Advancements in cancer treatment and early detection lead to improved prognosis and long-term survival rates of cancer patients.¹ New cancer treatments enhance the quality of life for survivors, offering better outcomes and fewer side-effects than previous treatments.² As a result, more cancer patients survive and return to work and may consider Disability insurance. With one-third of cancer survivors being of working age,³ underwriting cancer survivors for Disability cover is becoming increasingly relevant. To be eligible, the applicant must have returned to work, all cancer treatments must have been successfully completed and the cancer patient must be “in remission”, meaning cancer-free for a specified period.

Figure 1 shows three potential scenarios that could occur after an insurance application is submitted:

1. The applicant’s cancer does not come back.
2. The applicant’s cancer comes back, is successfully treated and returns into remission phase.
3. The applicant’s cancer comes back as a metastatic disease which cannot be successfully treated, and the applicant has terminal illness.

The duration of sick leave and return to work rate are important aspects in case the applicant’s cancer comes back as depicted in scenario B.

Figure 1 – Different Phases and Possible Scenarios of a Cancer Disease

Duration of Sick Leave in Cancer Survivors

Sick leave after a cancer diagnosis varies significantly, depending on factors such as cancer type, stage at diagnosis, treatment modalities, the patient’s overall health and workplace support.⁵ Studies have reported average sick leave durations from approximately six to more than 12 months.^6,7 Advanced stage at diagnosis and certain types of cancer such as lung cancer, leukaemia and brain cancer were associated with long sick leave durations and low return to work rates, whereas low stage at diagnosis and cancers such as stomach, thyroid and skin cancers had a shorter duration of sick leave and a high return to work rate. Other factors contributing to long sick leave durations are cancer recurrence, combined cancer treatment (e.g. chemotherapy in combination with radiotherapy), presence of co‑morbidity and regular use of medication.^8,9

Return to Work Rate in Cancer Survivors

The return to work rate for cancer survivors varies widely, ranging from 39% to 77%,^10,11 depending on the country of origin, type of cancer, cancer treatment, physical and mental health, workplace support, and socioeconomic status.¹² It has been reported that the return to work rate is higher in cancer survivors who were employed at the time of diagnosis, estimated to be between 69% and 80%.^13,14

A meta-analysis indicated that individuals who have been treated for cancer are 1.4 times more likely to be unemployed compared to healthy controls.¹⁵

Personal, Work-related and Socioeconomic Factors

People with children and/or living with a partner are more likely to return to work after a cancer diagnosis,^16,17,18 while being single, widowed, or divorced negatively influences employment status¹⁹ (Figure 2). This may be because family support enhances emotional wellbeing, provides practical help with daily tasks, and alleviates financial burdens.²⁰ Higher socioeconomic status and education levels facilitate job retention in cancer survivors,^21,22,23 while individuals with physically demanding jobs face barriers to return to work after a cancer diagnosis.^24,25,26 Additionally, intellectual work capabilities which require strong cognitive functions can be impaired in cancer survivors who received chemotherapy (“chemo brain”).²⁷

Figure 2 – Personal and Work-related Factors Influencing Return to Work in Cancer Survivors

In underwriting, we should not discriminate between people based on personal or socioeconomic factors. The risk assessment for disability should therefore focus on cancer-related factors.

Cancer-related Factors

Survivors diagnosed with a cancer that has a generally good prognosis are more likely to return to work²⁹ compared with metastatic disease at diagnosis,^30,31 or those who had received chemotherapy or radiotherapy with side-effects of treatment³² (see Figure 3).

Figure 3 – Cancer-related Factors Influencing Return to Work

Disability Risk – Cancer Recurrence

Recurrence refers to the return of the original cancer – as a regional recurrence in lymph nodes or tissues near the original tumour site, or as a distant recurrence, indicating that the cancer has spread to organs or tissues away from the original cancer site, also called metastatic cancer.

The probability of cancer recurrence is highest in the first years after diagnosis. During this time, it constitutes a high risk for disability in cancer survivors as it is associated with a phase of intensive treatment and extended sick leave. This risk is especially pronounced for metastatic cancer, which has a much poorer prognosis compared to a cancer that has not recurred.³⁴ The incidence and timing of cancer recurrence differs according to cancer type, stage at diagnosis, effectivity and availability of treatment and lifestyle factors. For example, data from studies on colorectal cancer show that 85% of recurrences happen within the first three years after diagnosis and only 9% of recurrences occur more than five years after diagnosis.³⁵ So, the more time has passed since diagnosis, the less likely a recurrence becomes. This is why Disability cover is usually not offered to newly diagnosed cancer patients – insurers tend to wait through the initial years after diagnosis which have the highest probability of recurrence.

Disability Risk – Treatment Toxicities

Most patients experience side-effects of cancer treatment. Typically, these side-effects gradually improve within a few weeks or months after the treatment is finished. However, some individuals may experience long-term effects that persist for more than six months, or late effects that emerge months or years after completing treatment³⁶ (see Figure 4 which shows the scenario of a cancer patient without recurrence). In other words, even if the patient has been cancer-free for years, it is important to know that late effects of completed chemotherapy or radiation treatments may still arise many years after the treatment has ended.

Figure 4 – Cancer Treatments: Side-effects, Long-term Effects and Late Effects^*

Side-effects

Side-effects of Cancer Surgery

The side-effects of and potential long-term impairments caused by cancer surgery are influenced by the type and location of the cancer. Examples are shown in Table 1.

Side-effects of Chemotherapy

The side-effects of chemotherapy depend on the type and dosage of treatment and are often severe. Chemotherapy works by damaging dividing cells. Since cancer cells divide more frequently than most other cells in the body, chemotherapy mainly targets and destroys cancer cells. However, it also affects dividing healthy cells, causing immediate effects on tissues such as skin, bone marrow, blood, hair, kidneys and the digestive system. These effects can vary based on the type of chemotherapy drugs used, the dosage, and individual patient factors.

Examples of the most common side-effects of chemotherapy are:^40,41

• Nausea and vomiting
• Increased risk of infections
• Hair loss
• Skin and nail changes
• Cognitive impairment / “chemo brain”
• Nerve damage (neuropathy) – Tingling or numbness in the hands and feet, fingers and toes; feeling numb and cold
• Fatigue and weakness
• Diarrhoea or constipation
• Hearing impairments
• Negative effects on kidneys, liver, heart and lungs

Side-effects of Radiotherapy

Radiation therapy uses high-energy rays (such as X‑rays) to kill cancer cells or to stop them from growing. It damages the DNA inside cancer cells, making it hard for them to multiply or to repair themselves. Over time, the damaged cancer cells die, and the body’s immune system gets rid of them naturally. Radiotherapy is effective in treating cancer but can cause side-effects. The side-effects differ depending on the irradiated body part and they occur because radiation also harms the healthy cells within the irradiated tissue. Some examples are shown in Table 2.

Late effects of chemotherapy and radiation

While chemotherapy and radiotherapy are effective in treating cancer, they can paradoxically lead to the development of new cancer types and other health conditions as late effects, emerging years after completing treatment. Cancer survivors experience varying degrees of late effects based on cancer subtypes, treatment exposures, chemotherapy drug classes, socioeconomic status and lifestyle factors.^{44,45,46,47,48}

Second Cancers Related to Treatment

Chemotherapy can increase the risk of getting different types of second cancers, most commonly different types of leukaemia, with the highest risk one to seven years after treatment.⁴⁹ The risk of developing solid tumours, such as lung, breast, and gastrointestinal cancers, can increase over a longer period of time, often appearing 10 or more years after the initial chemotherapy treatment.⁵⁰ The risk of second cancers is increasing with higher chemotherapy doses, dose-intensity and longer treatment duration. Chemotherapy agents that have a heightened risk for second cancers include alkylating agents, platinum-based drugs or anthracycline topoisomerase II inhibitors.⁵¹

Radiotherapy: Second cancers typically occur within the radiation field, i.e. the part of the body that was exposed to radiation. For example, radiation of the chest increases the risk of getting breast or lung cancer.⁵² The higher the radiation dose, the higher the risk. Studies have shown that the median time to develop second cancers is 10 years following radiation, but some were seen as late as 34 years after radiation.⁵³ The risk for radiation-induced second cancers is higher if the treatment was done earlier in life.⁵⁴ Common examples of second cancers include different types of leukaemia, soft-tissue sarcomas and various solid tumours such as those affecting the skin, breast, and the thyroid.⁵⁵

Chronic Health Conditions Related to Treatment

Many scientific publications show that cancer and its treatments increase the risk of developing chronic health conditions which manifest many years after diagnosis. The “Childhood Cancer Survivor Study” followed cancer survivors with a median age at diagnosis of 42 years for 30 years and their disease burden was compared with siblings of the same age (±5 years) who did not have a cancer diagnosis. The results show that cancer survivors had a 3.2‑fold increased risk of developing severe chronic health conditions, which were most prominent 20 years after the cancer diagnosis.

More specifically, cancer survivors had a fourfold increased risk of developing cardiac conditions, a sixfold increased risk of pulmonary and musculoskeletal conditions, a fourfold increased risk of endocrine conditions and a twofold increased risk of neurological conditions compared to their siblings who did not have a cancer diagnosis.⁵⁶

Another study from the U.S. shows that adult cancer survivors across all age groups had more comorbidities compared to non-cancer controls.⁵⁷ Figure 5 illustrates the increase in risk for various health conditions, comparing cancer survivors with non-cancer controls for two different age groups. Conditions typically associated with aging, such as musculoskeletal diseases and cardiovascular and cerebrovascular diseases (including angina, heart attack, and stroke), were significantly more prevalent among 18- to 39‑year-old cancer survivors.

Figure 5 – Risk of Chronic Health Conditions After a Cancer Diagnosis^*

Another study on cancer patients who were diagnosed before age 25 and followed for 20 years shows interesting results, focusing on the “cumulative burden” of cancer diseases, compared to age and sex-matched controls who did not have a cancer diagnosis. This study indicates that cancer survivors had a significantly higher morbidity risk, regardless of their primary cancer diagnosis and socioeconomic status.⁵⁹ Figure 6 shows that the risk of developing second cancers and co‑morbidities clearly differs according to the treatment received.

Figure 6 – Cumulative Burden in Cancer Survivors^*

Key findings of this study are that chemotherapy and radiotherapy both increase the risk of developing different health conditions such as second cancers, kidney and liver disease, cardiovascular disease or infections. Individuals who received chemotherapy in combination with radiotherapy had the highest disease burden caused by treatment toxicities.

Mental Health in Cancer Survivors

A cancer diagnosis and its treatments can significantly affect mental health and quality of life in cancer patients. A population-based study indicates that cancer survivors have a twofold increased risk of experiencing disabling psychological conditions compared to adults without cancer. Furthermore, cancer patients who additionally had other chronic illnesses faced a nearly sixfold increased risk of psychological disability compared to adults without cancer.⁶¹

The first one to three years after treatment are especially crucial for monitoring the mental health of cancer survivors. During this period, challenges such as fear of recurrence, changes in occupational roles, side and long-term effects of treatment, perceived loss of support from healthcare providers, and potentially reduced emotional support from family and friends may impact the survivor’s quality of life.

Depression and Anxiety in Cancer Survivors

Studies have shown that the prevalence of depression and anxiety is higher in cancer patients than in the general population^62,63 and may affect up to 20% and 10% of cancer patients, respectively.⁶⁴ The presence of depression seems to be highest during the first year of the disease and decreases after treatment has ended⁶⁵ but remains significantly increased compared to the general population for at least five years after diagnosis.^66,67 This indicates a prolonged mental health burden for cancer survivors.

A recent study on cancer survivors who had no signs of mental illness in the year before their cancer diagnosis found that they were at a higher risk of developing depression and anxiety during follow‑up compared to individuals without cancer. These risks seem to be particularly pronounced in cancers with a bad prognosis, i.e. low five-year survival rates. For instance, survivors of lung and oesophageal cancers had more than a 2.5‑fold increased risk for both depression and anxiety, whereas survivors of malignant melanoma had only a 1.2‑fold increased risk of depression and a 1.1‑fold increased risk for anxiety over the general population.⁶⁸ The highest risk of anxiety and depression was found within the first year after diagnosis but remained elevated even five years later in 90% of the cancers studied.

Risk factors contributing to a lower quality of life related to mental health among cancer survivors include young age, less education, presence of co‑morbidities, lower income and not having a partner or spouse.^69,70,71,72

Cognitive Impairment / “Chemo Brain”

Cognitive impairments are most pronounced during active cancer treatment with chemotherapy, radiation therapy and hormone therapy⁷³ with up to 75% of patients reporting issues such as memory lapses, attention deficits, and difficulties with executive function.⁷⁴ Approximately 35% of survivors continue to experience cognitive impairment after treatment has ended.⁷⁵ These symptoms may persist for months or even years, with some studies indicating that cognitive deficits may last up to five years or longer.⁷⁶

The causes of cognitive impairment in cancer survivors are multifactorial and include biological and psychological factors (see Table 3).

When Can an Offer be Made?

An insurance offer for Disability coverage can be considered once the applicant has completed all curative cancer treatments, entered medically confirmed remission, returned to work and remained cancer-free for some years after diagnosis. The terms and conditions, including time of postponement, possible exclusions and premium loadings, should reflect the residual risk of recurrence and the late effects of treatment. While a lower stage at diagnosis may be considered as insurable risk for disability, applicants with advanced cancer disease may not qualify for Disability insurance due to an increased likelihood of recurrence, chronic health conditions and second cancers.

The Right to be Forgotten and Disability Insurance

Recently, the “Right to be Forgotten” has been extended to Disability insurance in some countries (e.g. Belgium). While extra mortality of cancer survivors converges towards population mortality many years after diagnosis, the morbidity risk in cancer survivors remains high, as the studies cited in this article clearly show. Therefore, the concept of “forgetting” a cancer disease does not fit when considering morbidity and applying the Right to be Forgotten to Disability insurance should be considered with caution.

Summary

The long-term effects of cancer treatment are crucial when assessing Disability insurance risk because they significantly impact survivors’ overall health and quality of life. The increased risk of second cancers, cardiovascular toxicity, liver or kidney disease, and neurological complications can lead to severe health complications, necessitating ongoing medical care and potentially reducing life expectancy. Neurotoxicity and ototoxicity can impair daily functioning and quality of life, while renal dysfunction and hypogonadism further contribute to long-term health issues.

The heightened risk of infections, osteoporosis, and chronic fatigue can lead to frequent medical interventions and reduced physical capabilities. Mental health challenges, including anxiety, depression, and cognitive impairments, can affect survivors’ ability to work and maintain social relationships. These factors collectively underscore the importance of comprehensive risk assessment in Disability insurance for cancer survivors, ensuring that their unique health challenges are adequately addressed and managed.