Stephen Tseng and David Lu discuss the WHO’s recommendation on replacing the cervical smear test with an HPV DNA test, and what it could mean for critical illness insurance
Cervical cancer is a leading cause of female cancer.
In 2020, an estimated 604,000 women were diagnosed with cervical cancer worldwide, and about 342,000 women died from the disease. In November 2020, the World Health Organization (WHO) launched its global strategy to accelerate the elimination of cervical cancer as a public health problem by scaling up the human papillomavirus (HPV) vaccination, screening with a high-performance test, and helping women with a positive screening test or cervical lesion to manage their conditions appropriately.
The WHO strongly recommends replacing the cervical smear test with an HPV DNA test for cervical pre-cancer screening. It recommends that all women start at age 30, with regular screening every five to 10 years. The cervical smear test is a cytological test that checks whether cells in the cervix are abnormal, while the HPV DNA test is a molecular test that identifies high-risk carcinogenic HPV genotypes, especially HPV16 and 18. A positive HPV DNA would indicate that the woman is at higher risk of getting cervical cancer.
The HPV DNA test could detect high-risk carcinogenic HPV genotypes when cells are still normal, thereby allowing earlier intervention. Cytological or histological diagnoses may not be necessary in the screening and treatment protocols.
For the HPV DNA test itself, the WHO suggests using upper vaginal samples, either self-collected (at home or in-clinic) or taken by a healthcare provider (in-clinic). Many countries have simultaneously introduced the HPV-based screening and the self-sampling approach, and the COVID-19 pandemic and associated social distancing have accelerated the introduction of self-sampling. The pandemic is changing the perspectives of self-sampling as a primary screening method for all women in many countries.
Compared with the cervical smear, which needs to be done in-clinic by a trained medical professional, self-sampling can feel less embarrassing and less intrusive. It can also be less uncomfortable physically, as the sample can be collected with a swab.
“The HPV DNA test could detect high-risk carcinogenic HPV genotypes when cells are still normal”
Impacts on insurance
The WHO’s recommendations will have impacts on health insurance – particularly critical illness markets.
A carcinoma in situ (CIS) is a group of abnormal cells that remain in the place where they first formed, without spreading. They may become cancer and spread into nearby normal tissue. Many critical illness policies include a CIS benefit, with different payout ratios (percentages of face amount) in different markets. The higher the CIS payout ratio, the higher the recommendation’s impact on the market will be. This is because more CIS findings are expected after HPV DNA tests are adopted, as they are more sensitive than cervical smear tests. Commonly seen payout ratios in different markets include 25% in the UK, 10~25% in Canada and 20~30% in China. In Korea it is generally 10%, but 20~100% is increasingly seen due to sales pressure faced by insurers.
Adverse impacts will also be greater in policies with an additional CIS payout design than in those with an accelerated payout. An additional payout is paid on top of the final sum assured, so if a policyholder claims under CIS and then develops another malignant cancer, they would be paid out the partial benefit at the point of CIS diagnosis, followed by the full sum assured at the time of the cancer diagnosis. (While the chance of developing cervical cancer after proper management of a pre-cancer lesion is very low, the policyholder may still develop other malignant tumours.) Accelerated payouts are an acceleration of a part of the final sum assured. If a policyholder claims under CIS and then develops malignant cancer, they would be paid the CIS benefit at the point of CIS diagnosis, followed by the remaining sum assured at the time of the cancer diagnosis. Markets where additional payout design is common include the UK, Canada and China. In Korea, the benefit is usually sold as an optional rider (so, again, additional to the main benefit).
The earlier detection and intervention that are likely to follow from the recommendation will mean reduced cervical cancer cases in the long run. This counterbalancing effect in morbidity savings will be more apparent in whole-of-life and longer-term products, and may be entirely lacking in a term product. This effect is therefore more likely observed in markets such as China (mostly whole-of-life) than the UK (mostly term).
Higher anti-selection, especially when a direct-to-consumer self-sampling test is available, is to be expected in term products. Potential customers who are aware of their own infection may take out a policy due to the high leverage (high ratio of sum assured to premium). This is particularly likely in markets where underlying HPV prevalence and awareness are high – for instance in Northern European countries. Policy applicants can also withhold information on a positive finding at the underwriting stage if test results are not available on medical records. (Notably, they are available on medical records in the UK pilot study.)
For medical reimbursement plans, whole-life medical expenses should fall, as the cost of screening and treating cervical pre-cancerous lesions is much lower than that of treating later-stage cervical cancer.
The new WHO guideline allows a decision to treat a suspected pre-cancer lesion based on a positive HPV DNA test only, without cytological or histological confirmation. In fact, we may only know
that the HPV DNA test is positive without knowing whether it is a true pre-cancer lesion, or if the cells are still normal. Histopathology or cytology is a standard requirement for critical illness claims, but may not be necessary under the new WHO guidelines. If insurers were to continue with current guidelines and decline positive high-risk HPV DNA tests without histopathology, the practice could pose a reputation risk. On the other hand, if an insurer was to change its claims practice,
the potential impact on pricing would have to be considered.
Risk mitigation strategies and product design suggestions
Consideration of HPV DNA test results
The HPV DNA test is an effective risk selection tool because of its higher sensitivity. A prospective insured with a negative HPV DNA test is a better risk than a prospective insured with a negative cervical smear – so a better pricing offer could be considered given a negative HPV DNA test, even without a cytology report for critical illness or female cancer products, especially when the woman has been HPV-vaccinated. This is particularly true for customers of term products with a shorter coverage period, as the selection effect will gradually taper off.
Relative magnitudes of risk reduction that can be assessed through sensitivity or specificity of both HPV DNA and cervical smear tests are as follows:
Limits on pre-cancer lump sum payments
A smaller sum-assured cap on pre-cancer benefits will help to control increased claims due to both additional and accelerated incidences of CIN2/3. As some of the positive HPV DNA cases have normal cytology, insurers need to consider the insurable interests of such cases and make proper benefits and pricing adjustments. On the other hand, morbidity savings from lowered cervical cancer claims in the long run may partially compensate for this.
Stephen Tseng is senior pricing innovation actuary, Life and Health Products at Swiss Re
David Lu is chief medical officer, Asia at Swiss Re