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Genetics Testing: Nuances Matter
December  2019

It is that time of year again. You know what I mean, time to look back and give your opinion on the most significant innovations that have the potential to affect our industry. For underwriting in general you would have to say accelerated underwriting or utomated underwriting in some form is huge as it is now impacting millions of policies. And the potential exists for even more impact as more sources of data become available.

But my focus is more on medical underwriting: the cases that are too large to automate or the proposed insured’s age is outside the typical age range or, more commonly, there is a medical impairment that is kicked out by the algorithms.

My choice for the medical innovation that may have the most impact on risk assessment is the liquid biopsy. This is a commonly used term for the isolation and analysis of cell-free DNA (cfDNA) or RNA that is derived from malignant tumors. Due to the cell turnover associated with tumors, partial or intact cells are released into the blood stream or other bodily fluids. Technology has improved to the point that very small amounts of this material can be detected and analyzed for mutations that are unique to the tumor.

Clinical applications include early detection of tumors before they become clinically evident, early detection of recurrent tumor after treatment and detection of clonal tumors different from the one that may have been biopsied. There will also be the ability to monitor tumors that are difficult to access or monitor. And, finally, it will be possible to monitor and adjust chronic cancer therapy as new mutations and resistance to treatment emerges.

This is good news for all of us as we can expect improved survival in cases of cancer. But this is not necessarily good news for risk classification. In the effort to safeguard their citizens from “genetic discrimination,” some countries have prohibited the use of genetic information or information about mutations to DNA or RNA. They have not necessarily made a distinction for tumor-derived RNA or DNA. This leaves the door open for an imbalance of material information that could potentially damage an insurers’ ability to meet its obligations.

What to do? Perhaps it is time to revisit those blanket prohibitions on access to genetic information. Certainly every effort should be made to make regulators and legislators understand the nuanced difference between tumor-derived DNA or RNA and somatic genetic material.

In this issue Dr. Rooney discusses a case with an unbiopsied skin lesion. Dr. Kadouch examines the implications of coarctation of the aorta, and Dr. Rosace has an interesting EKG for our puzzler. 

Here’s hoping that you and yours have a very happy holiday and a prosperous new year.

Corcoran R and Chabner B, Application of Cell-free DNA Analysis to Cancer Treatment, N Engl J Med 2018;379:1754-65.