Underwriting | 30 August 2023
The change of nomenclature
The pituitary gland is a small, pea-sized gland located below the base of brain and connected to the brain via a ‘stalk’. It’s the master gland of the endocrine system and regulates the functions of the endocrine (hormone secreting) glands throughout the body. Pituitary adenoma is the most common type of tumour that develops within the pituitary gland. Most are non-functioning (no interference with hormones) and / or asymptomatic and are named as ‘incidentalomas’.
A recent review by WHO resulted in reclassification of pituitary adenoma as described below.
Under the 5th Edition of the WHO Classification of tumours of the pituitary region, the terminology 'Pituitary Adenoma' shall be renamed as 'Pituitary Neuroendocrine Tumour', or in short PitNET.
The International Classification of Diseases for Oncology (ICD-O) behaviour code for PitNET (effective from January 2023) is now revised from "0" to "3", which indicates a change from benign to malignant disease.
The previous terminology of Pituitary Carcinoma is also changed to the term Metastatic PitNET.
The possible impacts on claims for cancer benefit
The current situation
For critical illness and cancer only policies where a lump sum payment is paid upon the diagnosis of cancer, claims for pituitary adenoma would not be paid. This is because the condition is classified as a benign tumour... However, if the tumour has metastasised then the cancer claim is payable under the term of pituitary carcinoma, which accounts for approximately 0.2% of all pituitary tumours.
New classification
Under the 5th WHO classification, pituitary adenoma is now renamed as a pituitary neuroendocrine tumour and classified into the category of a malignant disease. This gives rise to the potential that it could now be covered under the cancer benefit of CI and cancer-only products, based on the general cancer definition in the majority of markets.
The epidemiology of pituitary gland tumours is interesting and shows a significant difference across various studies.
According to a large-scale US population-based study(1), the overall standardised incidence rate was approximately 5 cases per 100,000 persons per annum. However, the prevalence rate varies widely across demographic variants. One study indicates the prevalence of the disease in UK is 76-116 per 100,000 population, approximately 1/1,000, but a high incidental finding of pituitary adenoma at autopsy, ranging from 1.5% to as much as 30%, is reported.
If these reclassified ‘malignant’ pituitary tumours are considered to be covered under the cancer benefit, an assessment of the impact of these extra claim cases beyond pricing assumptions needs to be carefully considered.
Pacific Life Re's view on claims assessment of pituitary adenoma
Since 1932, Harvey Cushing first proposed pituitary adenoma as the cause of acromegaly. The disease is recognised as a benign tumour, which can be easily cured or controlled by conventional therapies, including surgery, radiotherapy and/or medical treatment.
A large proportion of the cases, which are identified incidentally and exhibit no symptoms, do not require any treatment. In these cases, periodic surveillance is the only medical measure required. Other than pituitary carcinoma (metastatic PitNET), only a very small subset of pituitary adenomas present aggressively in nature, which means rapid growth rate and being refractory to optimised standard treatment.
In the cancer definition, any malignant tumour must be positively diagnosed with histological confirmation.
In cases where no clinical treatment is required, or non-invasive treatment is the only medical measure to take, these tumours will not be diagnosed through histological methods.
A key point is that whilst being reclassified by WHO as malignant, these tumours exhibit variable growth patterns across a spectrum of malignant behaviour, with the vast majority exhibiting indolent and non-aggressive behaviour.
The change by WHO from benign to malignant is not representing a new disease process, it is a nomenclature change, a reclassification of previously considered benign adenoma to overt malignancy. The WHO reclassification will not influence the associated risk or clinical pathway because the diagnostic label has been amended. These are the same (previously labelled) adenomas brought into line under one new heading.
Therefore pituitary tumours without histological proof, or the necessity of specific cancer treatment such as surgery or radiation therapy, are beyond the scope of cancer coverage that CI policy reasonably intends to pay.
We would advise that any particularly unusual or ‘grey’ claims are referred to Pacific Life Re for opinion.
Underwriting of pituitary adenoma
As the change of the name and reclassification of tumour category do not affect the natural diagnosis, when underwriting a critical illness or cancer product, we need to consider that pituitary adenoma is now potentially a cancer risk.
Even in the case of non- functioning (not affecting hormone balance) and minor tumours, an exclusion of pituitary tumour is recommended to apply to the policy.
For those more aggressive cases with rapid growth rate or resistant to treatment, a more cautious underwriting outcome should be considered.
Our current view is that income protection and medical reimbursement (e.g. Medex) products are not materially impacted considering the natural diagnosis approach, and the treatment standard of pituitary adenoma not changing due to the WHO’s reclassification.
In the meantime, we advise that underwriters exercise caution when assessing critical illness or cancer only products where a history of pituitary adenoma or PitNET is found, and to refer to us for any further guidance on individual cases.
Next steps
It is acknowledged that this reclassification of disease has created some challenges and will evolve further over the coming months.
We are continuing to work through the various possible impacts and will be engaging with and supporting our clients in relation to their specific needs in this area.
Pacific Life Re Limited (No. 825110) is registered in England and Wales and has its registered office at Tower Bridge House, St Katharine’s Way, London, E1W 1BA. Pacific Life Re Limited is authorised and regulated by the Financial Conduct Authority and Prudential Regulatory Authority in the United Kingdom (Reference Number 202620). The material contained in this article is for information purposes only. Pacific Life Re gives no assurance as to the completeness or accuracy of such material and accepts no responsibility for loss occasioned to any person acting or refraining from acting on the basis of such material.
©2024 Pacific Life Re Limited. All rights reserved.
Andrew Doran
Chief Underwriting Officer
Paul Reddick
Principal Underwriter
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