disease trends challenges and opportunities · disease trends challenges and opportunities ......

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Southeastern Actuaries Conference

Mark Skillan, M.D.

June 20, 2014

DISEASE TRENDSChallenges and Opportunities

Leading Causes of Death and Disease Trends in the U.S.

Select Areas of Interest

Heart Disease

Diabetes

Cancer: Lung, Breast, Prostate, Colon, Melanoma

HIV

Added Challenges in Risk Selection

e-Cigarettes

Gender Identity

Genetic testing/rare Diseases

Agenda

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Age adjusted and crude death rates in U.S. 1960-2010


Leading causes of death in the U.S.2010

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1. Heart Disease

6. Dementia (Alzheimer’s)

2. Malignant Neoplasm (Cancer)

7. Diabetes

3.Chronic Lower Respiratory

Disease

8. Kidney Disease

4. CerebrovascularDisease (Stroke)

9. Flu and Pneumonia

5. Accidents (poisoning, MVA,

etc.)

10.Suicide

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Leading causes (continued)

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11. Septicemia (overwhelming

infection)

12. Liver Disease/Cirrhosis

13. Hypertension 14. Parkinson’s15. Other

Pneumonia’s

Life expectancy 78.7 years, continuing upward trend Age-adjusted death rate declined to a record low Homicide dropped from top 15 – first time since 1965 Lower death rates for ASCVD, cancer, lower respiratory disease, stroke, flu, pneumonia and septicemia

Highlights


Death rates by age and gender 1955-2010


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Age Adjusted death Rates for Selected Leading Causes of Death 1958-2010


Heart disease


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Heart disease

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Leading cause of death for both men (>50%) and women

600,000 deaths per year (385,000 from CHD)

Incidence Trend Increasing with aging population and prevalence of overweight/diabetes

Mortality Trend Steady decline in age-adjusted death rate since 1980* Decreased 2% for 2010

* except for small increase in 1993


Heart disease – trends and implications

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Mortality improvements related to risk factor modification ….and better care

High blood pressure – improved Lipids – definitely improved Smoking cessation – improved Diabetes – improved in some groups Overweight/obesity – not so much Physical inactivity – improved in some groups Excessive alcohol – awareness improved

Improved meds – cardiac, BP, lipids

Improved care – diagnostics, PTCA, ICU/CCU, cardiac rehab, etc.

Trend likely to continue though impact of overweight/obesity may offset gains… © 2014 Munich American Reassurance Company. All rights reserved.

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Diabetes

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Diabetes – 7th leading cause of death – likely an underrepresentation

Estimated risk of death is about twice that of people of same age without diabetes

Associated complications: Heart disease 2-4x risk Stroke 2-4x risk Hypertension – present in 67% of adults with DM Vision impairment/loss, a leading cause of acquired blindness Kidney disease – cause in 44% of new cases of renal failure Nervous system disease – leading cause of sensory, digestive issues, ED, CTS Limb loss – 60% of non-traumatic lower limb amputations are DM related


Diagnosed diabetes, U.S. 1958-2010


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Obesity and diabetes U.S. adults 1994-2010


Diabetes by age

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Age ≥ 20 years 25.6 million - 11.3% of all people in this age group

Group Number or percentage who have diabetes

Age ≥ 65 years 10.9 million - 26.9% of all people in this age group Men 13.0 million - 11.8% of all men aged 20 years or olderWomen 12.6 million - 10.8% of all women aged 20 years or olderNon-Hispanic whites 15.7 million - 10.2% of all non-Hispanic whites aged 20 years or olderNon-Hispanic blacks 4.9 million - 18.7% of all non-Hispanic blacks aged 20 years or older


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Age group and diabetes


Newly diagnosed diabetes, adults2010


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Trends and implications - Diabetes

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No change: 36.6% in 1994

36.1% in 2010

Worse: 40.2% in 1995

58.4% in 2009

Worse : 69.7% overweight in 1994

84.7% in 2010

Some improvement of Hemoglobin a-1-c levels:- some increase in best controlled

- some decrease in poorly controlled

Minimal change in BP control

Minimal: 21.7% smoked in 1994

19.9% in 2010

Increased: 46.2% in 1995

57.1% in 2009

Glucose Control1988-2006

Prevalence High Blood Pressure 1995-2009

Blood Pressure Control1998-2006

Smoking Cessation1994-2010

Weight Control1994-2010

High Cholesterol1995-2009

Physical Inactivity1994-2010

Progress in modifying risks for DM complications


Diabetes trends and implications continued

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35% of persons in the U.S. over age 20 have

pre-diabetes

50% of persons in the U.S. over age 65 have

pre-diabetes

Outlook appears unfavorable given the high prevalence of overweight and obesity as well as limited progress on controlling factors which lead to complications


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Breast Cancer

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Most common cancer in women 207,000 women, 2000 men in 2010 Second most common cause of cancer death in women (first among Hispanic)

Incidence trends, 2001-2010 – remained level

Mortality trends, 2001-2010 – decreased 1.5-2.0% per year


Earlier diagnosis Better treatment

Risk of breast cancer increases with age


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Traditional Approach to Underwriting Cancer:T2 N1mi M0, G2, ER Negative Breast Cancer, Ages 50 - 69

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Surveillance Research Program, National Cancer Institute SEER*Stat software (seer.cancer.gov/seerstat) version 8.0.4


0.5

0.6

0.7

0.8

0.9

1

1.1

0 2 4 6 8 10 12 14 16

% S

urvi

val

Year

“Postpone” = cut off steep part of mortality curve

O

E

T2 N1mi M0, G2, ER NegativeAges 50 - 69

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0

10

20

30

40

50

60

70

80

0 2 4 6 8 10 12 14 16

ED / K

Year

Year Total ED / K Remaining

5 159

6 116

7 61

8 23

+ 100 (Table 4)

Year Flat ExtraED/K

Remaining5 30 / m x 5 Y 1596 25 / M x 4 Y 1167 20 / M x 3 Y 618 12 / M x 2 Y 23© 2014 Munich American Reassurance Company. All rights reserved.

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Screening mammography has resulted in twice as many early stage breast cancers being detected yearly

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Figure 1. A

Women > 40 years of age

Bleyer A and Welch HG, NEJM 2013;367(21):1998 – 2005.


Early Stage (T1, T2) Breast CancerDistribution by Stage and Age

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0

10000

20000

30000

40000

50000

60000

T1a T1b T1c T2

70 - 79

50 - 69

30 - 49



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Early Breast Cancer: T1c N0 M0, Grades 1 and 2,Ages 50 - 69

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Survival curve is convex and similar to expected mortality

Earlier Dx

Improved Rx


Long-term adverse effects from therapy for early stage breast cancer result in ongoing increased mortality risk

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Radiation Increase incidence of coronary artery disease Myocardial damage from radiation

Chemotherapy


Increased incidence of hematologic malignancies Cardiomyopathy

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Early Stage (T1 T2 N0 M0) Breast Cancer

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Survival curves are convex

Little advantage to postpone period

Debits better reflect the risk vs. temporary flat extra rating format


Menopause and Age alter mortality risk in early stage breast cancer

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Menopause and age have measurable influences on mortality with breast cancer

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T N M Stage Grade Mortality Ratio

Below 50 Years

50 – 69 Years

70 Years & Above

T1a, T1b N0 M0 1 & 2 143 96 94

3 209 105 94

T1c N0 M0 1 & 2 214 115 104

3 299 125 111Surveillance Research Program, National Cancer Institute SEER*Stat software (seer.cancer.gov/seerstat) version 8.0.4


And above age 70…

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Early Stage breast cancer (T1 size) effectively treated with lumpectomy and tamoxifen

More sensitive to effects of hormonal Rx in later years –especially beyond 75 years


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Women 70 Years or Older, T1 N0 M0, ER + Breast Cancer and Clinically Negative Axilla – No Increased Mortality

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No survival benefit by adding RT to tamoxifen

Mortality Ratio = 97%

Only 1.5% later develop + axillary lymph nodes


Hughes KS, J Clin Oncol 2013;31:2382 – 2387.

T1C LN Status Undefined, Grade Undefined, M0Ages 70 and above

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20.00%

40.00%

60.00%

80.00%

100.00%

0 5 10 15 20

Observed

Expected

Mortality Ratio = 104 % Minimal excess late mortality for T1C breast cancer without consideration of axillary lymph node status in ages 70 & above

0

0.005

0.01

0.015

0 2 4 6 8 10 12 14 16

Surveillance Research Program, National Cancer Institute SEER*Stat software (seer.cancer.gov/seerstat) version 8.0.4© 2014 Munich American Reassurance Company. All rights reserved.

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Early Stage Breast Cancer: T1 and T2 Disease, Negative Lymph Nodes, No Metastatic Disease

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Debits better reflect risk than temporary flat extra’s

After year 1, additional PP period not warranted

Persistent increased mortality of minimal degree

Adequately treated with lumpectomy & tamoxifen

Surgical lymph node evaluation not required

Post-menopausal mortality significantly better

Convex Survival Curves Age Banding & The Menopause Ages 70 & Above with Clinically Negative Axilla


Trends and implications – Breast Cancer

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With aging population and better screening, incidence likely to riseOutlook for early stage breast cancer has improved

Improved understanding of the most common breast cancer risks encountered:

More limited PP period translates to earlier offers Small rating, no temporary extra premium charge Bottom line: More and more favorable offers than in past

For applicants with early stage breast cancer within 5 years of therapy

For the balance of the policy, more accurate pricing of the risk


Extra mortality for those entering insured pool after traditional PP period was often not previously covered

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Lung Cancer

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More Americans die from lung cancer than any other cancer Diagnosed: 201,000 – M:F 107,000: 94,000 (2010) Deaths: 158,000 – M:F 88,000: 71,000 (2010)

Incidence trends 2001-2010


Decreased 2.3 – 2.7% per year in men Decreased 0.6 – 0.7% per year in women, stayed level in black women

Mortality trends 2001-2010 Decreased 2.5 – 3.3% in men, biggest improvement among black men Decreased 0.9 – 1.0% in women

Trends and implications – Lung Cancer

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Decrease incidence and mortality in men reflects smoking reduction over past 20-30 years in men

Lack of improvement in women likely reflects both later adoption and discontinuance of smoking among women


Screening remains problematic and controversial – CXR, CT, etc

Therapies except for the earliest found lesions and one subgroup (NSCLC) remains less than optimal

Key to future remains risk factor reduction

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Colorectal Cancer

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Third most common cancer in men and women Diagnosed: 132,000 – M:F 68,000: 64,000 (2010) Deaths: 52,000

Incidence trends 2001-2010 Decreased 2.0 – 4.0% per year in men Decreased 2.0 – 3.3% per year in women

Mortality trends 2001-2010 Decreased by 1.4 – 3.0% per year in men Decreased by 2.0 – 3.3% among women

Second leading cause of cancer death in cancers which affect both men and women


Trends and implications: Colorectal Cancer

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Education, screening and surveillance has had a favorable impact More earlier stage lesions at diagnosis Able to offer on best cases and do so earlier

Incidence increases with age thus incidence likely to increase Treatment for later stage disease remains sub-optimal Current ratings for these may be underpriced in the market


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Prostate Cancer

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Most common cancer among men in U.S. Lifetime risk >16%

Second leading cause of cancer death in men


Diagnosed: 196,000 in 2010 Deaths: 29,000

Incidence trends 2001-2010 Decreased by 2.6 – 4.0% per year

Mortality trends Decreased by 3.0 – 3.8% per year (3.8% in black men!)

Trends and implications – Prostate Cancer

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PSA and DRE screening has resulted in earlier detection More earlier stage lesions

Key risk indicators


Age at diagnosis - <55, 55-60, 60-69, 70-74, 75+ Stage of disease – local (T2 or less) or extra-capsular (T3 and above) Tumor grade – Gleason score (2-10)

Post-treatment PSA level

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Trends and implications – Prostate Cancer(continued)

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With latest SEER data, improved ability to quantify risk Earlier offers for better/best risks Better offers for many than before, especially at >60, >70

Second leading cause of cancer death in men


Controversy over screening/over-treatment may lower detection of early tumors More men may elect “watchful waiting” Focus on ED risk may likewise affect number of younger men opting for radiation rather

than surgery with less certain outlook for cure in some cases

Skin Cancer - Melanoma

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Skin cancer is the commonest form of cancer in the U.S.Most are basal cell or squamous cell cancers with minimal mortality impact

Melanoma is potentially a bad actor Diagnosed melanomas: 61,000 M:F 35,200:25,800 in 2010 Deaths: 9,200 M:F 6,000:3,200

Incidence


Increased by 1.6% per year in white men, remained level in others Increased by 1.6% per year in white women, remained level in others

Mortality Increased by 1.0% per year in white men, remained level in others

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Trends and implications: Melanoma

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Education and screening has had an impact but this is likely being offset by Growth of aging population More outdoor activities Increasing residency in warmer climates Inadequate adherence to SPF protection measures

There is more data on mortality risk based on microscopic findings (stage, grade) atdiagnosis and other prognostic indicators


Improved offers for earlier stages with good prognosis markers Later stages remain problematic Newer therapies show promise

HIV Disease


Mortality trend for AIDS (Stage 3 HIV disease)

HIV infection incidence trend Remains level – 50,000 new infections per year M:F 39,000:11,000 Most new infections ages 20-50 Highest risk groups unchanged

A leading cause of death ages 15-64 1.2 million AIDS cases to date, cumulative deaths 636,000 Declining – 15,000 deaths in 2010

Prevalence of HIV infection in U.S.: 1,100,000 (180,000 or 16% unaware)

Recent advances in therapy (ART) appears to have changed the course for HIV disease

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Natural history of untreated HIV infection


Trends and implications: HIV Disease


Remarkable progress has been made in therapies since 1995 The latest drug combo’s appear to be effective over the long term (so far) with much more limited side effects than their predecessors There are reliable prognostic markers (CD4 count, HIV viral load, etc) Insurance (including whole life) is being offered in some other countries Just another chronic disease? Challenges include

niche market the newer drug regimens are relatively novel (?2006) even if HIV is successfully suppressed, there appears to be some increased risk for non-HIV related death (CAD, etc), i.e., premature aging

A vaccine to prevent HIV infection seems a long way off. PreP for those at risk is here but not a panaceaA long-acting pre-exposure prophylactic medication may be available near term

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HIV (+) Death Rate After ART Initiation


Is HIV An Insurable Risk for Life Insurance?


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e-Cigarettes: ToB or not ToB


Cigs Appeal


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e-Cigarette components


The Market – projected to be $6B by 2016


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e-Cigarette Challenges

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Nicotine Delivery Device or Stop Smoking Aid ?

Rapidly expanding market with huge money issues: profits, taxes

No current way to distinguish cotininesource - from smoking or vaping?

Nicotine has known medical toxicities and can be very addictive

Nicotine content may be variable depending on the source

Ability to modify content with refillable canisters

Effects of long term inhalation of propellant/nicotine vapor contents unknown

Effect on future use of other nicotine products unclear


Gender Identity


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Whose decision is it… anyway?

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Gender identity vs. chromosomal make-upWhich should prevail when applying for insurance? Activity in legislatures in 2013, more likely in 2014-15 Implications for insurers

gender specific conditions remain, e.g., prostate cancer, ovarian cancer, breast cancer supplemental hormone use side effects mental health issues may be part of the picture in some cases


Genetic testing

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Genetic information

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Medical, legal, social debates likely to re-surfaceWho can view a person’s genetic information?What constitutes genetic information?

Insurers view genetic information as medical information

Improving genetic tests (now at the research level) will highlight the issues


Become less costly to perform Direct to consumer testing (23 and me, etc) is far from perfect - now Genetic links to uncommon disorders are being uncovered Medical and actuarial data for uncommon disorders remains limited

Insurers will want to continue to “Do The Right Thing” but difficult challenges likely lie ahead

Thank you very much for your attention

Mark Skillan, M.D.

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disease trends challenges and opportunities · disease trends challenges and opportunities ......

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