative offer: Standard Smoker For the education of producers/brokers. Not for use with the public. 16

CASE CLINIC # 2 71 Male Diagnosed with Stage I adenocarcinoma 10/2007 with treatment ending 2/1/2008. Serial CEA readings since diagnosis with most recent CEA increased from last year’s CEA but still below CEA at time of diagnosis and within normal range. If CEA increase deemed significant, cannot consider. For the education of producers/brokers. Not for use with the public. 17

CASE CLINIC # 3 69 Female Non-smoker Diagnosed with Stage IIA adenocarcinoma 8/2009 with treatment ending 1/2010 Tentative offer: Standard Non-smoker with $5 extra for 1 year. For the education of producers/brokers. Not for use with the public. 18

CASE CLINIC # 4 60 Female Non-Smoker Diagnosed with carcinoma in situ with treatment completed 6 months prior to app Tentative offer: Non-smoker Plus For the education of producers/brokers. Not for use with the public. 19

RESOURCES For Quick Quotes, send an to To reach the RU of the Day, please call PRU ( ), prompt 1 and ask Account Representative for RU of the Day 20 For the education of producers/brokers. Not for use with the public.

IMPORTANT INFORMATION Insurance issued by the Prudential Insurance Company of America, Newark, NJ. Underwriting rules are subject to change at our discretion. For the education of producers/brokers. Not for use with the public. 21