How family history of breast cancer affects underwriting
Inherited factors can influence breast cancer risk. Understanding how this affects underwriting can help advisers guide clients more effectively, as Zurich’s Nicky Bray explains in our latest article on family history.
Breast cancer is the most common cancer in the UK, with around 55,000 women diagnosed each year – roughly one every nine minutes – and a lifetime risk of about 1 in 71.
While most cases arise without a clear inherited cause, around 25% of all breast cancers could have an inherited component. According to the charity Prevent Breast Cancer, an estimated 8% of breast cancers are caused by a single faulty gene, while 12% result from the cumulative effect of multiple small gene variants. Another 5% appear to have an inherited component not yet identified by genetic testing2.
“As we highlighted in our recent piece on prostate cancer, inherited pathways can be some of the clearest indicators of risk,” says Nicky Bray, chief underwriter at Zurich. “Breast cancer has been shown to have strong genetic links. Knowing whether a close relative was affected – and at what age – helps us to assess risk and ensure cover is priced fairly.”
In this piece, we explore how family history of breast cancer influences underwriting decisions – and what advisers need to know when discussing cover with their clients.
Why family history of breast cancer matters
Genetic research provides a clear picture of why family history matters for breast cancer. The most commonly linked breast cancer genes are BRCA1 and BRCA2, while others include PALB2, TP53, CHEK2 and ATM3.
Around 1 in 250 of the general population in the UK are believed to carry a faulty BRCA1 or BRCA2 gene4. Alterations in BRCA1 or BRCA2 account for around 2.5% of all breast cancers but carry a high lifetime risk. Women with a BRCA1 mutation have a 60-90% lifetime risk of developing breast cancer, while those with an altered BRCA2 gene have a 45-85% risk5.
“Understanding these connections helps advisers explain to clients why a family history of breast cancer can affect life and critical illness cover, and why underwriting may vary when cases occur at younger ages or in multiple family members,” adds Bray.
How family history affects underwriting outcomes
When assessing breast cancer risk, Zurich focuses on three key factors:
- The age of the customer
- The number of first-degree relatives affected
- The age at which those relatives were diagnosed
“We ask the age at which a relative was diagnosed with breast cancer and compare it with the customer’s age,” says Bray. “This helps determine whether life cover can be offered at standard rates or needs to be rated.”
Unlike prostate cancer, where family history typically has little impact on life cover, both life and critical illness premiums can be affected by a family history of breast cancer.
“The reason for this difference is that breast cancer is less easily treatable than prostate cancer, so there’s a higher likelihood of a significant claim,” says Bray, “Even when life cover is offered on standard terms, we adjust the critical illness cover to reflect the potential inherited risk.”
Cases occurring at a young age or in multiple family members are particularly relevant.
“Early-onset cases, where close family members are diagnosed under the age of 40, are especially significant,” says Bray. “Likewise, if more than one first-degree relative has been affected, premiums and the acceptance terms of cover will be adjusted accordingly.”
In some situations, Zurich may apply an exclusion for breast and ovarian cancer where the equivalent premium loading would otherwise be very high. This allows the customer to retain cover for other critical illness conditions, such as other types of cancer, heart attack or stroke, while reflecting the specific inherited cancer risk identified during underwriting.
“Where the level of inherited risk would require a very substantial premium loading, an exclusion can sometimes be the most practical solution,” says Bray. “It ensures the customer can still access meaningful cover for many other serious conditions.”
In some underwriting scenarios, Zurich may exclude cover for less advanced breast cancers, such as cancer in situ, while continuing to provide cover for invasive breast cancer. In these cases, a claim would still be payable if the cancer meets the full critical illness definition for invasive disease.
Where premiums are rated, these are generally highest for younger customers with a family history of early diagnosis. This pattern differs from prostate cancer. With hereditary breast cancer, risk is highest at younger ages and declines if someone reaches later life without developing the disease.
“If someone reaches their 50s or 60s without developing breast cancer, it becomes less likely that a strong inherited risk is present,” explains Bray. “That contrasts with prostate cancer, where the risk increases with age.”
What Zurich asks applicants about
When asking about family history, Zurich focuses on first-degree relatives only. For breast cancer, this typically means a customer’s biological mother and sisters, excluding half-sisters.
“It’s about the risk we can reliably assess,” says Bray. “Asking about aunts or grandmothers can be difficult for clients to report accurately and, whilst there is a higher risk if a second-degree relative is affected, in isolation this adds less value for underwriting. By restricting the focus to first-degree relatives, we ensure the process is fair, practical and meaningful.”
Zurich also considers whether a customer has been advised to undergo earlier or more frequent breast screening due to family history.
Women aged 50 to 70 are offered mammograms every three years as part of the UK population screening programme. For those with a family history of breast cancer, clinicians may recommend yearly mammograms or MRI scans from younger ages.
For example, the National Institute for Health and Care Excellence recommends annual screening from age 30 for those deemed high risk, such as carriers of a faulty BRCA1 or BRCA2 gene or those with more than a 30% likelihood of carrying a faulty BRCA gene. If a person’s family history matches certain high-risk patterns, GPs should refer them to specialist services for a detailed risk assessment.
“If a GP or clinician has recommended earlier or additional screening because of a customer’s family history, this indicates a higher inherited risk,” says Bray. “We ask whether screening was recommended, whether it was attended or if it was declined.
“Where recommended screening has been declined or incomplete, life cover may be rated, and critical illness cover may include exclusions for breast or ovarian cancer.”
A study of the Swedish mammography screening programme, published in the BMJ last year, supports this approach: women who did not attend their first scheduled mammography were more likely to present with advanced-stage breast cancer and had a higher 25-year breast cancer mortality rate than attendees (9.9 versus 7.0 per 1,000 women)6.
Non-participants were significantly more likely to develop stage three or four breast cancer, illustrating that adherence to recommended screening is key to early detection and risk management.
Illustrative underwriting scenarios for customers under 50
Understanding how age, family history and adherence to recommended screening interact can help advisers to set realistic expectations for clients applying for life and/or critical illness cover.
Although underwriting decisions can be complex, the following scenarios illustrate how factors interact in practice:
| Family history scenario | Screening behaviour | Likely Life Cover outcome | Likely Critical Illness outcome |
|---|---|---|---|
| One first degree relative diagnosed under 50 | GP consulted; screening not required or completed with clear results | Standard | Rated or exclusion for less advanced breast cancers; invasive disease still covered |
| One first degree relative diagnosed under 50 | No GP discussion or screening declined | Rated | Full exclusion for breast and ovarian cancer |
| Two first degree relatives affected (any under 50) | No GP discussion or screening declined | Postponed or declined | Postponed or declined |
| Two first degree relatives affected (any under 50) | Screening completed as recommended | Rated | Full exclusion for breast and ovarian cancer |
| Two first degree relatives affected (both diagnosed over 50) | Screening completed | Rated (lower than early onset cases) | Full exclusion for breast and ovarian cancer |
“So, the outcomes for life or for critical illness cover can be quite different depending on whether the customer has or hasn’t talked to their GP or health professional and complied with any recommended screening,” adds Bray.
A key reason Zurich may apply exclusions for both breast and ovarian cancer is the shared genetic risk associated with BRCA1 and BRCA2 mutations. These inherited gene alterations increase the lifetime risk of both cancers; the average cumulative risk of ovarian cancer by age 80 is estimated to be up to 49% for women with a BRCA1 mutation and up to 21% for those with a BRCA2 mutation.
This combined risk explains why underwriting decisions based on a family history of breast cancer may also affect terms for ovarian cancer. Where strong inherited pathways are indicated—particularly when cancer occurs at younger ages or in multiple first degree relatives—the risk is not confined to one organ or cancer type.
Where the level of risk would otherwise require very substantial premium loadings, Zurich may apply a single exclusion covering both breast and ovarian cancer. This approach allows customers to retain meaningful cover for other serious conditions while reflecting the underlying genetic risk identified during underwriting.
Breast and ovarian cancer in practice: when Zurich pays
Underwriting helps to determine the terms of cover, but advisers are often equally interested in how breast cancer is defined when a claim is assessed. Almost one in three new cancers diagnosed in women will be breast cancer7, making it particularly important for advisers to understand how policies respond in practice.
“In insurance terms we’re trying to reflect how the condition presents clinically,” says Bray. “There is an important distinction between very early cellular changes and cancers that have become invasive and spread into surrounding tissue.”
Under Zurich’s core critical illness policy, the full sum assured is paid for malignant breast cancer that has been positively diagnosed with histological confirmation and is characterised by uncontrolled growth of malignant cells and invasion of the surrounding tissue.
Pre-malignant conditions, those that have borderline malignancy or low malignant potential and cancer in situ are not included in the full cancer definition, as these represent earlier stages where abnormal cells are present but have not yet spread into surrounding tissue.
Where breast cancer is diagnosed at an earlier stage, however, Zurich provides a separate partial payment benefit.
This applies where cancer in situ of the breast has been diagnosed and treated with surgery to remove the tumour. In these cases, the policy pays the lower of £25,000 or 25% of the sum assured.
Certain rare tumour types are also covered within the definitions. For example, neuroendocrine tumours of the breast – a rare form accounting for a small proportion of all breast cancers – may qualify for payment depending on their grade or stage.
This distinction reflects how breast cancer is treated. Early-stage conditions such as cancer in situ are often detected through screening and can be highly treatable, while invasive cancers may require more extensive treatment and can have a greater impact on long-term health.
“For advisers, the important thing is that the definition reflects the clinical seriousness of the condition,” says Bray. “Where breast cancer meets the agreed criteria, the policy will pay in line with the terms set out.”
Key takeaways for advisers
Advisers play a crucial role in helping clients navigate how family history of breast cancer affects insurance cover. The key is gathering accurate, relevant information while explaining the implications clearly.
Focus on first-degree, biological relatives
Collect information on close biological relatives. Although breast cancer can affect men, incidence is low, so the focus here is typically on mothers and sisters. Advisers do not need to record more distant relatives, such as half-sisters, aunts and grandmothers. They only share 25% of the client’s DNA, so are considered second-degree relatives, which Zurich does not consider for underwriting purposes. Step-relations and adopted relatives are not relevant from an underwriting perspective because they do not share DNA.
Capture ages at diagnosis
Early-onset cases – diagnosed under 40 – signal higher inherited risk. Risk also increases with each additional first-degree family member affected. Advisers should document both the number of relatives and their ages at diagnosis to provide a clear picture for underwriting. This helps insurers distinguish between general population risk and a materially increased inherited risk that could affect the claims experience during the term of the cover.
Understand the importance of medical referrals and screening
Where clients have been advised to undergo earlier or more frequent screening due to familial links to breast cancer, attendance matters. Advisers should note whether clients have:
- Discussed their family history with a GP or clinician
- Been recommended early or more regular screening
- Attended or declined screening
Explain the implications clearly
Advisers should highlight that inherited risk is highest at younger ages and generally declines if someone reaches later life without developing breast cancer.
Put risk into context
Most women with a family history of breast cancer will still never develop the disease, for example, women with one first-degree relative affected have roughly double the lifetime risk, while those with three or more first-degree relatives affected may have nearly quadruple the risk10. Advisers should emphasise that underwriting reflects these relative increases without penalising clients unnecessarily.
Gathering a clear, accurate picture helps us assess risk fairly,” says Bray. “We aim to ensure cover works as intended for clients who need it, while recognising that hereditary pathways can materially affect underwriting decisions.”
Sources
- 1Breast Cancer in the UK 2025: A Compendium, Breast Cancer Now, p7
- 2Genes and Family History, Prevent Breast Cancer
- 3Breast Cancer in the UK 2025: A Compendium, Breast Cancer Now, p13
- 4Genes and Family History, Prevent Breast Cancer
- 5Breast Cancer in the UK 2025: A Compendium, Breast Cancer Now, p13
- 6First mammography screening participation and breast cancer incidence and mortality in the subsequent 25 years: population based cohort study, The BMJ, September 2025
- 7Breast Cancer in the UK 2025: A Compendium, Breast Cancer Now, p7
- 8Familial breast cancer: collaborative reanalysis of individual data from 52 epidemiological studies including 58,209 women with breast cancer and 101,986 women without the disease
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