1. UNDERWRITING CORRELATION FOR CANCER CASES

2. Are we going to accept a proposed insured with known cancer?

3. IT DEPENDS

4. Accurate risk assessment requires Correlation with Family History Correlation with Family History Present Occupation Present Occupation Lifestyle : diet, smoker, drinker, hobbies Lifestyle : diet, smoker, drinker, hobbies A working knowledge of the anatomy A working knowledge of the anatomy An understanding of nomenclature used in pathology reports (staging, size of tumor, lymph nodes, mets) An understanding of nomenclature used in pathology reports (staging, size of tumor, lymph nodes, mets) Attending physicians statements (since when, Dx, course of CA, treatment, other therapies, present status) Attending physicians statements (since when, Dx, course of CA, treatment, other therapies, present status) General familiarity with current medical treatment (surgically removed, chemo, radio, ablation, etc.) General familiarity with current medical treatment (surgically removed, chemo, radio, ablation, etc.) Co-morbidities Co-morbidities

5. For underwriting work up, the following requirements are suggested: Application FormApplication Form Financial Advisers ReportFinancial Advisers Report Full medical examination (FME)Full medical examination (FME) Attending Physician StatementsAttending Physician Statements Histopathology (biopsy) ReportHistopathology (biopsy) Report Tumor MarkersTumor Markers

6. Differentiation of the characteristics of tumors BENIGNMALIGNANT Growth pattern Expansion Invasion (infiltration) Tendency to recur Usually slight Common Metastasis Extremely rare Common Growth rate Slow Usually rapid DifferentiationNormal Near normal to anaplastic Mitosis Few or rare Many Effect on host Usually insignificant Often fatal

7. TNM Classification Tis – pre-invasive carcinoma (CIS – carcinoma in situ) Tis – pre-invasive carcinoma (CIS – carcinoma in situ) T0 – no evidence of a primary tumor T0 – no evidence of a primary tumor T1 – small tumor confined to the organ of origin T1 – small tumor confined to the organ of origin T2 – relatively large but restricted to the organ of origin T2 – relatively large but restricted to the organ of origin T3 – some invasion of adjacent tissue T3 – some invasion of adjacent tissue T4 – massive invasion of adjacent tissue &/or organs T4 – massive invasion of adjacent tissue &/or organs TX – unable to assess primary tumor TX – unable to assess primary tumor

8. TNM Classification N0 – no regional lymph node (LN) involvement N0 – no regional lymph node (LN) involvement N1 – evidence of involvement of movable regional LN N1 – evidence of involvement of movable regional LN N2 – evidence of involvement of fixed regional LN N2 – evidence of involvement of fixed regional LN N3 – massive LN involvement N3 – massive LN involvement N4 – involvement of juxta-regional LN N4 – involvement of juxta-regional LN N0 – unable to assess regl &/or juxta-regl LN N0 – unable to assess regl &/or juxta-regl LN. M0 - no evidence of distant metastasis. M1 - distant metastasis present. MX - unable to assess distant mets

9. Staging System* Stage 0 – Carcinoma in situ: no associated invasive (infiltrating) carcinoma Stage 0 – Carcinoma in situ: no associated invasive (infiltrating) carcinoma Stage I - T1-2N0M0 Stage I - T1-2N0M0 Stage II - T1-2N1M0 Stage II - T1-2N1M0 Stage III - T1-2N2-3M0 Stage III - T1-2N2-3M0 T3-4N0-3M0 T3-4N0-3M0 Stage IV - Any TAny NM1 Stage IV - Any TAny NM1 * differences are found in different organs

10. Histopathology Report provides an indication of the type and staging/grading of the tumor provides an indication of the type and staging/grading of the tumor read carefully and correlate with the APS read carefully and correlate with the APS

13. Grade Refers to the degree of differentiation of malignant tumor : Grade 1 – Well differentiated, low grade carcinoma Grade 1 – Well differentiated, low grade carcinoma Grade 2 – Moderately undifferentiated, intermediate grade carcinoma Grade 2 – Moderately undifferentiated, intermediate grade carcinoma Grade 3-4 – Poorly differentiated ( markedly undiffertd, anaplastic), high grade carcinoma Grade 3-4 – Poorly differentiated ( markedly undiffertd, anaplastic), high grade carcinoma

14. Tumor Markers Are by-products of tumor growth; may be hormones, enzymes, other proteins Carcinoembryonic antigen (CEA ) for GI tract (colon), pancreas, lung, breast Carcinoembryonic antigen (CEA ) for GI tract (colon), pancreas, lung, breast Human chorionic gonadotropin (HCG) for uterine choriocarcinoma, ovarian/testicular Human chorionic gonadotropin (HCG) for uterine choriocarcinoma, ovarian/testicular Alpha-fetoprotein (AFP ) for liver, yolk sac remnants, testes and ovary Alpha-fetoprotein (AFP ) for liver, yolk sac remnants, testes and ovary Prostate Specific Antigen (PSA) for prostate Prostate Specific Antigen (PSA) for prostate

15. Serial measurement of tumor markers will give an indication of the size and activity of the tumor and adequacy of treatment Persistently elevated tumor marker levels mandate medical consultation Persistently elevated levels may indicate that there is residual tumor that was not removed

24. The general criteria and ratings or the tumor rating guide varies from one company to anothers insurance manual

25. Underwriting is more than a science: it is an art Underwriting is more than a science: it is an art

26. Thank You