The potential of cancer prevention – exploring the untapped treasure

Cancer is one of the leading causes of morbidity and mortality worldwide. There were more than 23m estimated new cancer cases and 10m cancer-related deaths globally in 2019 – and the burden is growing. Cancer-related claims impact multiple product lines, including critical illness, term life and disability.

Besides treatment improvements, measures that lower incidence and accelerate detection may improve morbidity and mortality. According to a 2022 analysis published in The Lancet, almost half of cancers and cancer-related deaths could be prevented if we applied knowledge that we already have – but despite this, the proportion of tumours attributable to modifiable risks is still significant.

Cancer risk factors may be modifiable or not (Table 1). Behaviours such as smoking, alcohol consumption, suboptimal nutrition and physical inactivity, as well as their combination, prompt higher risks. Modifying these behaviours may have significant potential to decrease the likelihood of certain cancers. The analysis in The Lancet assessed the global cancer burden attributable to modifiable risks (such as behavioural, environmental, occupational and metabolic factors) and estimated these accounted for 4.46m deaths globally (2.88m in males, 1.58m in females) in 2019, representing 44% of cancer-related deaths.

The top three factors in regions with a high socio-economic index were smoking, alcohol and metabolic risks such as high body mass index (BMI) or obesity. Further factors included air pollution, occupational risks and unsafe sex. The leading cancer type regarding risk-attributable cancer deaths for both males and females was lung cancer (36.9%), followed by colorectal, oesophageal and stomach cancer in men, and cervical, colorectal and breast cancer in women (Table 2). A study published in 2018 concluded that 38% of cancer cases in the UK were attributable to known risk factors, with smoking and obesity identified as top contributors.

Prevention includes measures that lower the risk of cancer occurring, or primary prevention (such as lifestyle changes), and those that detect it earlier, or secondary prevention (such as cancer screening).

Most countries underinvest in primary prevention, which requires political will and co-ordination, as well as improved dissemination and implementation of research. Given the high costs of cancer treatment, cost effectiveness has been demonstrated for primary prevention measures. Crucial elements include orchestrated policies regarding smoking, alcohol, and metabolic risks such as unhealthy foods. Examples of successful prevention of specific cancers include vaccination against human papillomavirus and screening programmes to remove cancer precursors.

Tobacco use increases the risk of many cancers, predominantly of the lung. Many countries have made substantial progress in reducing tobacco exposure during the past few decades, for example through taxation and advertisement bans. Smoking cessation and non-initiation has resulted in a decline in lung cancer rates and deaths in men. They have been increasing in women, although lung cancer mortality among women has stopped rising in Europe. Still, smoking continues to be the leading cancer risk globally, and 10%-15% of UK insurance applicants continue to smoke.

With a dose-dependent association, alcohol also increases the risks of cancers including liver, oesophageal, colorectal and breast. During the pandemic, several European countries saw increased alcohol consumption in combination with smoking, with a bias towards females.

Metabolic risks comprise being overweight or obese, poor diet and nutrition, physical inactivity and diabetes. This group is currently experiencing the largest relative increase among modifiable cancer risks and is associated with cancer types including breast, colorectal, uterine, ovarian, kidney and liver, as well as difficult-to-treat tumours such as those of the pancreas, oesophagus and gallbladder.

The main drivers are thought to be inflammation, metabolic changes (including insulin resistance), hormonal factors (growth or sex hormones), and changes in the gut microbiome. Adults under the age of 50 appear to be particularly at risk. Studies show that obesity-related cancers are on the rise among younger individuals, specifically for colorectal, breast, kidney, pancreas and uterine cancer; lung, laryngeal and bladder cancer rates are decreasing. It is estimated that early-onset colorectal cancer will become the leading cause of cancer-related death in those aged 20-49.

While multiple causes of these metabolic risks are preventable and reversible, the average BMI is rising in most countries; none have reversed this trend. Obesity strategies will be crucial. In the UK, data indicates that the soft drink sugar levy may help to reduce obesity among students, but broader efforts will be needed to improve nutrition and increase physical activity. For insurers, supporting customers’ metabolic health improvements should be mutually beneficial. Health or lifestyle apps and incentives regarding premiums look promising – but compliance and adherence are a challenge.

A growing body of evidence indicates that metabolic health is impacted heavily by not only diet but also negative psychological relationships with food. Any interventions must therefore be holistic and tailored or cohorted to drivers of poor metabolic health. The main drivers in changing public health hold true: education, access to quality nutrition, motivation and time. Insurers could compare this moment to the moment at which aggregate rates moved to smoker/non-smoker – a portfolio that is managed for optimising metabolic health may be the non-smoker cohort of tomorrow.

Analysis of claims data from UK and Ireland portfolios show that cancer was the leading cause of claims in critical illness (59%; females: 73%, males: 46%) and term life (43%; females: 49%; males: 39%) from 2019 to 2022 – see Figure 1.

As Figure 2 shows, in women, breast cancer was the leading cause of loss for both critical illness (53%) and term life (18%), followed by colorectal cancer (4%) in critical illness and lung cancer (15%) in term life. In men, the leading cancer types in critical illness were prostate (26%), colorectal (10%), kidney (4%), lung (4%) and melanoma (4%), while cancers of the lung (16%), colorectal (9%), pancreas (7%) and brain (7%) were the leading cancers in term life.

These results indicate the predominance of cancers showing high proportions of cases and deaths attributable to modifiable risks such as smoking and metabolic illness – underlining the potential for primary prevention measures to have a significant positive business impact.

Primary prevention cannot eliminate cancer development altogether, so screening is important to help detect it early. Traditional strategies detect single cancers, for example via mammography or colonoscopy. Such screening programmes were significantly impacted during the pandemic, often recovering quickly following lockdowns but remaining below the pre-pandemic baseline level. This may result in delayed cancer detection and higher severity.

New technologies are emerging. New multi-cancer early detection (MCED) tests, in which multiple cancers can be detected using a single blood test, may shift the paradigm, particularly when available direct to consumer. The UK NHS-Galleri MCED trial has enrolled 140,000 individuals aged 50-77 and is awaiting results. In a modelling study, this test was able to reduce late-stage cancer incidence by 78%, with a five-year cancer mortality reduction of 39% in those intercepted.

For the life and health insurance industry, there is an enormous potential in supporting both primary and secondary measures. Medical expertise is needed when specifically providing customers with secondary prevention measures such as new screening tests.

This article was first published in "The Actuary", 7 September 2023.