PSA Values & Mortality Risk: Coverage Considerations
What to do about an elevated PSA value that is newly found on insurance screening or under “active surveillance”?
We know that the mortality risk is low for prostate specific antigen (PSA) screening values <10 ng/mL both from our own long-term studies of tested applicants and from complementary screening studies of other cohorts. Additionally, there is continued improvement in management of prostate cancer further reducing mortality from what we have documented, especially for hormonal therapy. Click this link to review our article on PSA values and increased mortality risk. The PSA cut-off levels that minimize both insurer risk and postponements are age-dependent and may be higher than you realize. Make sure you are not taking adverse action at levels lower than you need to protect your company.
A newer wrinkle in care for those diagnosed with localized prostate cancer is “active surveillance” instead of surgery or radiotherapy where underwriting guidelines are clearer. Active surveillance was recently discussed in an article by Jane Brody in the New York Times and is becoming both a more common approach and underwriting issue. Typically, active surveillance is considered for smaller tumors of Gleason grade 6 or lower. Assuming you find that the surveillance is active (similar to cancer follow-up), can you make an offer without postponement even with PSA elevated but stable? The excess mortality risk for those under active surveillance has been shown to be small, likely consistent with similar patients treated with surgery or XRT. Furthermore, almost all the excess risk would be 10+ years in the future so that if needed, a small permanent rating might cover the risk.
If you are not offering coverage to applicants in the active surveillance group now, it might be worth exploring. Low-risk prostate cancer is common and a substantial percentage of is now treated in this manner. A good reference by Juan Garisto can be found by clicking this link.
About the Author
Michael Fulks, MD, Consulting Medical Director, is board-certified in internal and insurance medicine. After leaving practice, he served as a medical director, creating or editing several underwriting manuals and preferred programs. For the past 13 years, Dr. Fulks has consulted for CRL, participating in its mortality research on individual tests and all laboratory test results, BP and build in combination. He is also involved in the development and implementation of automated screening tools for non-laboratory data.