If you’re a man age 50 and over, and you apply for life insurance, the blood sample you provide will be screened for — among other things — the test that can signal prostate cancer.

But chances are you won’t even know the test for prostate-specific antigen (PSA) was performed until after the fact, and only if the results cause concern, says J. Alexander Lowden, MD, PhD, a senior vice president and medical director for LabOne Inc., a large laboratory that contracts with several insurers.

“[The applicants] are told in vague terms that the sample will be tested for a series of indications of risk — the wording varies from one insurer to the other,” says Lowden. “HIV risk is explained in great detail from a brochure given to each applicant, which they are required to read before the blood draw.”

That lack of pre-testing information concerns some health advocates such as Robert Smith, PhD, director of cancer screening for the American Cancer Society (ACS), and others quoted in a report in theJournal of the National Cancer Institute (Vol. 93, No. 13: 968-970).

Smith says that insurers certainly have a right to screen people who may be motivated to buy life insurance because they know they are at risk for prostate cancer, but if such a test is to be given, the applicant should know the facts first.

One fact is that what is considered a high enough level of PSA to cause concern to the insurer can exist in a man who might not develop life-threatening prostate cancer symptoms, Smith says. Because treatment for prostate cancer can have a big impact on quality of life — such as bladder control and sexual function — a lot of information should be given to men before they have the test, he notes.

“To me, where this really becomes a problem is where the insurance company has required you to have testing that you agree to without knowing what it entails,” says Smith.

That kind of pre-testing information is not routinely given, Lowden says, and probably impractical because of the range of diseases for which insurers screen.

After a person applies for life insurance and consents to a blood draw, the company usually contracts with a lab, which sends a paramedic to take blood samples from the applicants, at the request of the insurance company to which the person has applied, Lowden says.

“These people who are being tested have agreed to release a lot of personal information, medical, financial, and personal, to allow the insurer to assess the risk of writing a contract on their life,” Lowden says.

“Usually the applicant knows little about what the insurer uncovers,” Lowden says. “[But] sometimes the insurer finds the applicant has diabetes, heart disease, high blood pressure, and other illnesses that were unknown to the person before he applied for insurance. Sometimes, the insurer discovers the applicant has an elevated PSA. In all cases, it is probably better that the applicant knows about his risk.

“Insurers know full well that many of these men will not have prostate cancer — but some will,” Lowden says; “Is it not better to investigate and then decide on management than to bury one’s head in the sand? Insurers do not diagnose, they assess risk.”

The question is, what is the risk? There is not a single PSA level that has the same meaning for men of all ages, Smith notes.

Conventionally, a level of four ng/ml on a PSA test is considered the threshold at which a man should seek further testing, he says. However, a lower level in a younger man with a family history might prompt a workup. A level slightly over four in a much older man might not be considered sufficiently serious to recommend additional testing.

“An individual’s primary care provider is likely to be in a better position to help with those decisions, whereas the insurance company is not likely to have a sense of that responsibility,” Smith suggests.

Based on what the results show, a man would have to make some informed decisions, Smith says. Such results ought not be handed, mailed, or phoned to the applicant without information.

Lowden says the results from LabOne are not mailed to the applicant, but relayed to the applicant’s attending physician, who then tells his or her patient. In California, however, the applicant can request to receive the results directly, he adds.

“The insurer, on finding a person with an elevated PSA, usually refers the man back to his physician for counseling and further workup,” notes Lowden.

“Ideally, you should not get this information in the mail,” Smith says; “you should get this information from someone who can help you with the next step.”

After a PSA test comes in at four or above, the next step is usually an ultrasound-guided needle biopsy, Smith says. A decision on whether the cancer warrants treatment means weighing the risk of death with the risk of incontinence, impotence, and other side effects of radiation, chemotherapy, or hormones.

Factors to consider in this decision include:

• how high the PSA level is;
• the cancer’s Gleason score (how abnormal the tissue
  appears under a microscope);
• whether the rectal exam suggests spread to tissues
  next to the prostate;
• a man’s age; and,
• general state of health and his personal preferences.

The ACS recommends that health-care providers offer the PSA test and a digital rectal examination (DRE) yearly, beginning at age 50, to men with at least a 10-year life expectancy. Men at high risk, such as African-American men and those who have a father or brother diagnosed with prostate cancer at an early age, should begin testing at age 45.