By: Nicola Mawson
Anyone who has seen a loved one battle lung cancer will tell you just how debilitating it is, watching them wheeze, undergo chemo, and potentially need oxygen. It’s perhaps the type of cancer most associated with that dirty word.
However, lung cancer is extremely hard to detect and, to qualify as a prescribed minimum benefit, must meet certain criteria that allow it to be deemed as treatable. According to the Cancer Association of South Africa (CANSA), lung cancer is the biggest killer out of all the cancer types.
Netcare has alarming statistics:
- 1 in 241 South Africans have a lifetime risk of developing lung cancer
- Two-thirds are diagnosed with late-stage cancer when the disease has spread to other parts of the body
Lauren Pretorius, CEO of Campaigning for Cancer, told Personal Finance that the figures for cancer (the second most common cancer among men at 12.4% and the fourth most common among women at 4.7%) are likely underestimates.
This, she said, is because there is a low diagnosis rates, limited access to treatment, and the lack of comprehensive data and reporting across the lung cancer continuum.
Pretorius explained that South Africa does not offer population-level lung cancer screening, even for high-risk groups, as the healthcare system prioritises the HIV and tuberculosis epidemics.
“The lack of data on the true cost of inaction is one of the major barriers to driving change. Without robust data, it is challenging to effectively advocate for the support and resources that lung cancer patients so urgently need,” said Pretorius.
The SA Journal of Oncology noted that lung cancer has a relatively high incidence in both women and men, with most lung cancer cases occurring from ages 50 onwards. “Historical data show that the incidence of lung cancer is increasing at a much higher rate in women than in men,” it said.
“While advanced therapies are available in the private sector, public hospital patients are left with older treatments and survivorship care is often overlooked. These systemic shortcomings create a 'leaky pipeline' where many patients fall through the cracks,” said Pretorius.
Yet, lung cancer, from a medical aid point of view, qualifies as a prescribed minimum benefit (PMB) only if it is “treatable” in terms of the Medical Schemes Act.
The definition of treatable, as provided by ASI Financial Services, includes:
- They affect the organ of origin and have not spread to adjacent organs;
- There is no evidence of spread to other organs that are far from the organ where the cancer has started;
- They have not brought about incurable damage to the organ in which they originated, or in another life-supporting organ;
- Or, if none of the above apply, there is scientific evidence that more than 10% of people with similar cancer, in the same state of advancement, survive on treatment for at least five years.
These very definitions of “treatable” pose a conundrum given that, as the World Health Organization states, “lung cancer is often diagnosed at advanced stages when treatment options are limited”.
CANSA stated on its website that more than two-thirds of lung cancer patients are diagnosed at a late stage after the cancer has spread to other parts of the body. “Even with surgery, radiation therapy, and chemotherapy, the five-year survival rate in lung cancer patients is amongst the lowest [of all cancers].”
Dr. Dion Kapp, Executive Manager for Managed Healthcare and Providers at Bestmed Medical Scheme, explained that cancer of the lung, bronchus, pleura, trachea, mediastinum, and other respiratory organs that comply with the definition of treatable cancer are PMB conditions.
“The PMB treatment includes the clinical-appropriate medical and surgical management. This also comprises of chemotherapy and radiation therapy as part of the PMB entitlement, subject to scheme rules, protocols, and pre-authorisation processes,” he added.
If the cancer doesn’t fall into treatable categories, paying for treatment will then be subject to the medical aid’s oncology benefits and limitations depending on which option is selected, said ASI Financial Services.
As ASI Financial Services pointed out, each scheme covers different services from its oncology benefits, and not all medical aids automatically provide cover for pathology and radiology services, radiotherapy, chemotherapy, and surgery from this limit.
Naseema Ephraim, MD of Employee Benefits at ASI Financial Services, explained that each medical scheme will have its own authorisation process, and any benefits are subject to an oncologist treatment plan. “The scheme then assesses what medical plan you are on, and they may issue rand limits or benefits limits to your treatment plan based on the plan you’re on,” she said.
It is generally accepted that the most prevalent cause of lung cancer is smoking. The Council for Medical Schemes stated that: “Cigarette smoking remains the primary risk factor for developing lung cancer and is estimated to account for approximately 90% of all lung cancers.”
In 2020, the Journal of Thoracic Oncology stated that it was estimated that 26.5% of adult males in South Africa are smokers and 5.5% are female. “The data on smoking prevalence are outdated and probably underestimated,” it said.
Richard Clemitson, Specialist Health and Gap Cover Advisor at Atacus Financial Services, said that being a smoker or not is irrelevant to cover, as long as the criteria for the cancer being treatable is met in accordance with Medical Schemes Council definitions for PMB. “Medical aid will cover costs as per plan type, regardless of the reason you contracted cancer.”
PERSONAL FINANCE