Impaired Risk Review...
All Cancers Aren't Created Equal
Robert Goldstone
November 2018

It sounds a bit flippant, yet it is a request that medical directors and underwriters see quite often.  An informal application or quick quote comes in with a request about “history of brain tumor.”  Or maybe a question of pancreatic cancer.  The underwriter is expected to make an educated guess based on these minimal findings.  All tumors truly aren’t created equal, and people have individualized responses to different abnormalities.  The more information supplied the better chance there is for not only a placeable but a sustainable quote.

No one likes a quote that they confer to their client that doesn’t hold up once more information is obtained or the underwriting process is well underway.  Time is wasted on the broker or agent’s part and good will evaporates when the original offer conveyed to the applicant no longer holds.  Sometimes, especially with cancer, time is the most valuable commodity, and the longer the process is post diagnosis makes for a better prognosis in the long run.  Particularly with cancer, outcomes often surprise us even as physicians.  

Let’s use brain tumors as an example of a condition recently in the spotlight for well known people who have received the diagnosis. John McCain was lost recently to a brain tumor, and his prognosis was guarded from the outset.  The cancer turned out to be a glioblastoma multiforme, which has a particularly poor outcome.  Years before, Senator Edward Kennedy was diagnosed with a similar condition and the news led us to believe a cure was quite possible, when indeed the disease was relentless.  Knowing the type of cancer rather than just annotated as “brain tumor” tells an awful lot about an eventual outcome.  

Jimmy Carter was diagnosed with a brain tumor in in 2015.  The outcome was considered to be a quickly fatal disease—all the public heard was brain tumor.  It turns out his cancer was a metastatic melanoma, a type of skin cancer that can spread to the brain.  While this was a uniformly fatal outcome years ago, President Carter received immunotherapy with newly developed drugs and is considered by his physicians to be cancer-free.  While Carter is probably too old for a potential offer of insurance at this point, others with similar findings will find themselves insurable in what was previously a hopeless situation.   

Film and stage actor Mark Ruffalo was diagnosed with a brain tumor in 2001 after shooting a film.  His symptoms were similar to many with brain tumors: Loss of balance, tinnitus, loss of hearing on the affected side.  Whereas a quick quote on “brain tumor” might have resulted in decline, it turns out Mr. Ruffalo had a tumor called a vestibular schwannoma or acoustic neuroma.  These kinds of cancer are benign and cause symptoms by compressing brain tissue as they grow.  After surgical removal or radiotherapy the tumors are cured and life expectancy is the same a it was without the growth being diagnosed.  While therapy left him without hearing in the ear on the affected side, he is considered disease free.  

Other cancers also have markedly different outcomes depending on their presentation, extent at diagnosis, and their type of pathology.  Pancreatic cancer is a particularly lethal disease with five year survival rates hovering in the low single digits.  The famed actor Patrick Swayze and renowned tenor Luciano Pavarotti succumbed to the disease quite quickly.  Steve Jobs was diagnosed with pancreatic cancer in 2004 and lived 8 years until it took his life, but his cancer was what is called an endocrine pancreatic cancer, one that takes much longer to manifest its effects.  Few know that Supreme Court Ruth Bader Ginsburg was diagnosed with pancreatic cancer in 2009 on a routine physical exam.  She was one of the minority caught at a very early stage at which cure was possible.  In the three above cases, the same “pancreatic cancer” diagnosis had three significantly different results.

Cancer is a multimodal disease, dependent on so many independent variables.  The type of cancer, the type of mutations associated with it, the extent at diagnosis, the progress of medical therapy in that individual field, and the individual response of each patient to intervention makes for completely different set of circumstances in each involvement.  All cancers aren’t created equal and represent some of the most difficult diagnostic dilemmas for underwriters, particularly with limited information and follow-up. 

Author's Bio
Robert Goldstone, MD, FACE, FLMI
MD, FACE, FLMI, board certified internist and endocrinologist, was most recently vice president and chief medical officer for Pacific Life and Pacific Life and An­nu­ity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endo­­­crinology and has written monthly for Broker World since 1991. Goldstone does consulting full or part-time as well as on a fill-in basis for companies who need a medical director/physician. He can be reached by ­telephone at 949-943-2310. Emaill: drbobgoldstone@yahoo.com.















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