Laboratory testing is an essential part of risk selection. Most insurers run PSA levels to help test and screen for prostate cancer. In fact, the FDA has approved the use of the PSA test to help detect prostate cancer in men 50 and older.
The PSA test has been scrutinized for its value because incidentally found prostate cancer does not always become life threatening and false positives occur when this biomarker is elevated due to secretions from noncancerous inflamed prostate glands. However, it provides valuable information when risk factors such as degree of elevation and rate of rise are combined with a physical exam.
The recent release by the United States Preventive Services Task Force (USPSTF) has certainly stirred controversy, not only among the practicing medical community, but also in our insurance industry as well.
Basically the USPSTF’s message is that healthy men should not be screened with PSA testing because the test does not save lives overall and often leads to additional testing and treatments that cause pain and complications. The chairwoman of the USPSTF (ironically a pediatrician) stated that PSA testing cannot tell the difference between cancers that will and will not affect a man during his lifetime. That being said, there will be a lot of reaction in the medical field over the next weeks and months on this controversial recommendation. There are strong opinions on both sides of the PSA controversy.
Thousands of men who have had complications from being treated for prostate cancer of unknown virulence (including incontinence, impotency, bleeding, and effects of radiation on neighboring body organs) are vehement about the adverse effects. On the other hand, there is seemingly no end to the men who believe PSA detection and subsequent treatment saved their lives—men such as Major League Baseball’s Executive Vice President Joe Torre, bond financier Michael Milken, and former NYC Mayor Rudy Giuliani.
Two major health insurers are currently paying for testing and have affirmed they will do so in the short term. Others have taken a wait-and-see approach on their future position. The question of whether money will be saved administering the tests and avoiding end-stage cancer treatment versus the cost of the test and the complications of treatment make it a financial and political issue as much as a strictly medical one.
From a life insurance perspective, the choice about PSA testing seems a bit more clear-cut. Life insurers are in the business of assessing risk. Life insurance is priced on relative risk—those at the lowest end of the spectrum receive the best pricing and those at higher risk are likewise priced accordingly. Life insurance does not dictate who to treat, nor what treatment modalities should be chosen after evaluating complications and benefits. It is about life expectancy and providing for financial loss and beneficiary protection in that event.
PSA screening helps life insurers estimate a risk and provide more competitive rates to those whose risk is lowest. While no one can truly predict who will live for a long time and who will not survive prostate cancer, certain factors are quite clear and borne out medically.
Those whose PSAs are highest are most likely to have prostate cancer. Those with a lower free fraction PSA are more likely to have cancer than those in which an elevated PSA has a high free fraction. Those in whom PSA velocity rise is fastest are more likely to have cancer than those who don’t have this finding. Finally, those in whom prostate cancer is detected and definitively treated have better mortality than those who are untreated. This is not meant to take into account complications of treatment that are not life-threatening, but simply life expectancy—the tenet of life insurance underwriting.
Men have the option of treating prostate cancer or following it with their urologist for progression. They likewise have the option of not treating or not knowing; however, testing is a matter of preventive health.
Several years before, the USPSTF came out with a similar recommendation on mammograms: that they should be used far less or not at all as a screening procedure for women. That recommendation was met with even more controversy and has not appreciably decreased mammogram testing (which can certainly be life-saving when cancer is detected early).
Life insurers order tests all the time that assess risk but do not cause intervention. In fact, the entire blood profile—from liver function tests to evaluation of kidney status, fructosamine and hemoglobin A1C screening for diabetes and cholesterol and lipid panels—is designed to segregate risk and reward for those in whom the results show the best outcomes.
Life insurers do not practice medicine nor do they tell men and women what treatments or interventions they should be receiving. Likewise this will apply to PSA, where risk will be assessed just like any other parameter and priced accordingly.
Men have the right to know or decide not to know what their health status is or, with the counsel of their doctor, whether to pursue further treatment for any medical result. The right to be informed is a controversial issue—a decision that some don’t want to face while others insist on knowing. Either way it falls, knowing someone has a lower risk of disease is paramount to life insurance underwriting—and particularly the preferred pricing which the industry consumers demand.
All life insurers will be monitoring the debate on PSA testing very closely, conducting their own mortality studies and carefully monitoring those of major medical trials to see if any changes need to be made to the current model as well as what will work best and most economically for the life insurance purchaser and consumer.
In the meantime, PSA testing is a part of risk assessment that allows insurers to continue to make the most competitive offers possible, working with information that certainly helps to predict life expectancy over the long term.
