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.