Around age 50, a man faces the decision of whether to have a prostate-specific antigen testa decision that might save his life from cancer but may also lead to difficult treatment choices and debilitating side effects.
For men seeking a sizable life insurance policy at this age, another factor is increasingly likely to weigh in: no PSA test, no policy. With many companies, PSA level has become part of a standard battery of blood tests, along with HIV, cholesterol, liver enzymes, and other predictors of premature death.
Steven H. Woolf, M.D., of Virginia Commonwealth University, Fairfax, Va., noted that tests such as a blood cell count or a cholesterol test as part of a physical have less onerous consequences because the results have valid health significance.
However, "most major medical groups recommend that men not have the PSA test without receiving counseling from their physician, because they face a substantial risk of needing a needle biopsy or even undergoing unnecessary surgery as part of the cascade of events that begins with the blood test," he said. "The insurance company essentially preempts that counseling by including [PSA] with their tests and denies the applicant the opportunity to understand what he is getting into."
In contrast to the looming hulk of genetic testing, which the insurance industry has worried over and debated for years, PSA testing slipped quietly into the testing protocol. But screening experts say the trend is troubling. They worry that men are being tested first and learning about the risks and benefits later. In many cases, men do not even know that their PSA level is being tested.
A retired government administrator in Maryland recalled when, in his late 50s, he decided to apply for additional life insurance. The insurer required a physical examination and blood tests that, unknown to him, included a PSA test. When the result came in at 4.5 ng/mL, just over the standard cutoff of 4.0 ng/mL, the insurer told him he would need urologic evaluation. Consulting with his doctor, the man learned that his doctor had ordered a PSA test about one month prior to the insurance companys test as part of a routine physical exam.
The test ordered by his doctor came back at 3.2 ng/mL, but he was not informed of the results because they were within the normal limits. Concerned about the disparity between the test results, the doctor recommended a third PSA test. The third test came back at 4.0 ng/mL.
After further consultation with his doctor, the man decided to forego further tests and biopsies and was declined by the insurance company. About a year later, he found a company that wrote him a policy despite a PSA level of 4.6 ng/mL.
Test Required
A survey of 20 life insurers found that nine require PSA screening of all male applicants irrespective of the size of the policy, typically starting at age 50, but with starting ages ranging from 40 to 60; six insurers screen if the policy is over $250,000 or $500,000; and five others screen only "for cause."
LabOne Inc., a testing laboratory in Lenexa, Kan., performs about 60% of all U.S. life insurance testing, said senior vice president and chief medical director J. Alexander Lowden, M.D., Ph.D. Among male applicants over age 50, 47.9% are tested for total PSA. Of these, 3.7% have results in the mildly elevated range between 4 and 10 ng/mL. The company recommends that these men have follow-up testing for free PSA levels versus total PSA levels, a more specific indicator of cancer, but only one third of them do so, Lowden said.
Some researchers who study PSA screening say the situation is troubling.
"Ethically, its really problematic to do a test and say, well deal with the consequences later," said Christopher Coley, M.D., of Harvard University Health Service, Boston, who was a member of a national Patient Outcomes Research Team for prostatic diseases. "PSA is particularly problematic because the clear proof of benefit, at least for the average man, just doesnt exist the way it does for mammography, for instance."
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David Atkins, M.D., coordinator for clinical preventive services at the federal Agency for Healthcare Research and Quality in Rockville, Md., agreed.
"Insurance company screening raises two problems," Atkins said. "It is coercing individuals into getting tested with an unproven technology, which may actually do more harm than good to the individual. Second, it removes testing from the clinical setting where actions can be taken to reduce harms and maximize benefits."
Robert Smith, Ph.D., director of screening at the American Cancer Society in Atlanta, agreed that it is "a little troublesome that someone would be compelled to have a PSA test in order to get life insurance." But because no screening test is perfect as a predictor of premature mortality, he noted, it is difficult to draw a solid line defining which tests are appropriate for life insurance decisions.
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"Insurers do lots of tests on people to find things they didnt know," he said. "We find lots of people who didnt know they had type II diabetes. This is considered reasonable because you can alert the person to his problem and perhaps he can do something about it. Whats the difference between doing that and finding out somebody has prostate cancer that they dont know about?"
Antiselection
In reality, what concerns life insurance companies most are conditions that applicants do know about but do not want the insurer to know. A priority for insurers is avoiding antiselection or adverse selectionas defined in an insurance text, "the process in which the exercise of choice by insureds leads to higher-than-average loss levels since those with a greater probability of experiencing a loss are most likely to seek that kind of insurance." If a man knows he has an elevated PSA level but conceals the fact, it might put the insurer at risk.
"If patients didnt have these things done on a very regular basis in their physicians offices, we probably wouldnt be doing them," said Charles S. Jones Jr., M.D., vice president and medical director of ING Security Life of Denver and secretary-treasurer of the American Academy of Insurance Medicine.
According to the LabOne Web site, 70% of U.S. men over 50 have had a PSA test and know their results. Experts said data are lacking on how many men have had the tests, although 70% is a reasonable guess. But the American Cancer Societys Smith added that "Being tested and knowing your number are two different things ... Im skeptical that many men could quote their numbers."
Coley noted that insurance companies do not ask applicants to undergo flexible sigmoidoscopy screening for colon cancer, "where theres actually a much stronger database of evidence suggesting that its helpful." But Jones explained that it does not make sense for insurers to do tests like sigmoidoscopy that are invasive, costly to the company, and may put off a potential applicant. PSA, by contrast, is simple to add to a list of blood tests. Before the AIDS epidemic, he said, insurers rarely did blood tests at all. But once they began screening for HIV, it was a natural step to add others, including PSA. Insurers are less likely to do blood testing on applicants for small policies, he added.
"Look at it from my point of view," said Jones. "A man comes to me asking me to insure him for a million dollars. Id love nothing better than to sell him the policy, but I have to assess the risk involved, to have some way of determining what his mortality expectation is. I have some sympathy for a man maybe not wanting to know his PSA, but if hes that concerned, thats finedont come and ask me for insurance."
Peter Albertsen, M.D., of the University of Connecticut, Farmington, also defended insurers use of PSA testing. These companies are not concerned with whether screening and treatment alter the natural history of this disease, he noted, but rather with identifying anyone who might have an increased risk of dying prematurely from any cause.
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Lowden added, "I dont think too many insurers are worried about coercion in doing PSA testing. That might have been an issue 10 years ago, because the public was concerned that, if you had prostate cancer, the first thing they were going to do was operate on you and make you impotent or incontinent or both. I think thats not as big an issue as it was." The main reason a man would balk at having a PSA test, he said, is concern about employabilityhe may lose out on a job if the prospective employer fears exorbitant health insurance costs tied to the test result.
On its Web site, LabOne asserts that "The majority of cancers detected by an elevated PSA result are aggressive cancers. PSA does not detect latent or indolent, slow-growing cancers."
But experts challenged this statement, with Woolf calling it "absurd."
"There is no good evidence to support the statement that most are aggressive," Woolf said, "and most experts would argue the opposite: that most cancers detected by PSA are not destined to progress to clinical significance."
Even Lowden agreed that the statement is inaccurate and "really shouldnt be there." But "Its written for underwriters who are nonmedical people," he said, "and what were trying to do is sell tests."
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