Genomic Risk Profiling (or the £50 Heart Disease test)
Last month it was widely reported that a new genetic test, costing just £50 could identify people at risk of a heart attack years or even decades in advance. In actual fact the study referenced in many of the articles refers to a new Genomic Risk Score (GRS) developed by researchers based in Norway, with the early results of their study being published in the European Heart Journal. (Genomic prediction of coronary heart disease)
The study, part-funded by the British Heart Foundation (BHF), looked at using DNA testing to assess a person’s chance of developing coronary heart disease (CHD) much earlier in life and before symptoms even develop.
Currently, heart disease risk is typically calculated through clinical and lifestyle indicators such as blood pressure, cholesterol, and smoking. The Framingham (Coronary Heart Disease) Risk Score (FRS) is an algorithm used by doctors to predict a person’s ten year risk of developing heart disease and it is often the basis for GP’s to determine when a patient should commence medication. The FRS is however, less effective for lives under the age of 50 because coronary heart disease risk factors are usually only detected in middle aged people as they often do not cause symptoms until later in life.
What did the early results show?
Use in a clinical environment
If the new GRS becomes widely adopted in clinical medicine, we could see a move towards precision medicine (customised healthcare tailored to individual patient sub-groups), however history has shown us that biomedical scientific discoveries often take decades before they are adopted into public health care. The increased availability of improved data and genomics should accelerate this but if you consider blood transfusions as an early example of precision medicine (long before the phrase was first used) and that blood transfusion by blood type first became part of public health care in the 20th century, maybe we should accept the development of GRS with interest but with applied caution.
Almost 12 months ago, another similar breakthrough was announced - a relatively inexpensive blood test that could detect inherited heart conditions. Research into genetic testing for inherited heart conditions – such as cardiomyopathy and arrhythmia’s started over 20 years ago but since then, the technology used in genetic testing has advanced, becoming quicker and cheaper and therefore more widely available.
For those identified as having an increased risk of heart disease through their GRS blood test, it is almost certain that the increased risk will be identified at a much earlier age therefore giving the patient a greater chance of avoiding a heart attack through earlier clinical intervention such as Statin’s and by making improved lifestyle choices.
Of course lifestyle changes are frequently made by people at an increased risk of CHD but currently that increased risk is usually identified later in life. We know CHD starts at an early age and new genetic testing is therefore likely to lead to an improved mortality through the introduction of medication and lifestyle changes being made from a much earlier age.
How does this change underwriting?
It is important to remember that having a genetic predisposition to CHD, does not guarantee that person will have a heart attack. As with most diseases genetics only plays one part in determining whether someone goes on to develop a disease. Environmental factors and lifestyle choices also play a part, however these can be modified to reduce the risk, unlike those found to have an inherited disease.
It is too early to say whether the development of this new gene test will have a significant impact on the underwriting process because it is difficult to predict the availability of such testing for those who are thought to be at an increased risk, often because of a family history of heart disease. Furthermore it is likely to be many years before such a test is adopted into treatment protocols.
It also remains to be seen how much better it is in predicting heart disease at a young age compared to looking at existing factors, such as a person’s family history?
One advantage of the test is that it can be done at any age and it is more accurate at predicting risk for lives under 50 which is a benefit for the insured protection population and furthermore would become more important if we ever lose the ability to ask for family history at the point of underwriting.
It is also worth reminding ourselves that currently, insurers are not allowed to ask for the results of predictive genetic tests and even if the results of such a test are disclosed during the underwriting process, a positive test must be ignored. On this basis it is therefore unlikely that the underwriting process will change because of this clinical breakthrough especially as at this stage the test is only approved for research purposes.
Impact on Critical Illness cover?
Could the new GRS test result in an increase in claims or even lead to changes in the conditions typically covered by a UK Critical Illness policy?
As mentioned above, one likely outcome of the widespread use of a GRS for heart disease is earlier detection of those at risk of developing heart disease. As most people’s reaction to finding out that they are at an increased risk is to look for preventative measures, we are unlikely to see an increase in CI claims because of improved awareness leading to preventative measures being introduced.
Head of Underwriting
Article first published November 2016 on Cover online