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It’s important for Claims Assessors to understand that diagnosing cancer is a complex process. A precise diagnosis helps to determine the best treatment plan for that cancer. This blog will review treatment modalities and claims considerations to help Claims Assessors better understand pathology reports and what comes next for the patient.
The pathology report is a complex medical report that describes the diagnosis based on the results of the blood work, diagnostic imaging and biopsy results. If cancer is diagnosed, the report will include specific information including the type of cancer, the histologic grade, lymph node status, stage and the presence of hormone receptors or biomarkers.
The results of a biomarker test could show the cancer has a certain biomarker that is targeted by a known treatment protocol. Or it could show that the cancer has a biomarker that may prevent a certain therapy from working. Off-label treatment (not FDA approved) may be recommended because the treatment is approved for a different type of cancer that has the same biomarker.1
A concise pathologic diagnosis provides important information for the oncology team regarding treatment decisions, risk of recurrence and prognosis.
In the past, patients diagnosed with a particular type of cancer (brain, breast or pancreatic for example), received the same treatment as others with the same diagnosis. Over the past decade research in cancer biology led to advancements in biomarker detection and increased the knowledge and understanding of cancer at the molecular and cellular level, which provides defining diagnostic information to help guide treatment and predict responses to a particular therapy.
Challenging or unusual cancer cases may be discussed at the tumor board, a multi-disciplinary approach to treatment planning with doctors from different specialties, who determine the best possible treatment based on the diagnosis.
In addition to documenting the test results, the pathologic diagnosis and the treatment plan and dates, the oncologist will also document a performance status.
There are two widely used scales for performance status which measures the patient’s level of functioning for patients with cancer. There is the Eastern Cooperative Oncology Group (ECOG) scale and the Karnofsky Performance scale (KPS).
The KPS measures the ability to perform ordinary tasks. The ECOG measures the patient’s level of functioning in terms of their ability to care for themselves including daily activities and physical ability.
Barring any other factors impacting quality of life, the performance scale should correlate with physical performance and with survival. The performance scale also plays a role in determining treatment and prognosis.
Karnofsky Status |
KPS Grade |
ECOG Grade |
ECOG Status |
Normal, no complaints |
100 |
0 |
Fully active, able to carry on all pre-disease performance without restriction. |
Able to carry on normal activities / Minor signs or symptoms of disease |
90 |
0 |
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work. |
Normal activity with effort. |
80 |
1 |
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work. |
Care for self. Unable to carry on normal activity or to do active work. |
70 |
1 |
Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours. |
Requires occasional assistance, but able to care for most of his needs. |
60 |
2 |
Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours. |
Requires considerable assistance and frequent medical care. |
50 |
2 |
Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours. |
Source: https://oncologypro.esmo.org/oncology-in-practice/practice-tools/performance-scales |
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The most common modes of treating cancer are surgery/biopsy, chemotherapy and/or radiation. Chemotherapy is a type of cancer treatment that uses drugs to kill cancer cells. Radiation therapy is a cancer treatment that uses high doses of radiation to kill cancer cells and shrink tumors.
There are many treatment modalities that include immunotherapy, hormone therapy and targeted therapy. A patient’s treatment plan will include one or more treatment modalities.
In some situations, clinical trials may also be an option; however, there are eligibility requirements which can include gender, age, type and stage of the cancer, treatment history and overall health. Access may be limited due to geographical location.2
Bear in mind that the insured may decline surgery and/or any of the above treatments given the stage of the cancer and likelihood that it is not curable.
Cancer, including treatment-related impairments, can result in functional limitations that impact the insured’s ability to perform their occupational duties and activities of daily living. Impairment depends on the type of cancer, when it is diagnosed, and how far it has spread. Treatment side-effects can include physical and/or emotional ones:3
Not all cancer claims are equal. To ensure appropriate assessment and claims management, it is important for Claims Assessors to understand the pathologic diagnosis and ask the right questions if they don’t see the answers in the report.
Was the cancer operable (or was there a diagnostic biopsy)? |
What stage is the cancer? |
What grade is the cancer? |
Were any biomarkers identified? |
Is treatment palliative or curative? |
What was the response to the treatment (complete response, side effects)? |
What affect, if any, did the diagnosis have on mental or emotional health? |
Are there any other conditions that impact the Insured’s ability to perform the material and substantial duties of their occupation? |
Being diagnosed with cancer may or may not affect the insured’s ability to work. Some people choose to continue working either full time or part time during treatment, with or without modifications. Some continue working to maintain a sense of normalcy or for financial stability. Others stop working during treatment and return to work when treatment ends. Those diagnosed with end-stage cancer may want to work, but symptoms from their disease or treatment prevent them from working.
Claims Assessors should also consider an opinion by the Medical Director, or a peer review, to comment on the clinical opinion provided on the Attending Physician Statement. How do the reported restrictions and limitations impact activities of daily living and/or the insured’s ability to perform their occupational duties? What is the prognosis and likelihood of return to work?
Claims Assessors can also request the Medical Director schedule a call with the attending physician to discuss how the insured is responding to the treatment, the current R&Ls, the prognosis, and when a return-to-work is expected with or without modifications (such as working remote, no travel or flexible hours).
When Claims professionals work with cancer claims, they should be aware that no two cancers are the same. Each individual cancer has different characteristics, even cancers of the same type. As this blog suggests – and my first one focused on “Understanding the Pathology Report” – the diagnostic tests and classification systems provide information essential for the medical team and, by extension, the Claims assessor. Additionally, Claims assessors need to consider how the insured responds to treatment and how the diagnosis of cancer or treatments are impacting their lifestyle, notably their ability to work.
Do not hesitate to reach out to me or your Gen Re representative with any questions.
