Insurance blood testing for most, if not all, insurers includes a PSA (prostate specific antigen) test in males above a certain age range. Unlike testing for diabetes or kidney or liver disease, however, the PSA test is more controversial. It allows insurers to price more aggressively with a favorable result and requires more investigation with a questionable one. On the surface it appears no different from any of the other tests that screen applicants and reward good health with lower premiums.
Yet PSA is still very controversial. Enough so that the U.S. Preventive Services Task Force recommends against screening with PSA for men unless there are prostate disease symptoms or a strong family history. The American Society of Urological Surgery, as well as the American Cancer Society, disagrees with this approach. Diseases such as prostate cancer may well have passed the curable state if not screened for and found at the vulnerable period. Perhaps the biggest problem lies in how an applicant or patient handles the information and the consequences involved with next step testing and treatment.
Certainly no one disagrees that prostate cancer is significant—it is the most common malignancy in men and the second leading cause of cancer death in men behind lung cancer. The lifetime risk of developing prostate cancer at some point in a male is as high as 40 percent, with evidence of clinical disease evident in almost 20 percent, and approximately 5 percent of men afflicted with prostate cancer will eventually die from the disease. Pre-malignant conditions such as prostatic intraepithelial neoplasia (PIN) also are associated with higher risks of prostatic carcinoma. Significant enough that many men would want to know this risk to make their own decisions on doctor follow-up and potential therapy, as would an insurer in trying to arrive at an estimate of life expectancy.
PSA is the marker that is clinically used in initial screening for prostate cancer. PSA is produced by the prostate gland only, and significantly higher than normal numbers are suspicious for prostate cancer. There are other conditions of the prostate that may elevate PSA, such as inflammation of the gland, infection in the cells, and even a larger size prostate than normal. At a point where symptoms develop (such as urinary blockage, blood in the urine, pain), a doctor may suggest a further step in evaluation, such as a biopsy of the gland. The biopsies are uncomfortable, sometimes painful, and certainly inconvenient. They may also be repeated over time depending on measurements.
Rather than indiscriminately biopsying every man with an elevated PSA, doctors have more tools on their side in testing. Free PSA (a fraction not bound to proteins) is considered a non-pathologic form, and elevated levels generally are just followed. PCA3 is another, newer test that allows a doctor to decide if a biopsy is prudent. Many physicians have a protocol of watchful waiting, where results are monitored closely, particularly a sudden or determined surge or increase in PSA (called PSA doubling time). Treatments range from an entire removal of the gland to use of radiation, ultrasound and cryotherapy, each with its own set of risks and potential benefit.
The Task Force recommendations are most influenced by the fact that every prostate cancer does not turn ruthlessly malignant, and depending on age, other coinciding health conditions and quality of life considerations, will not be the absolute cause of death in people who do have more indolent cancers. Many are slow growing and don’t reach a point where they metastasize into bones or other organs, depending on a number of factors, including the age at diagnosis, the aggressiveness of the cells and the rate of PSA increase over time. The surgery itself is not without consequence—most men will be incontinent for a period of three to six months (although more than 96 percent recover fully) post surgically, and there is the definite risk of impotence, sometimes partial, sometimes critical. Again the odds are in favor of the individual on these counts as well, but a risk some men are not willing to take.
Insurance companies include PSA as a screen because the risk of cancer is significant enough to do so with an elevated PSA and no follow-up. When a doctor/urologist is following the case and the results favor a benign process, even best class rates are available to those with elevated PSA levels. In those with cancer that has been treated, the same guidelines apply for all cancer-free individuals who get policies as time bears out their successful result. The Task Force looks at things like potential costs of treatment, possibility of complications, and the fact that quality of life may be unacceptable to those whose treatment may result in a cure but a compromise in male or urologic function. However, you only have to ask one man who is dying of the painful bony metastasis of this disease in a hospice what it would have meant to have his life saved by judicious treatment.
Again, inherent in risk assessment pricing is knowing the odds of a cancer shortening life when determining premiums and insurability. If you are diagnosed with diabetes, for example, you know the risks of treating or not treating yourself with insulin, and you make an informed choice. The same occurs with hepatitis B and C, or kidney disease or heart blockage. You may turn down interferon or dialysis or coronary artery bypass, but you would most likely want to know the facts of the situation in order to make your best informed choice. As would your insurer in determining your policy status. So it is no different for PSA. I can tell you as a physician what my recommendations would be, and as a patient you have the option to pursue that course or another. Since the “other” choice definitely impacts the overall life mortality and morbidity in an insurance product, PSA is and remains a “must see” for the insurer in the blood profile results.
Robert Goldstone, MD, FACE, FLMI
MD, FACE, FLMI, board certified internist and endocrinologist, was most recently vice president and chief medical officer for Pacific Life and Pacific Life and Annuity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1991. Goldstone can be reached by telephone at 949-943-2310. Emaill: firstname.lastname@example.org.