Prostate Cancer: Forget the Defense…Let’s Go on Offense
With the Defense Secretary, Lloyd Austin, going AWOL recently with a newly diagnosed Prostate Cancer, it seems an appropriate time to visit the topic – Prostate Cancer, PSA readings and the life insurance underwriting concerns surrounding elevated PSA’s.
Prostate Cancer is the third leading cause of cancer deaths in men in the US. However, the very good news is that despite a prostate cancer diagnosis, only about 1 in 40 (very low risk) will actually die of the disease. What that means is that routine PSA testing is working and we are finding these cancers early. Yes, men should get PSA/ Free PSA routine testing.
This week’s ONE Idea will discuss things to consider when presented with a client who has had prostate issues.
AGE OF ONSET
Nearly every man over the age of 90 (almost 100%) will have prostate cancer present when they die, according to autopsy statistics. However, men are more likely to die WITH the cancer present than die OF the disease! This statistic shifts dramatically the younger we are and is in direct correlation with the levels of testosterone present at younger ages and diminishes as men get older. Testosterone is like Miracle-Gro to a prostate cancer cell so with testosterone levels falling off with age, the prostate cancer tumor cells grow much more slowly. Conversely, at younger ages with higher levels of testosterone, real mortality risk is present.
PSA
The PSA blood test (Prostate Specific Antigen) has been utilized effectively for decades as the best screening test to detect prostate cancer. Most men under age 70, will have PSA levels less than 3 but even up to 4 is considered normal. The ABNORMAL flag arises when PSA numbers are above 4.0. Every male above age 50 should have PSA and Free PSA testing performed at the same time as routine blood testing for comparison purposes moving forward.
FREE PSA
This blood test is often performed in tandem with the basic PSA screen. Free PSA breaks the total PSA into two component parts like total cholesterol testing that is broken into good (HDL) and bad (LDL) cholesterol percentages. The Free PSA component for a normal healthy male is 25%. Flags of concern don’t start until that number drops to 18%. So, the lower the Free PSA component, the more likely that a prostate cancer exists.
PSA VELOCITY
This term applies to the rise in PSA levels that routinely occurs as men get older and the prostate naturally enlarges (BPH-Benign Prostatic Hypertrophy). For ease of understanding, let’s say a male 60 has a PSA reading of 2.0 while the next year, the PSA reading is 2.5. A flag should be raised by a competent physician that, although the PSA level is still in the normal range below 4.0 as discussed earlier, this PSA velocity (speed of rise) year-over-year is a concern and should be investigated. In this example, the PSA velocity is 25% and a flag should be raised. That is exactly what happened in a case AgencyONE had last year with a very astute urologist in Pittsburgh.
THE DRE
The dreaded Digital Rectal Exam – a gloved finger examination of the prostate via the rectum. The prostate should be smooth and firm but in prostate cancer, nodules may be present, or the gland can feel boggy and enlarged. An abnormal DRE warrants further investigation by the doctor.
THE PROSTATE BIOPSY
If an elevation in PSA exists and the physician further screens with Free PSA testing or other diagnostic tests available today (like MRI), the next step could be a biopsy. The prostate gland is like a plum or apricot in size with two “lobes” and the urethra running through it. When/if the prostate enlarges, it can impinge on the urine flow through the gland (another topic for another time). In the case of a Prostate Biopsy, it is normal procedure to take 6 samples from each side of the prostate gland so 12 samples total from targeted and documented areas of the gland. These are called CORE SAMPLES and result in a pathology report for all 12 of these prostatic tissue samples.
GLEASON SCORE
The biopsy cells are graded on a scale of 1 to 5 as there are 5 very distinct cell patterns that occur as normal prostate cell tissue changes into tumor cells. The first score involves the predominant pattern of cells in the biopsy specimen. The scoring then takes a second step noting the second most prominent pattern and adds them together resulting in the TOTAL GLEASON SCORE. So, a male with a biopsy grade of 3 might have a SECOND most predominant pattern of 4 making a total Gleason score of 7 (3+4=7). A Score of 7 is a serious cancer. A score of 6 is less serious and more common. Higher numbers are worse.
TREATMENT OPTIONS
Prostatectomy – the surgical removal of the prostate does result in a second pathology report since the first report of Gleason Scoring was the result of just 12 biopsy probes. The Gleason Score on the final whole gland pathology can change for the worse.
Brachytherapy – Radioactive seed implants result in destruction of prostate cells from the inside out and have much less complications than the results of a total prostatectomy.
External beam radiation – Improved and better-focused medical technologies have created less complications with this course of therapy.
Active Surveillance – also called Watchful Waiting. This treatment option is noteworthy because a younger male, say age 60, with a low Gleason Score prostate biopsy might opt for no treatment since prostate cancers are slow growing and watching the PSA velocity may be the best course for a couple years. Additionally, there can be serious life changing complications with the treatment of prostate cancer, such as male erectile dysfunction. The second group of males – age 70 and over – seems to be the statistical cutoff line (the Defense Secretary is 70). Again, testosterone levels are falling so the cancer does not grow as fast and clients are likely to die with prostate cancer, not of it.
Underwriting a Watchful Waiting case can be challenging as many carriers prefer NOT to participate unless a definitive treatment has been chosen.
Case examples:
1. Mr. Smith, age 58, had an annual checkup 3 years ago. A lab panel was completely normal and included a PSA reading of 2.8. However, the attending physician APS notes indicated concern about his previous PSA reading of just 2.15. This .75 rise (PSA VELOCITY RATE) in Mr. Smith’s PSA reading warrants further investigation. The subsequent workup found a significant 4-core sample prostate cancer graded Gleason 7 (3+4). The client elected for removal of his prostate. No further spread was noted beyond the gland. AgencyONE was successful in negotiating a Standard Plus offer, and $4 million of permanent life insurance protection was placed for Mr. Smith.
2. Mr. Johnson is 64 years old and received a fresh diagnosis of Gleason 6 (3+3) Prostate Cancer in 2022. The client chose Watchful Waiting (active surveillance) which calls for follow-up biopsy checks, sometimes annually. In this case, Mr. Johnson underwent a one-year follow-up biopsy in December 2023 which showed a similar Gleason Scoring and no significant increase in spread inside the gland (core sample percentages). AgencyONE negotiated and received a STANDARD offer. The case is being finalized now at $7.5 million face.
AgencyONE’s breadth and depth of medical and underwriting knowledge and experience is a tremendous benefit to all of our advisors and their clients. We look forward to helping you with your 2024 cases and beyond.
Please contact AgencyONE’s Underwriting Department at 301-803-7500 for more information or to discuss a case.