Robert Goldstone

Fibromyalgia is a disease categorized by widespread musculoskeletal pain, fatigue and poor sleep of at least three months duration that is not characterized by any other systemic or rheumatic disorder. While fibromyalgia is often a disease of exclusion after other causes are ruled out (such as rheumatoid arthritis and lupus for example), a good detailed history and physical exam can lean strongly toward the diagnosis. Changes in the diagnostic criteria in the recent literature have resulted in more cases meeting the diagnostic criteria for this disorder.

It is estimated that about two percent of the population in the United States has fibromyalgia. It is significantly more common in women than men and may be diagnosed in both adults and children. Other terms given to the disease include fibrositis, chronic pain syndrome, muscular rheumatism and myofascial pain syndrome. While the exact cause of fibromyalgia cannot be pinpointed, it appears to involve disordered signal processing that involves the pain pathways. Suggested as possible causes are hypothalamic-pituitary-adrenal axis dysfunction, inflammation, small fiber nerve problems, and infections such as Epstein-Barr, Lyme disease and even viral hepatitis. Bottom line—it remains unknown.

Pain is the most common symptom, involving muscles and ligaments and most common in neck, shoulder, back and hips. Diagnostic criteria historically involved multi-site pain from six or more of nine possible sites: Head, left arm, right arm, chest, abdomen, upper back and spine, lower spine, left leg and right leg. Sleep disorder, cognitive symptoms (such as poor concentration and forgetfulness), and diffuse tenderness in multiple areas are also accompaniments. The three-month period is used to exclude such causes as acute injury, viral infection, etc., owing to the chronic nature of fibromyalgia as a disorder.

The differential diagnosis of fibromyalgia is difficult because it shares symptoms with so many other diseases. In addition to the aforementioned rheumatoid arthritis and lupus, systemic sclerosis, polyarthralgia rheumatica, Lyme disease, hyperthyroidism, hypothyroidism and even early multiple sclerosis have to be considered and ruled out. Even medications such as statins in treatment for high cholesterol may cause symptoms similar to fibromyalgia. There are no specific blood tests or imaging that are specific for the disease, and as such it remains an exclusion diagnosis.

Treatment for fibromyalgia has been less than satisfactory. Patient education and self-management, exercise, cognitive behavioral therapy and hot and cold application have been used with only varying degrees of success. Studies with cannabinoids and marijuana use are early and have shown some benefit. Analgesics are given but not as primary therapy, as addiction to chronic pain medication is a worry. Antidepressant drugs such as amitriptyline (Elavil), pregabalin (Lyrica) and duloxetine (Cymbalta) also have been used, but often the side effects cause just as many problems as the disease itself. No universal treatment regimen to this point has proved satisfactory.

Fibromyalgia is generally not a concern in life underwriting for mortality, excepting that chronic pain may cause significant emotional distress and consequences. Associated depression, suicide, accidents, excessive use of alcohol or drugs, and adverse drug effects from treatment certainly affect prognosis. It is more the effects of chronic pain and disability (including absences and time off of work) that comprise the risk more the disease itself. Those must be considered in waiver of premium and disability riders and applications.

Perhaps the one limitation with fibromyalgia is in consideration for preferred status. Preferred consideration may be given when pain is mild, there are no physical limitations, low dose medication is used, there is no change in medication dosage and no continuous opioid or benzodiazepine use (which carry their own risks). Likewise there should be no concerns regarding alcohol or drug misuse and no associated psychiatric or concurrent medical diagnosis that increases risk on their own.

There’s a great commercial on television that takes place on a golf course. A well-meaning man, who doesn’t look like he is testosterone deficient, sits next to an ex-football player and ex-baseball player, who look like they have enough testosterone to supply the entire country club. Of course, this leads to the question of whether or not testosterone supplementing agents should be used, with a conclusion that doesn’t leave much to the imagination. This raises a wonderful question on when testosterone therapy should be a concern, and if there aren’t a slew of underlying problems that didn’t make the final commercial cut.

Without going into the synthesis and essential functions of the hormone (careful, this is being written by an endocrinologist), we’ll limit this to testosterone supplementation and when it can do more harm than good. Male testosterone levels naturally drop as they age, and some men have low testosterone levels “just because.” The emphasis on promoting emotional, physical, sexual, and mental health is one guide, and bodybuilding, and muscle development is another. Most underwriting manuals don’t address testosterone and as such underwriting elevated testosterone levels can be murky. An entire cadre of physicians has gone into the “wellness” business, and for men testosterone supplementation is a regular prescription.

Normal testosterone ranges are wide. The labs give the expected range as between 300-1200 ng/dl. But as is the case with many hormone levels in the body, you can feel very normal at either end of the spectrum. With normal muscle development, sexual function, and activities of normal living, a level of 400 ng/dl in one man may be just as adequate as an 800 ng/dl in another. The Endocrine Society as well as multiple other endocrine associations recognize testosterone replacement only for testosterone deficiency or for cases of hypogonadism. It is sometimes used as an adjunct in treating frailty from chronic disease or malnutrition. In real life, a man complains of feeling tired, not being as muscular as he was earlier in life, depressed, or having some degree of sexual dysfunction. He is often prescribed testosterone no matter what the starting level of the hormone was. Testosterone is also a cornerstone in advanced bodybuilding. It may be used with other anabolic steroids not to treat a deficiency but to achieve a more desirable body image or status.

An astute question follows: “Should we look at it differently if there was a true diagnosis or deficiency rather than just used without a specific indication more than increasing the levels?” Assuming there are no other endocrine diseases associated with simple hypogonadism or even what would be considered a low normal value, the simple answer to the question is no. When testosterone levels increase to high levels, there are untoward consequences. High testosterone levels are implicated with increased incidence of myocardial infarction and stroke. There is increased blood clotting. Secondary polycythemia, with high hemoglobin and hematocrit values often result. High testosterone chronically drops HDL (good cholesterol), increases propensity to deep vein thrombosis and pulmonary embolus, may predispose to heart failure, and have an increased incidence of obstructive sleep apnea. While testosterone doesn’t cause prostate cancer per se, existing cancer uses testosterone almost as a fuel, and malignancy speeds up in growth rate. It is one of the reasons in biochemical recurrence or metastatic prostate cancer, therapies that essentially cut testosterone to zero are used (androgen deprivation therapy). Most consider it a contraindication to ever prescribe testosterone to those with a history of breast or prostate cancer.

Yet another question in underwriting comes up with concomitant anabolic steroid use with testosterone therapy. Many bodybuilders use both, which in addition to all the complications above will include liver failure and liver cancer. While we generally will not ensure men known to be taking anabolic steroids, detecting which clients may be users is a quandary. Lab testing may detect this, but we often don’t get specific labs on everyone we underwrite. Looking for low HDL with high liver function tests and secondary polycythemia can be a strong hint in that direction.

Replacement of testosterone in men who are deficient with levels that fall within the normal range during therapy pose little underwriting risk from that. Those however who show high testosterone levels over what would be needed in simple replacement, who show increasing weight and muscle development and perhaps increasing serum creatinine levels, who have a tendency toward the cardiac and clotting phenomena that increased testosterone promotes, or those who have secondary polycythemia, high liver function tests or decreasing HDL levels have to be underwritten with caution, and underwriting conservatively (or questioning specifically) is a wise option.

Image by JR from Pixabay

Raynaud’s phenomenon (RP) is a disease when sudden ischemia of the digits appears, generally as a response to small arterial blood vessels going into spasm. Most commonly the underlying cause is cold or emotional stress. The term Raynaud’s is used to describe both a disease and a phenomenon. Raynaud’s disease is symmetrical, most often appears in the fingers, and does not progress to anything serious. Raynaud’s phenomenon (or Raynaud’s syndrome) can be part of a much more serious group of impairments which can affect the esophagus, skin and fingers, and progress to gangrene in its more severe form.

The disease in Raynaud’s is more of an annoyance than a problem. Those affected can complain of sensitivity to the cold, and a pain and stinging feeling in their digits that gradually subsides with no long-lasting effects. It is the more common of the two. Raynaud’s phenomenon is often associated with rheumatic disease (especially systemic sclerosis) and can be quite severe.

RP generally starts slowly with several fingertips involved, but as it progresses, it starts to involve the entire palm. Intense throbbing, numbness and tingling, pain, and swelling then ensue. Numbness and an aching pain can last longer. It is a disease that primarily affects younger women.

RP can evolve and become secondary to many serious rheumatologic diseases. These include collagen vascular disease such as systemic sclerosis, systemic lupus, and
rheumatoid arthritis. Arterial diseases, arteriosclerosis and arterial occlusion can be primary causes. Neurologic disease, blood disorders, certain medications (like ergots given for migraine), and frostbite may also precede or be associated with RP. In other words, the associated conditions are quite concerning.

RP in its benign form is generally easily diagnosed from the short acting symptoms with no sequelae. Men suffer from a similar set of symptoms (particularly male smokers) called Buerger’s disease, but in Buerger’s lower pulses are absent. Frostbite is more easily distinguished by the characteristic exposure to severe cold.

Primary Raymand’s disease generally has no findings in between attacks, and physical findings are absent. When associated with a more ominous disease such as progressive systemic sclerosis, the underlying disease generally becomes apparent in the 24 months after diagnosis. The most common cause of PSS involves a syndrome known as CREST: calcinosis, Raynaud’s, problems with swallowing (esophagus), sclerodactyly (thickening of the skin), and telangiectasia. It may actually eat away bone when the disease is active.

When the diagnosis of the more serious Raynaud’s phenomenon is entertained, a series of specialized blood tests looks to determine the underlying cause. An X-ray of the thoracic outlet, sedimentation rate, CBC, antinuclear cytoplasmic antibody, antinuclear factor (ANF), cryoglobulins, and cold agglutinins blood testing is drawn. An angiogram may have to be performed to look for obstructing lesions. Gangrene and progressive internal organ damage are late and very damaging signs of the disease.

In assessing Raynaud’s phenomenon, underwriters look first and foremost for an underlying condition that may significantly affect mortality. The severity must be assessed, as well as any underlying complications, and prompt and effective treatment. Most simple cases of Raynaud’s disease do not result in any rating and preferred status is available. Raynaud’s phenomenon however is underwritten according to the severity and prognosis of the underlying disease, which may result in rating or decline.

Pulmonary nodules are almost always incidental findings on a chest X-Ray that are either discovered accidentally or when looking for something else. With the advent of new screening programs for high risk adults with a previous smoking history, more than a million new cases of pulmonary nodules are found, with approximately a five percent malignancy rate. It is no wonder underwriters and physicians take these findings seriously, and a thorough work-up is done to be sure any nodule encountered has a benign outcome.

People with cough, suspected pneumonia, difficulty breathing, or an abnormal lung field exam on physical are obvious candidates for X-Rays that may discover a lung nodule. In addition, the US Preventative Services Task Force (USPSTF) now recommends annual screening for lung cancer with low dose CT scanning in adults aged 50-80 who have a 20 pack year history and are either current smokers or who have quit smoking in the previous 15 years. The objective evidence is striking for this testing: findings showed a 20 percent reduction in lung cancer related mortality as a result of the scanning.

While multiple nodules may involve a more systemic process such as fungal infection, sarcoid, bacterial infection or tuberculosis, the single pulmonary nodule is most concerning as the risk of malignancy is significant. The growth may be a primary cancer or a secondary malignancy (metastasis) from a different body organ, and work-ups to try to determine the etiology as the only certain method of distinguishing a malignant from a benign process is by biopsy, which is often invasive.

The risk of malignancy is highest in solid nodules that are large sized, have calcifications that are not symmetric, and that double in size between one month and one year of observation. Nodules that grow more quickly are more likely inflammatory or infectious, and a different cause should be sought. Other characteristics of suspicious nodules include irregular or spiculated borders, ground glass appearance on X-Ray, and location in the upper lung lobes. Increasing age and cigarette smoking are associated with higher risk of lung cancer.

Work-up of the nodule is done in a sequential manner. If discovered on X-Ray, a CT scan is usually the next step to identify exact size and characteristics. Smaller lesions are generally monitored with serial CT scans. If a generalized process is suspected, that is worked up at the same time. Bronchoscopy can help make a diagnosis with direct visualization and cell washings from the suspicious area. CT guided biopsies are often sufficient for a definitive diagnosis, but open lung biopsies may have to be obtained when the lesion is small or in a spot that is inaccessible to the bronchoscope or to getting tissue in a vulnerable area.

The recommended management of an incidentally detected solid pulmonary nodule as defined by CHEST (the American College of Chest Physicians) recommends follow-up based on nodule size and intermediate and high risk factors that combine the aforementioned characteristics favoring malignancy. Nodule biopsies and bronchoscopy are considered when the nodule is within the reach of either procedure. When the risk of malignancy is significantly high, surgical resection is the procedure of choice. Nonsurgical options like ablative therapy or stereotactic radiotherapy may be considered for those who are at high risk of complication or death from a resection.

Underwriting a case with a pulmonary nodule starts with the results of investigation—a new nodule has to be worked up and evaluated before any case can proceed. There should be a good description of the nodule or nodules, including size, consistency, shape and margins from the original study. There should be follow-up of the nodule to see if it has been increasing in size, and how long that interval is. Biopsy and bronchoscopy results and the work-up from the chest physician and/or surgeon should have detailed and inclusive notes. If the nodule is for a more generalized cause, that should also have been worked up and treated.

A solitary pulmonary nodule is never a welcome and most often an unanticipated finding, but the good news is that most turn out to be benign lesions or part of a more generalized treatable cause. Either way, results from a detailed investigation are necessary for a good and expedient case outcome.

Fibromyalgia is a disease categorized by widespread musculoskeletal pain, fatigue and poor sleep of at least three months duration that is not characterized by any other systemic or rheumatic disorder. While fibromyalgia is often a disease of exclusion after other causes are ruled out (such as rheumatoid arthritis and lupus for example), a good detailed history and physical exam can lean strongly toward the diagnosis. Changes in the diagnostic criteria in the recent literature have resulted in more cases meeting the diagnostic criteria for this disorder.

It is estimated that about two percent of the population in the United States has fibromyalgia. It is significantly more common in women than men and may be diagnosed in both adults and children. Other terms given to the disease include fibrositis, chronic pain syndrome, muscular rheumatism and myofascial pain syndrome. While the exact cause of fibromyalgia cannot be pinpointed, it appears to involve disordered signal processing that involves the pain pathways. Suggested as possible causes are hypothalamic-pituitary-adrenal axis dysfunction, inflammation, small fiber nerve problems, and infections such as Epstein-Barr, Lyme disease and even viral hepatitis. Bottom line—it remains unknown.

Pain is the most common symptom, involving muscles and ligaments and most common in neck, shoulder, back and hips. Diagnostic criteria historically involved multi-site pain from six or more of nine possible sites: Head, left arm, right arm, chest, abdomen, upper back and spine, lower spine, left leg and right leg. Sleep disorder, cognitive symptoms (such as poor concentration and forgetfulness), and diffuse tenderness in multiple areas are also accompaniments. The three-month period is used to exclude such causes as acute injury, viral infection, etc., owing to the chronic nature of fibromyalgia as a disorder.

The differential diagnosis of fibromyalgia is difficult because it shares symptoms with so many other diseases. In addition to the aforementioned rheumatoid arthritis and lupus, systemic sclerosis, polyarthralgia rheumatica, Lyme disease, hyperthyroidism, hypothyroidism and even early multiple sclerosis have to be considered and ruled out. Even medications such as statins in treatment for high cholesterol may cause symptoms similar to fibromyalgia. There are no specific blood tests or imaging that are specific for the disease, and as such it remains an exclusion diagnosis.

Treatment for fibromyalgia has been less than satisfactory. Patient education and self-management, exercise, cognitive behavioral therapy and hot and cold application have been used with only varying degrees of success. Studies with cannabinoids and marijuana use are early and have shown some benefit. Analgesics are given but not as primary therapy, as addiction to chronic pain medication is a worry. Antidepressant drugs such as amitriptyline (Elavil), pregabalin (Lyrica) and duloxetine (Cymbalta) also have been used, but often the side effects cause just as many problems as the disease itself. No universal treatment regimen to this point has proved satisfactory.

Fibromyalgia is generally not a concern in life underwriting for mortality, excepting that chronic pain may cause significant emotional distress and consequences. Associated depression, suicide, accidents, excessive use of alcohol or drugs, and adverse drug effects from treatment certainly affect prognosis. It is more the effects of chronic pain and disability (including absences and time off of work) that comprise the risk more the disease itself. Those must be considered in waiver of premium and disability riders and applications.

Perhaps the one limitation with fibromyalgia is in consideration for preferred status. Preferred consideration may be given when pain is mild, there are no physical limitations, low dose medication is used, there is no change in medication dosage and no continuous opioid or benzodiazepine use (which carry their own risks). Likewise there should be no concerns regarding alcohol or drug misuse and no associated psychiatric or concurrent medical diagnosis that increases risk on their own.

Prostate cancer is a significant disease—approximately 10 percent of men will be diagnosed with prostate cancer in their lifetime and the lifetime risk of dying of the disease is three percent. In addition, prostate cancer is one of the few cancers that is actually rising in incidence, with a five percent year over year increase in diagnosis of men with advanced stage disease. While recognizing it is a significant disease, controversies on how often to screen for it (or whether to screen for it at all) exist within not only insurance medicine but in the population in general, as well as other differences in our field in rating and insuring the disease.

Screening recommendations for physicians (my son, in his third year of medical school, is being taught to rely on these guidelines) is under the oversight of the USPSTF (the United States Preventive Services Task Force). Their recommendations cover just about every suggested cancer screening from colon to breast to reproductive cancers. In their statement regarding prostate cancer, they advocate that the decision to undergo PSA screening on a periodic basis should be up to the individual and not the doctor. Excepting in very high risk individuals, the USPSTF would not screen for prostate cancer with PSAs at all. I can’t tell you how many men I’ve personally known who likely wouldn’t be here today without screening and prompt treatment of elevated PSA values. Yet the USPSTF comes to the conclusion from their data that the complications involved in prostate testing and/or prostate disease treatment outweigh the number of lives saved by said screening.

Many insurers include PSA screening as part of age and amount requirements when blood work is being done. The screening catches cases where prostate cancer is undiagnosed or when a workup should at least exclude cancer from the differential diagnosis. It also catch cases of non-disclosure where prostate cancer is a known disease and there is no treatment being chosen. Since this cancer is often a slow growing one, anti-selection may occur as the cancer may be an eventual death well after the contestable period has passed but well short of a standard or preferred priced mortality. While death certificates may reveal when prostate cancer is the proximate cause of death, those where the cancer contributes to a premature death from a different cause often isn’t captured in the statistics. Suffice to say, insurance experience favors a use of the screening PSA in mortality experience.

It is also controversial in obtaining the result just in and of itself. Most insurance applicants consent to a blood test when required, but few actually review what is being tested for. It absolves liability, but a man who consciously chose not to be screened by his personal physician may find he is non-consciously screened by his insurer. Harmless when negative, if positive and a cause for declination, just inquiring as to the reason for the decline may implicate the problem. The insured still has the option to consult with his physician as the next course to take (if any), but it is still an open ethical question.

Many men who are diagnosed with prostate cancer (particularly early in the disease) choose not to have active treatment but rather a process known as “active surveillance.” Here, both insured and doctor delay any intervention until a point where they deem the cancer to be aggressive enough to warrant it. The cancer may never become aggressive and last an indefinite number of years in an early state. Treatment may also be postponed until a man either has a medical risk that outweighs the benefit of treatment or postpones a procedure that may interfere with his sexual function until an indefinite point in time. Active surveillance is well recognized in the urological community of physicians as a very acceptable process in early or non-aggressive stages, but the insurance company is in a bit more of a difficult position. An insured may be lost to follow-up, or choose non-treatment regardless of any malignant change, or the cancer can progress to an incurable stage during the time period. Most insurers will take such cases if the stage of the cancer is early, the aggressiveness (Gleason score) is low, and the period of time being watched increases without any malignant change. But it is always an insurance risk, particularly if aggressively priced for.

The mode of treatment is also somewhat controversial, even amongst Urologists. Surgical resection is the most clear of the treatment modalities, but radiation treatment has been found to be very effective for qualifying individuals. Radiation is a little more difficult to follow clinically, since PSA (which drops to zero if the prostate is removed successfully) always has a measurable PSA in its aftermath. Cryotherapy, high intensity focused ultrasound (HIFU), and proton beam radiation are also less invasive modes of therapy, but with different overall success rates, and are looked at differently in terms of acceptable mortality by insurers.

Most insurers in known prostate cancer will insist on regular follow-up, and many will require that follow-up to be by a urologist. Specialist treatment is often a bit of contention—a family practice physician or internist may feel he or she is quite capable of managing the insured, but a specialist is more equipped to have dealt with similar problems and be current on the latest literature and treatment modalities. Either way, the more reassured an insurer can be, the better the offer that will result.

One more difference in opinion in insuring prostate cancer, whether treated or observed, has to do with the period of stability. There will be differences in how long after surgery (or radiation) an insurer may choose to wait before issue, and how long a period of time is considered adequate for stability of disease (and lack of aggressiveness) in active surveillance. There’s no concrete data regarding an absolute time period in either scenario, so the actual decision may vary amongst companies and underwriters.

Cancer treatment in the United States and results from same have improved markedly in the last decades. While some cancers remain uniformly deadly, others have progressed to remarkable cure and remission rates that would have been unheard of in years past. Most disturbing about prostate cancer though is its increased incidence particularly in advanced disease, and as such controversies remain not only in its clinical diagnosis and screening but in its insurance outcomes as well.