Unless you have been asleep at the wheel, you certainly heard at least passing mention of recently announced guidelines from the U.S. Preventive Services Task Force regarding the use of prostate specific antigen (PSA) testing as a screening for prostate cancer. You can read all about it here
if you missed it or need a refresher.
Further, if you have been in the life insurance business for any period of time, you have had a case come through your office with an elevated PSA history that was nothing but an exercise in frustration. I know I have seen my share of them, and there is perhaps no better issue to demonstrate the difference between clinical medicine and medical underwriting.
All of that said, what, if anything, does this recent announcement mean? Is it a game changer? Will it provide any relief from the frustration this type of history can cause both the insured and underwriter? Rather than speculate, I went to the Rolodex and called Will Walker, director of Member Services Underwriting at the Advantage Insurance Network. Together we posed the following questions to Dr. Jim Topic, Head Medical Director at Protective Life:
As a physician, what is your reaction to the recent announcement regarding PSA testing?
I was expecting the move toward this response. I wish more emphasis had been placed on risk selection and proper follow of high PSA. The main reason for the lack of clear benefit of screening is twofold in my opinion: High levels of crossover of screened versus non-screened populations and the high adverse effect of PSA follow up.
Will this study change the role of PSA testing as part of normal age and amount requirements?
I do not believe it will.
Will there be any impact on the underwriting of elevated PSA levels and prostate cancer
based on this new information?
If clinicians are no longer performing PSA testing, how would an elevated PSA discovered on the medical exam be handled?
First, it is unlikely physicians will change quickly. Second, PSA is still a valid marker of cancer and risk needs to be assessed.
What testing would you expect the clinician to perform to reach a level of comfort with an elevated PSA risk? Repeat PSA/Free PSA testing? PCA3 urinalysis? Biopsy?
All of the above, and I would expect more use of active surveillance post biopsy.
Currently, insurance companies run Free PSAs as a reflex test if the PSA is elevated on the exam. If clinical medicine no longer utilizes routine PSA testing, will you put more credence on the Free PSA results from the insurance exam?
Free PSA falls rapidly if the sample is not frozen. We do not advise use of free PSA on insurance labs unless proper handling is guaranteed. We currently use medical records, Free PSA, PCA3 ,PSA velocity and will continue to do so.
What do you perceive the insurance community will ultimately do if the PSA test is no longer used at the clinical level?
PSA will continue to be used by insurance companies. As therapy changes or becomes more specific, we will see more surveillance — likely rated as if partial therapy accomplished (if done at a documented center under a solid protocol). Better late chemotherapeutic approaches may allow lower Flat Extra/Table Ratings in future years. Most manuals have incorporated current advances as they can be documented. Due to the disease behavior, though, it takes years to document long-term effects.
Although we chose to incorporate the Q& with Dr. Topic, similar answers were given from other Tier-1 insurance companies' medical directors. Their feelings could be summarized by this statement:
"We are not reacting to recommendation by the U.S. Preventive Services Task Force. There's inconsistency regarding PSA screening in the clinical community between U.S. Preventive Services Task Force, American Urological Association and American Cancer Society.
Prostate cancer is still the second leading cause of cancer deaths among men after lung cancer. We continue to review PSA and prostate cancer assessments on an annual basis."
Clearly, this is far from a game changer. In fact, it may increase the frustration when dealing with this history because there seems
to be a body of opinion that discounts the relevancy of PSA testing. That leaves us in the field with a bit more work to do when working on a case with this history. Educating the client becomes paramount, and involves two aspects, as I see it: The first is the difference between clinical medicine and medical underwriting.
Simply put, the clinician has the luxury of time. He or she can afford to use a wait and see approach. The underwriter, however, needs to make a one time decision and then live with it for the life of the client. The second aspect is referenced in the last answer from Dr. Topic: it takes time for any new medical information to result in usable data for the underwriting
Of course, this is no guarantee the client will agree with you, but we have to play the hand we are dealt on this one.
Special thanks to Dr. Topic and Will Walker for their contributions.