Hi everyone, this week we are focusing on bowel cancer. This is a topic that is very close to Matt’s heart as he was diagnosed with Stage 3 bowel cancer some years ago.
Matt is sharing his experience of spotting the signs of bowel cancer, pushing for extra medical checks and the time that he learned of his diagnosis. We then talk through the treatments that he underwent and go through some medical terms, to break down some of the most common classifications for assessing cancer.
The key takeaways:
- Bowel cancer is the fourth most common cancer in the UK, and the second biggest killer.
- The main symptoms of bowel cancer.
- How staging and grading of cancer works and the TNM system.
I will be back in a couple of weeks with Roy McLoughlin and we will be chatting about group insurance. There is so much potential for introducing group cover to your clients, especially small-to-medium businesses.
Remember, if you are listening to this as part of your work, you can claim a CPD certificate on our website.
Kathryn: Hi everyone, this is episode seven of season three and I have Matt Rann with me. Hi Matt!
Matt: Good morning, Kathryn. You keeping well?
Kathryn: I’m keeping very well thank you, how are you?
Matt: Yes, yes not too bad apart from I’d like to have some sunshine and on the basis might be stuck in this country until at least August depending on which paper you read or which media outlet you read, then it’s an awful long way away but never mind, maybe the UK will do something.
Kathryn: Absolutely. I think we’re planning on something like that as well. We are focusing on bowel cancer today and like we usually do, we’ll be chatting about some statistics, what bowel cancer is and what to expect when applying for insurance. This is the Practical Protection podcast. So Matt, I have been looking at some statistics and I know that bowel cancer is something that is obviously incredibly important to you and sharing information about. If I go through some of the stats first and then I will give you a chance to chat about your side of things if that’s okay?
Matt: Yeah, sounds great.
Kathryn: Brilliant. So for anybody listening, cancer – well bowel cancer is considered to be a cancer that affects the colon and rectum. It also can be called colorectal cancer. Something I found quite interesting when I was looking into this for doing the podcast is that bowel cancer is the fourth most common cancer in the UK and the second biggest killer as well. The main risk factors for somebody developing bowel cancer would be being over 50, having a family history of bowel cancer, any polyps in the bowel and things such as quite extensive inflammatory bowel diseases such as Crohn’s or ulcerative colitis or potentially type-II diabetes. Now I know you’ve got quite a lot to share, Matt. Would you like to share your story with us please?
Matt: Yeah, absolutely. Well, as you know, we’ve spoken about it before, I have a history of bowel cancer myself. I was diagnosed 12 years ago. I’m still up and running and generally fit 12 years later so I was one of the lucky ones. I’ll give you a bit of background ‘cos I think there are some pointers here, at least with peoples’ general health at least. I went along to the doctor with one symptom and one symptom only and that was bleeding from my rectum. It was quite obvious that – to me, that I had haemorrhoids – piles in other words but nevertheless, particularly mainly with the degree of medical knowledge that I have, rather than just take that diagnosis as was, I went along to the GP. I always remember this GP being a very young lady, I think she was new out of university. A qualified GP obviously but very new, very young and all these – she was a locum GP for our local surgery and I always remember thinking, “Goodness knows, the poor lady’s going to have to do a digital rectal examination on this old man,” oldish man, I should say. But she did and God bless her for that. I wish I’d known her name as I’ll always thank her as the way things turned out.
Either which way, she got me off to the consultant – a consultant surgeon at the time and yes, he confirmed piles and said, “Oh come in any time you want to just to have them bandaged and treated in other words, and I said to him, “Well, you know, that’s all well and good but I’d rather have a colonoscopy.” Now colonoscopies aren’t – I think the general public, maybe our listeners, would thinking having a colonoscopy is quite a horrendous experience but now I’ve had quite a few, I can assure you that even the first one, apart from what came out of that, they’re not too bad at all. You are sedated a little bit and it wasn’t uncomfortable. A strange feeling but not uncomfortable at all. Anyway, so I said to him, “Look, can I have a colonoscopy ‘cos I’m not really sure about this?” to which he said, “Well you don’t need one however if you’re going to insist, yeah, come along.” Because it wasn’t seen as important, if you like, two months later I went for my colonoscopy and I remember this day extremely well because I was on the table and the scope was up my backside and sedated but I remember the guy who was obviously another consultant suddenly stopping and there on the screen right in front of me was this most amazing looking, I don’t know what I thought it was at the time, all I can really say is I remember it looking like a cauliflower.
Matt: What makes quite, dare I say it about a tumour, but quite a beautiful-looking thing! It was a very, very odd feeling. Either which way, cut a long story short, that was the beginning of my cancer journey. I was taken to hospital and again, they weren’t in a rush to do anything but taken to hospital. Six to eight weeks later, that was after various scanning techniques because obviously they want to see whether it had spread –
Matt: Beyond the colon and those were clear. I’ll come back to that.
Matt: Anyway, anterior resection of the bowel, all normal way of dealing with this type of thing, surgery went okay. Obviously I wasn’t – didn’t feel too great to start with, I was on a lot of morphine etcetera but, you know, it’s one of those things.
Matt: The bad news came, for me anyway, particularly as an underwriter, when in fact I went to see the surgeon and he had the histology of the tumour that they’d cut out and sadly – I say sadly, unfortunately it was a stage 3A so what had happened there was – we’ll talk about staging a little bit later but then we have 3A, straight in – what had happened was that the tumour had eaten its way through the bowel wall in totality and had gone into one of the local lymph nodes.
Matt: Now, it’s interesting. I always go back to the fact that the scan didn’t pick that up. That was only when they went in and cut the tumour out and did the histology.
Matt: I must admit, that was probably the first time I was a bit upset about the diagnosis. Before then, I wasn’t too bad really ‘cos I was fully expecting to get a stage one, maybe two but not a stage – probably a stage two to be honest with you by the size of the tumour. But –
Kathryn: I suppose as well, having all your medical knowledge – ‘cos sometimes we find that in our team is that obviously we don’t have the same medical knowledge as say yourself and obviously as quite a lot of underwriters but with the knowledge that we have and sometimes you see symptoms and you see different things, you kind of almost do think, “Hang on a minute, I remember a client that had this and this is what happened and this is what happened and this is the treatment they had to have,” and you do almost kind of – almost start to in a sense probably self-diagnose a little bit so we have to be very careful obviously not to do that. But for you obviously, in your experience, hearing obviously the stage 3A, I mean that’s going to have obviously sort of like brought home a lot of things to you that you’ve faced during your work?
Matt: Very much so, yes, and bearing in mind my history and experience in claims –
Matt: Death claims and critical illness claims, as well as income protection obviously, then yes it does bring home a lot of the – and to be honest, as a claims person you see – as an underwriter, ‘cos you see people who survive even some of the stage four cancers and stage four are the worst cancers in terms of the fact that they’ve spread.
Matt: And they survive and people can survive. Sadly, some people don’t make it but there we are. Nobody ultimately knows why one person with a stage 3A cancer will live a long, long time and somebody else with a stage 3A cancer will die tomorrow. Sorry, I’m a bit exaggerating – will die within a few years.
Matt: That’s quite remarkable. So I was stage 3A, got a little bit tearful at that particular time but soon got over that and marched on towards chemotherapy of which I had to have eight cycles, two hours at a time in a local hospital and I’ll be honest with you, the first one or two weren’t too bad at all but once it got to three, four, five, I felt absolutely awful.
Matt: And I have to say is probably the worst I’ve felt physically – not so much mentally but physically incredibly ill. It’s one of those things it’s really mind over matter whereby you have to think, “This is good for you, this is good for you.”
Matt: You hope and then six, seven and eight – in fact, to be honest with you, on the sixth, seventh – the eighth one you’ve got the finishing line in sight but certainly sixth and seventh, I wasn’t going to continue the chemotherapy. I felt so, so ill and it’s my dear wife who twisted my arm to continue going so –
Matt: Good on her.
Kathryn: Absolutely. One thing I was just wondering if I could quickly just sort of like pop in and ask there if that’s okay? So obviously I think a lot of us have all heard of chemotherapy. A lot of us know what chemotherapy is in a sense of chemotherapy treats cancer but I was just wondering if you could actually explain what it is? Is it something that, you know, is it, I kind of have an image that there’s like a tube going into an arm, that there’s something put through the body. Is that what it is?
Matt: Well yeah. I mean, absolutely. I mean, there are some extremely exciting modern improvements with treatment and immunotherapy and so on and so forth but yeah, I mean, it’s – to put it plainly, it’s poison.
Matt: Putting it very non-scientifically.
Matt: But it’s a poison which kills the cancer cells. One of the challenges is it also kills normal cells.
Matt: But effectively yeah, it’s chemicals, they’re pumped into the body and helps particularly with chemotherapy, you normally see chemotherapy certainly with bowel cancer when the staging gets to three to four. In other words, the cancer has spread.
Matt: Okay, and then the impact of the chemicals is that they will – they float around the body in terms of the bloodstream and seek out cancer cells in particular but also unfortunately healthy cells as well. So that’s effectively what it does but as being – if I can use that term, which is very unfair for chemotherapy really, bearing in mind what it does, it is a type of poison and the symptoms that you can get from it can be pretty severe. I do know people who have had chemotherapy and they have been pretty good, they don’t have the side effects but with me, again it’s one of those conversations you’ll remember forever but when I went to see the oncologist – so the surgeon has done his piece –
Matt: With me, in other words he’d removed the tumour as best he could so the next stage with a stage 3A, i.e. one that has spread, is for chemotherapy to do the treatments I just outlined and the guy said to me, lovely guy, lovely, lovely doctor and he said to me, “Well, with your staging, you’ve got a 50% chance of living five years.”
Matt: A one in two chance and he said, “I can give you a drug and I can also give you a combined chemotherapy and this will take you to –” From memory, the first drug took me to something like 60 –
Matt: 55, 60 and the second drug would add another five to 10% on the chances of living but he did say the second drug would make you feel ill.
Matt: “So what would you like to do?” I was always asked the direct question with Theresa, my wife, sat next to me, you know, “Which one do you want to do?” and I think anybody, particularly being a Dad and a relatively young one, I was actually 48 when this happened, you take the one to give you the best chances.
Matt: So it went on from that and as I say, that was finished literally two weeks before Christmas which was kind of a nice early Christmas present if you like. You have to stay off work for three months while your immune system builds back up so I did that, started work in March/April the following year and the rest is history really. I’ve been very, very lucky. Five years of follow-up with the doctors. That was always clear so very, very good news there and I’ve done a few tests myself – blood tests, which shows up tumour markers in your blood. Those are done privately and they’ve always been normal as well so I’ve been a very, very lucky man. Of course, it’s not today’s topic but the other angle on all this is, three years after I was diagnosed with bowel cancer, my wife – my dear wife was diagnosed with breast cancer. So it was quite a time really.
Matt: There might be people out there saying, “Well Matt, you’re an underwriter, you have knowledge of insurance, did you have insurance?” and the answer to that is yes we did, we did have critical illness policies both of us on a single life basis and all I can really say there is – and they weren’t huge policies but it did provide that degree of comfort if you like that, you know, in terms of the day to day expenses etcetera, etcetera, etcetera, there was that money in the bank and in terms of life insurance, yes, absolutely we’ve both got a fair amount of life insurance and we also have income protection insurance. So we were lucky but it’s, you know, I’m in the business, we’re both in the business, Kathryn.
Matt: So we know these things happen and, you know –
Matt: We prepared so really that’s my story. The one thing I would probably sum that up by saying is that if you ever feel that you disagree or you want a second opinion from another doctor and to put your mind at rest, I would always go for it.
Matt: I wouldn’t think doctors know everything. They’re only human beings just like us and I’m very, very lucky that I went with my instinct because maybe one year, maybe two years later, I wouldn’t be here now if I’d have left it.
Kathryn: No absolutely, I think that’s one of the things that was going to be sort of one of my key takeaways from this really is that knowledge and I think as well that’s something that, you know, some people may go well, again, you know, “Matt, you’ve got so much experience, so much knowledge on the medical side of things,” that you have that confidence to turn around and say, “No actually, I want you to be doing a proper check of this. I’m not messing about.”
Matt: Yeah, to be fair Kathryn, yeah.
Kathryn: Yeah, and I think that that’s really powerful for people to take away and I know obviously again it’s not this – it’s not the subject of this one but obviously I’m quite open about the fact that I’ve hypermobility syndrome –
Kathryn: And I had it – I have the not-so-nice version of it in a sense. I have hypermobility syndrome but I am – some people have it and they’re just quite bendy and, you know, obviously that’s fine. I’m bendy but I also can potentially break and sprain more easily than other people and, you know, we had – with my Mum, you know, she was just – when I was little, she had so much going on basically just saying to the doctors, “You’re not listening, this isn’t right, there’s something going on,” and she just kept going and going and going at them. She was accused of Munchausen’s and so many different things, you know, and it’s just the case of, you know, sometimes you do just have to really stick with your gut instincts and really force forward with that. So I’m obviously – I’m sure that everybody listening as well as me is really grateful that you put your foot down, Matt, with that and obviously as well I know you were given – I know you said about five years or so but obviously that you’ve absolutely smashed that timeframe.
Matt: [laughs] Well I think, as I say, there’s a degree of completing that chemotherapy thanks to my wife. There is also a degree of luck in there as well. There’s no two ways about it. The example I mentioned about somebody dying a couple of years after diagnosis with a 3A was actually a true story.
Matt: A friend of a friend – a lady, she was a little bit younger than me at the time of diagnosis but she died three years later and I always remember presenting at a reinsurance seminar in – well, London and Dublin for that matter but either which way and I mentioned this fact and a doctor – a young doctor got up and said, “That is what we need to find out – why?”
Matt: “Why did Matt survive and why did the other lady not?”
Matt: Which I’m sure will be down to genes and other factors called luck but either which way, thank you for all those kind words, you know, but I have to say, I’m a lucky man.
Kathryn: Well I think if we sort of like do – sort of like helping advisers and underwriters who may be listening – so if we can go through some of the key things there. So, with bowel cancer, what are sort of the main symptoms and I know this is obviously really important. What you said as well is you had one symptom, so you don’t have to have all of these but it was just one symptom you had. What would be the main symptoms for it?
Matt: Well bleeding is certainly a major one and bleeding, you should always go and see your GP. End of, don’t feel embarrassed. Certainly ones that you see in terms of the NHS sites and so on and so forth are changes in bowel habit. Now that is a difficult one to really say whether that’s because you had a lovely curry the night before or something – some kind of food that didn’t agree with you but I think the key – the red flag there, or the orange flag maybe is the fact whether this change in bowel habits lasts over a period of time, maybe up to a month. You know, everybody has a bad stomach now and again but if it’s – if you’ve got a change over a month, then go and see your doctor. Again, unexplained weight loss is an absolute classic but with bowel cancer it’s not an obvious feature. It doesn’t happen that often that you get a rapid and unexplained weight loss but nevertheless it is something to bear in mind and think about in the round if you like.
Again, tiredness. Everybody gets tired particularly in the world that we live in but if this lasts over a period of time then again, that is an indicator that there might be something wrong. I think with the tiredness, that could well be linked to iron deficiency which is another common finding to be honest with you in bowel cancer and when you first go for a – if your doctor is worried about that you might have a problem, then they will often take a blood test and look at your amount of iron. If you’re bleeding internally, then the amount of iron will go down and that will certainly not help with tiredness. And there’s the kind of obvious one – pain, lumps and bumps. Again, not necessarily easy to tell unless it’s extremely obvious and sometimes you will need a medical person just to – or a partner for that matter, just to have a feel in your abdomen and just get another view. I think those are probably about it. Interestingly, in terms of – this isn’t really a symptom but the – overweight, being overweight is often linked with bowel – or increasing the chances of bowel cancer as well.
Matt: But we can talk about that one later.
Kathryn: Yeah, of course. I think what really stands out about those is that obviously bleeding you would guess that most people would – if they saw blood would probably think, “Right, okay this is probably, you know –” hopefully they’ve been told at some point, if you ever have blood coming out of your bowels then that’s really something that, you know, obviously you need to get checked out. But for the rest of the things there, like you were saying, it’s hard sort of like because I think sometimes people brush off some of these things, sort of like saying, ‘cos it’s kind of the thing of, “Well a change in bowel habits, oh well that could be anything,” you know, everybody has a change of bowel habit. “Oh well, the tiredness, well I’ve got kids, of course I’m tired.” You know, and I think it can be quite difficult sometimes to pick out because as well, you know, I’m sure I’m not the only person as well where sometimes you’ve had symptoms and you’ve gone in onto the online checkers with everything and I’ve done it before with the NHS or something and I’ve put in like what would I think would be quite a mild symptom of something and it just says straight away, “You must immediately go to A&E.” And you kind of, you know, think, well, you know, it’s –
Matt: I completely agree with you. It’s a dangerous area I think.
Matt: In terms of kind of media reporting and so on and so forth but, you know, I think a lot of us know our bodies.
Matt: And if there is a symptom, no matter what it is, that is not normal for you and it persists, get on that phone to your doctor.
Matt: They, I’m sure, will be delighted to help and I don’t think any symptom that persists for a while, they’re not going to think you’re wasting their time.
Kathryn: No, no, I would agree.
Matt: Get down there and get checked out as soon as possible. That’s the key and we’ll talk about this later I’m sure –
Matt: But that’s the key with cancer. I know everybody would know this time and time again, get it early and the chances of survival increase dramatically.
Matt: So don’t put it off.
Kathryn: When it comes to obviously the diagnosis of cancer as well, there’s obviously quite a few different medical terms that fly about and I think sometimes as well, you know, obviously I know underwriters probably learn this quite early on and I think a lot of advisers come across this but it is something that can sometimes throw people sometimes in terms of, “What on earth do all these numbers and letters mean?” I was just wondering, just I know that you were saying before to me that there’s quite a few different kind of classifications of cancers but I think some of the main ones that we tend to sort of like see when we’re looking at things are – obviously we know the terms staging and grading but then there’s also something known as the TNM, so that’s Tango-November-Mike system as well. Could you just go through that for me please and explain what it means?
Matt: Yeah, absolutely. If I take a step back and a question just to start with, doctors developed staging systems if you like. I think the earliest one was in the 1920s, 1930s, particularly for all cancers but this was a specialist one for bowel cancer and this really is all about – from a doctor’s perspective, it’s how really to proceed with the treatment of a cancer. Okay, so it’s very important for them to have an idea and a most obvious scenario would be if the cancer has spread then they will treat that differently to whether it was completely localised. So these things have been developed with treatments in mind. The TNM classification certainly is a very well-known one and certainly as an underwriter is an incredibly valuable tool. It’s a very invaluable tool to a doctor so it’s also very valuable to an underwriter who will take it in the context of what’s the level of risk they are actually looking at here? So in terms of the TNM, the T really stands for the size or the extent of the primary tumour, okay? It’s interesting that now there seems to be at least seven or eight different categories for the T element. For instance, a TX – doctor’s, you know, this is important to know but TX actually stands for a tumour that cannot be assessed.
Kathryn: Oh right.
Matt: Of course that’s important for the eventual outcome and the way that somebody is treated. For instance, TIS is carcinoma in situ which is very, very low grade cancer, well, I’ll call it a cancer. TO, no evidence of tumour and then the rest of them really are around whether the tumour has eaten through the lining of the bowel and that goes right down to T4 which is where the tumour has grown outside the lining of the bowel wall. If I go back to my example, I was a T4.
Matt: Kathryn, does that sound okay for –
Kathryn: Yeah, yeah, absolutely fine for the tumour ones. So just sort of like probably a quick summary because I found this on Bowel Cancer UK. It was a really, really good resource for anyone to look at it.
Kathryn: So if someone’s told T1 that means the tumour is in the inner layer of the bowel, T2 means that the tumour has grown into the muscle layer of the bowel, T3 is that it’s going into the outer lining and then the T4 means that it’s gone through the outer lining of the wall. So I think that’s probably just a good little summary for everyone to maybe understand those types of things.
Kathryn: So the N now starts to go onto the next bit doesn’t it I think? The next stage of assessment is it?
Matt: That’s right. N stands for nodes and that’s really looking at the degree of spread to the regional lymph nodes, so the lymph nodes that all lie outside the colon and throughout the body for that matter. So this is where the tumour has eaten through the bowel, excuse the term ‘eaten’ –
Matt: But spread into the lymph nodes. Now with somebody who has not – it’s localised within the bowel itself will get an N0, okay? NON0. Again, you’ve got the categories of N2, N3 and effectively my cancer, to use the example again, was an N1, okay? You’ve also heard me mention it as a stage 3A –
Matt: Which is where these things – these stagings lie against each other.
Matt: 3B is two by the way in the classification that was used with me.
Matt: 3A and 3B, sorry, yes that’s right, but again N2 is where in fact it’s four or more, okay?
Matt: Again, it’s important there, you’re nearly always going to get chemotherapy with bowel cancer for when the cells have spread into the lymph nodes.
Matt: You know, to the eye, it’s pretty difficult, well in fact it’s impossible to know where those little cancer cells have spread in the body, hence why you have chemotherapy but here the histology would show under a microscope – what happened with me let’s say is that they took out the lymph nodes around the bowel and then they took – opened up four lymph nodes, one of which was crammed with cancer cells but the other three looked to be clear but I do use the term ‘looked to be clear’ –
Matt: That’s why I had chemotherapy because these things are so tiny, they can disappear everywhere and you don’t know and that’s again another reason why you’re followed up subsequently.
Kathryn: Of course.
Matt: Actually, do you want to say anything more about that, Kathryn? Did you just want to say anything?
Kathryn: I had a question in a sense. So for me, a lymph node, again, I’ve heard of lymph nodes, kind of know what they are but I also kind of don’t know what they are so if somebody said to me the heart, the stomach, you know, the kidneys, I can go back to sort of like GCSE, you know, biology and things like that in my mind. I can think, “Oh yeah, it’s going to look like that and it’s going to look like this,” and the same with muscles and things like that. But I actually don’t know what a lymph node is. Is it like a little ball or what is it? [laughs]
Matt: Yeah, it’s a node so whatever that conjures up in the mind and effectively it’s the drainage system. They contain lymph and that’s the body’s drainage system to get rid of unwanted materials if you like.
Kathryn: Oh so that’s why, if it spreads it’s seen as – it can then – ‘cos I believe with the lymph nodes, it can spread quite far in the body, is that correct in a sense?
Matt: Absolutely. The body is crammed with lymph nodes because, you know, all the organs need draining of the waste material and yes, once they get into lymph nodes it can travel very fast.
Matt: So again, that’s why I mention that I was a lucky man.
Kathryn: No, I know, of course.
Kathryn: Yeah, that’s absolutely – that’s really good for me I think and the next bit we have is the M.
Matt: [laughs] Yes, again, metastases so that is where the cancer has spread to beyond the lymph nodes. It’s often – people think it’s travelled distantly in the body, that’s another way of looking at it but technically it’s beyond lymph nodes and bowel cancer – the most common site for metastatic spread is the liver.
Matt: And you could also – the spine is another area, the lower spine also, you know, once the cancer has spread an awful lot then the lungs, brain etcetera, etcetera.
Matt: But the primary area that the doctors would look at initially would be the liver. That’s where it will settle –
Matt: And start to – the cells start to multiply in a random way which is of course what cancer cells do and it impacts the function of the liver.
Matt: So that’s what metastases are all about and in the context of me, sorry to keep on talking about me all the time –
Kathryn: No, go for it.
Matt: Just to bring back the live study if you want, I know it’s boring, so T4N1M0.
Matt: That was me and hopefully that gives you an idea.
Kathryn: Yeah, absolutely. So M0 means that the cancer hasn’t spread to other parts in the sense of it’s not – it has – so we know from you that the – it was N1, so it had started to go into the lymph nodes but it had been caught in time so it hadn’t gone elsewhere so that was M0 and M1 would be that the cancer had spread to other parts of the body?
Matt: Absolutely. Yeah.
Matt: So that’s a very quick run through. As I say, again these tables were not developed by underwriters at all.
Matt: But the underwriters have kind of piggybacked on them if you like and the primary uses for treatment, how doctors will treat you but because the treatment is a good indicator of the prognosis, how somebody will do in terms of being cured or not, then the underwriters will look at these and take them very, very seriously indeed and if the guys listening – the people listening ever come across a client who has cancer, if the client knows and bizarrely quite a lot do in my opinion from when I did tele-interviews and so on and so forth, people know straight away what their TNM is or was –
Matt: That’s an essential part of the underwriter’s book if you like in order to take things one at a case. To get that information, excuse me, right up-front, it will save a lot of time later on and managing expectations as well.
Kathryn: Absolutely, no I completely agree. Am I right in thinking that with the metastases, you wouldn’t have metastases if there hasn’t been lymph node involvement?
Matt: That’s a very good question. With bowel cancer, I believe the answer to that is no –
Matt: I would think there could well be other types of cancer where that could be the case.
Kathryn: Okay. No, it was just an interesting question. So we’ve just gone through obviously the TNM system. I know there are some other ones as well but I think a lot of us will be most familiar with hearing the terms staging and grading and I think from an adviser’s point of view that’s possibly what they’ve heard from clients the most. Could you just quickly in a sense give us – it’s very similar I think the staging to what we were just talking about with the T system in many ways but can you just give us a bit of a rundown about what staging means and what grading means please?
Matt: Yeah, certainly. The staging really is – again it’s a system okay, which effectively means how and if the cancer has spread. It’s simply a way of recording the way that the cancer has spread from its primary site and certainly stage – stage one is going to be the best, it goes through stages two, three, four if you like and again, it’s similar ground, that stage one as I said hasn’t spread outside the organ if you like, where the cancer has originated. Stage two, it’s moved into the outer layer of that particular organ, a bowel wall in terms of today’s topic. Again, stage three, the cancer has spread to nearby lymph nodes and stage four, the cancer has spread to other parts of the body. So you’ve got a familiar scene there I think –
Matt: From the TNM classification and as I say, stage literally is almost like an administrative term. It’s not a technical term per se for how the cancer has developed from its original site to, worst-case scenario, other parts of the body. In terms of grading, this is a little bit more technical I suppose, again a very simple word but it’s really how the tumour itself has developed. Now, cancer is again – simply called, it’s where the replication of a cell in the human body is very uniform, it’s slow and the cells don’t break away really to other parts of the body. Now, with a cancer cell, it’s – and this is where the grading comes in, can – I think I was reading an article the other day where it said that a cancer cell under a microscope looks like a wild forest.
Kathryn: Oh right.
Matt: It’s replicating all over the place and it’s completely random as opposed to a normal cell which is very uniform and steady which is an interesting analogy but there we go. Now, in terms of grading, if a cell hasn’t particularly – has shown signs of change but certainly hasn’t got to the wild forest scenario, then you call that a low grade, okay? So effectively the cancer cells are very similar to normal cells and you’ll hear the term ‘well differentiated’ for those. In terms of the next grade, and this is where the cells start to look more abnormal, so a minor abnormality, you could say is well differentiated or grade one. When they become more abnormal then that would be termed a grade three and when the cancer cells, using the wild forest analogy again, sorry, rather boring today –
Kathryn: It’s alright. No, I like wild forests, well obviously not cancer wild forests but I like wild forests [laughs].
Matt: It makes you think, doesn’t it? That’s why we’re –
Kathryn: You’re making it sound quite nice actually which is [laughs] –
Matt: Yeah, I did say my tumour looked, yeah, interesting.
Kathryn: Yeah [laughs].
Matt: Strange really. But again, high grade, so you’ve got low grade, moderate grade, high grade – these are where the cancer cells look very abnormal and multiply all over the place and look totally unusual and that’s again also termed as poorly differentiated. So that’s – I hope I’ve explained staging and grading. Grading is all about the cells and how they look.
Matt: Okay? One being the best, third being the worst and in terms of the staging, that’s really again – I hope people can see or hear that there’s similarities between T, N and M –
Matt: That’s where the cancer has spread outside the organ of origin, the primary tumour, stage one and then right through to other parts of the body, stage four. Does that work for you, Kathryn?
Kathryn: It does. One thing I was going to ask about the grading is, I know we’ve said that the grading is classed as like one, two, three – one being the least bad. That sounds terrible grammatically and three being the worst.
Matt: No, no, you’re absolutely correct.
Kathryn: Are they sometimes referred to as, in a sense A, B, C? ‘Cos I’ve sometimes come across people saying like the cancer, you know, there’s stage – that it was maybe 1A. Like you say, you know, yours was 3A.
Kathryn: So does that A – is the A just another interpretation or way of saying grade one?
Matt: I have to say that tumour classifications, you’d almost have to – because there are so many –
Matt: And they change all the time, you’d almost need to look them up in a textbook.
Matt: But to answer the question as best I can, and as I say these things do change –
Matt: Then yes, I would say that is a very good place to start.
Kathryn: Okay. That’s –
Matt: 1A would be good.
Kathryn: Okay, thank you. And right so probably the next thing is to sort of like talk about the treatments. Now I know we’ve spoken a little bit about surgery and the chemotherapy. I think we mentioned radiotherapy as well I think. Are there any other kinds of treatments or what would you typically expect to see? I do appreciate that obviously with bowel cancer there’s – quite a lot of the time I think it’s – I’m hoping it’s being caught earlier and earlier but I do think it’s typical that it tends to be a cancer that’s caught later down the line. So what would you typically sort of like imagine that the – would you expect your treatment schedule to be one that would be quite a standardised process?
Matt: Yes I believe it is. Again, the tables that we’ve been talking about – the TNM, Dukes’ classification as well, staging, grading, they were all designed to formalise treatment.
Matt: Okay? And therefore as a – with bowel cancer in particular, surgery with – when it’s metastasised or gone to the lymph nodes then next stage down the line metastasised outside the lymph nodes, then chemotherapy is required and we talked about chemotherapy earlier and what it does. The reality is of course it impacts all areas of the body and that’s where these little cancer cells can go to once they’re out of the organ of origin if you like.
Matt: Surgery, yes, they cut the tumour out and all the surrounding lymph nodes in my case. I think from memory I had 24 centimetres of colon taken out.
Kathryn: Oh, so a good amount?
Matt: That’s a large amount and it might be worth saying, I don’t – I think with maybe some of the disability benefits of course which are on the market place, in my particular case, my tumour was quite low down in the bowel, okay, so it wasn’t a rectal tumour but it was quite low down in the bowel and as part of the surgery I had most of my rectum cut out –
Matt: Removed. Now it’s – I didn’t have a stoma in other words that’s a colostomy bag. I missed that by about two centimetres I was told afterwards.
Matt: So I didn’t have to go through that and of course these kind of things can be temporary as well, let’s add that to the discussion but going back to O-level biology, the rectum is where you store the waste before you dispose of it completely.
Matt: The waste matter of the body and if you don’t have one, that can be on occasions quite problematical.
Matt: So it’s something that may come up from an underwriter’s perspective, looking at disability.
Matt: Not for life, when we talk about life insurance and of course people have to go through a postponement period which I think we’ll probably get onto – flag that with me please and then a rating schedule after that. But it’s an interesting one really. What I’m trying to say is there that yes, I think my life expectancy is pretty good at the moment but that’s not to say 12 years later on I still have some of the side effects from the surgery.
Kathryn: Yes, no I can appreciate that.
Matt: Hence the disability bit coming out. That’s why I mentioned that and apologies to everybody if that’s a little bit too graphic but I think it’s –
Kathryn: No, I think that’s fine.
Matt: But it’s important to know I think.
Kathryn: I think it’s really important to know so my Dad had emergency surgery to – it wasn’t last – not last December, the December before to remove part of his bowel because he kept – part of a complication it seemed to be with his Parkinson’s and different things was that he kept getting a twisted bowel.
Kathryn: So he had to have part of his bowel removed and he has been fitted with a stoma and, you know, there are lots of different things that actually, you know, stomas can be – especially for my Dad, it was – I’m convinced it was life-saving.
Kathryn: But, you know, there are potentially complications afterwards which obviously insurers and underwriters may be wanting to know about. Something that’s quite interesting I think as well is for people to sort of like understand, is that this is something we were told but obviously for somebody like yourself who’s had bowel cancer and they’re going through all that treatment, in a sense you’re not just having the treatment for the cancer, you’re also having to cope with the fact that somebody’s played about with your bowels quite a bit and from what I’ve been told, the bowels really don’t like anybody fiddling with them and they kind of go into a – we were told that basically if anything kind of like operation or anything is done on the bowel, that the bowel kind of shuts itself down and kind of basically goes, “Well stuff you then! If you’re going to do this to me, I’m not going to work anymore.” Obviously it’s quite a long time for your body to recover from that as well. It’s not a – cancer is obviously a massive thing to be dealing with but also the bowel surgery is something in itself that is quite an intense thing for the body to be coping with at the same time.
Matt: Yeah, very well said. Very well said indeed. Yeah. No, I would agree. It’s – all those things would be of interest to an underwriter. I think when you get to life insurance underwriting, then hopefully a lot of those things will be sorted out by the time the person can actually get life insurance.
Matt: But it’s something to bear in mind.
Matt: Without any shadow of a doubt. Is your Dad okay now, Kathryn?
Kathryn: Yeah, well yeah [laughs].
Kathryn: No, he’s good, he’s just a bit of a grouchy old man and doesn’t want to – I’m going to have to – I have to keep prodding him or trying – I’m doing that thing of, you know, like sort of like – and he’ll probably listen to this and he’ll just agree with me completely but I’m doing that kind of thing of like obviously I’m the adult but he’s the adult, you know, he’s my Dad and it’s very weird to change that dynamic to suddenly be kind of like, “No, you are going to do this and you are going to start moving and you are going to eat healthy,” [laughs] and at the same point he’s still his own man and it’s just like I can’t actually force him but I kind of – yeah, but no, he’s doing well, thank you.
Kathryn: He’s – obviously he’s well recovered from the surgery and he’s recovered well from his – he had his deep brain stimulation surgery so he’s recovered well from that.
Matt: Excellent, excellent news.
Kathryn: Absolutely. So we’ve got a little bit of a case study, not an extensive one to chat through but just a quick one for advisers. So we’d been approached by somebody that had been wanting to arrange some insurance for their company and obviously we were chatting away, we were going through things and looking as well on their personal side of things as potentially options there. And one thing that we did establish was that about two years prior to speaking to us, they had finished – just – well at that point, two years prior they had finished treatment for bowel cancer and they had what was known as a Dukes’ B4 cancer. Now I know that’s a different system to what we’ve been discussing but that’s just something maybe for people who are listening to maybe have a look up on that.
Matt: Yeah, great.
Kathryn: And what we were able to do was look at him – obviously because of the brilliant thing about group insurance is – obviously assuming that the company is eligible, that comes in terms of obviously where they’re located, the size of the company and a few other things that we were able to get that for him with a certain amount of free medical underwriting which basically means that you don’t need to go into medical history and the insurer doesn’t ask about it under certain levels. So we were able to arrange for the employees of the company to have £250,000 worth of life insurance to age 70 and that came to a premium of just under £70 per month. Another thing that I wanted to just bring to advisers’ attention as well is that there are potentially non-medically underwritten options and I know that some advisers can be a bit so-so about those because there are obviously pre-existing exclusions for a certain amount of time, usually anything within three years prior to the policy starting is excluded until they are – the person is at least two years free of symptoms and also even general follow-ups.
But what can be quite good, certainly on the personal space with somebody who’s had bowel cancer, depending upon obviously again the staging and the grading, for quite a long time it could be that with some insurers they would be declined insurance or that they’re going to be given particularly high per mille ratings and obviously as an adviser, that isn’t particularly easy to encourage somebody to have, depending upon how high the premium is going and obviously sometimes people just don’t want that. And what can be quite good, specifically as well in this situation, is that sometimes people can be outside of the non-medically underwritten exclusion period so they are covered for claims relating to the cancer and the bowel cancer on the non-medically underwritten options whilst they are still potentially seeing particularly unreasonable premiums. I say unreasonable premiums, I’m saying unreasonable in the sense of somebody’s budget – their allowance as to what they may be able to afford and so it can be potentially a good option to look at. So even if you are an adviser who’s not particularly sure of those routes or maybe doesn’t traditionally like using those routes, some clients, some situations – they can actually end up being very, very beneficial. So, that’s us coming towards the end of this. So this has been absolutely brilliant, Matt, thank you so much for going through all that with me. I think there’s been a lot of medical information in there and obviously bringing it home to your own personal experiences has just been extremely helpful. So thank you.
Matt: My pleasure.
Kathryn: Well next time, I’m going to be back with Roy McLoughlin and we’re going to be chatting about group insurance. If you’d like a reminder of the next episode, please drop me a message on social media or visit the website www.practical-protection.co.uk. And as always, please remember that if you’ve listened to this as part of your work, you can claim a CPD certificate on the website too. Thank you for joining me Matt!
Matt: Thank you, thank you for having me. See you next time.
Kathryn: See you next time, bye.