Prostate cancer has hit the headlines recently as the Government announced a national screening programme. But what are the underwriting implications for those who already have prostate problems, asks Katie Bamber
The prostate is an integral part of the reproductive system for men. It is a small gland about the size of a walnut which provides the fluid necessary to transport sperm during ejaculation. It surrounds the first part of the urethra which carries urine from the bladder to the penis. The growth and function of the prostate gland depends on the male sex hormone, testosterone, which is produced in the testes.Three common diseases of the prostate are :
• Benign prostatic hyperplasia (BPH).
• Prostatitis.
• Prostate cancer.
Symptoms
The symptoms of both benign and malignant tumours are similar:
• Urinary hesitancy (slowed or delayed start of the urinary stream).
• Weak urine stream.
• Nocturia (needing to urinate two or three times per night).
• Pain with urination.
• Bleeding urine.
• Urinary retention (difficulty urinating).
• Increased urinary frequency.
• Strong and sudden urge to urinate.
• Incontinence.
About a quarter of men with prostate disorders have weak bladder muscle (detrusor muscle) function which is the major cause of the symptoms.
Tests
Various investigations are undertaken and the intention is to confirm the bladder outflow obstruction and then determine the cause (exclude malignancy):
• Rectal examination.
• Needle biopsy to take a sample of cells to examine under a microscope.
• Urine flow rate may be measured (men with BPH have a rate less than 10ml per second).
• Post-void residual urine (the amount of urine left in the bladder after urination) may be measured.
• Pressure flow studies to measure the pressure in the bladder as you urinate.
• An intravenous pyelogram (IVP) may be done to confirm the diagnosis or look for blockage, this is done by injecting a dye into a vein, usually the arm and it is carried by the blood stream to the kidneys. The GP can watch the passage of the dye from the kidneys to the bladder on an x-ray screen.
• Urinalysis to check for blood or infection.
• Urine culture if signs of infection.
• Prostatic-specific antigen (PSA) blood test. PSA is a protein produced by both normal and cancerous prostate cells. A high level of PSA can be a sign of cancer, but PSA levels can also be raised in benign prostate conditions.
There is not one PSA reading that is considered normal . The reading will vary from man to man and the normal level increases with age, but a value around four or less is considered to be in the normal range. A reading higher than four but less than 10 is usually due to a benign enlarged prostate. A reading higher than 10 may also just be benign prostate disease, but the higher the level of PSA, the more likely it is to be cancer.
• Cystoscopy to visualise the prostate and bladder.
Benign prostatic hyperplasia (BPH)
The definition of BPH is a benign growth within the prostate gland. The actual cause is unknown, but the condition may be related to the hormone testosterone and its relationship to other hormones that change during the ageing process.
It has been noted that eunuchs (men who have had their testicles destroyed or removed) do not develop BPH. Furthermore, after castration, BPH has been observed to regress. Although the tumour is benign, progressive growth of the tumour may cause significant obstruction of the urethra and interfere with the normal flow of urine.
The incidence of BPH increases with advancing age. BPH is so common that it has been said that all men will have benign prostatic hyperplasia if they live long enough. Some degree of BPH is present in 80% of all men over 40-years-old and this figure increases to 95% of all men over 80-years-old.
Medical treatment is sufficient to treat mild cases of BPH, but it often has to be treated by removal of part or all of the prostate gland. The most common operation is transurethral resection of the prostate (TURP) which is done through the urethra. The blockage is taken out using an instrument attached to the tube which can cut away the abnormal areas.
If the prostate is considerably enlarged, a direct surgical approach through the lower part of the wall of the abdomen and wall of the bladder may be necessary (prostatectomy).
• Life and critical illness (CI) protection ' when underwriting an application for life and CI assurance, if there has been no surgery involved and the individual has a normal urinalysis, and no renal impairment then the case can be quoted at standard terms. Any abnormalities would usually be postponed until all investigations had been carried out and evaluation made. If the individual has had surgery and is fully recovered with no residuals, then the case can be quoted on standard terms. Otherwise the rating will depend on the nature of residual abnormalities.
• Total and permanent disability (TPD) and waiver of premium ' as above the same decisions would apply. Terms quoted can be on an own, any or activities of daily living (ADL) basis depending on occupation.
Prostatitis
The definition of prostatitis is inflammation of the prostate gland. There are two main classifications of prostatitis:
Acute bacteria prostatitis ' this is an acute infection of the prostate gland, usually occurring in men aged 40 to 60 years. It is caused by a bacterial infection of the prostate gland. Many bacteria are capable of causing prostatitis. Escherichia coli is one of the more common types of infection. Ecoli is typically found in the colon.
Some sexually transmitted diseases can cause an acute prostatitis. These include gonorrhea and chlamydia. Typical signs and symptoms are fever, dysuria, discharge of cloudy fluid from the urethra and pain at the base of the penis. Urinalysis shows pyuria (the presence of pus in the urine making it cloudy) and bacteriuria.
Chronic bacterial prostatitis ' recurrent infection of the prostate occurs in men aged 50 to 80 years. It is associated with chronic urinary infection and commonly prostatic stones. Chronic prostatitis causes intermittent symptoms of urgency, dysuria and urinary frequency. It may complicate and aggravate prostatic hypertrophy and the symptoms will then overlap.
Antibiotics are usually successful in clearing an acute infection, although chronic prostatitis tends to be more resistant since bacterial infection is not always the cause of prostatitis. The prognosis is good with acute prostatitis but varies according to the severity and cause of chronic prostatitis.
• Life and CI protection ' when underwriting an application for life and CI cover, if the condition is present and the individual has a normal urinalysis then the case can be quoted at standard terms. Any abnormalities of the urine will be rated depending on the abnormality in question.
• Total and permanent disability and waiver of premium ' as above the same decisions would apply, terms quoted can be on an own, any or activities of daily living (ADL) basis.
Prostate cancer
In developed countries, prostatic cancer has become the most common malignancy in men and the second leading cause of death from cancer. For a middle-aged man the life-time risk of developing histological evidence of cancer of the prostate is about 40%, although evidence of clinical disease only becomes evident in about 10%. It may be discovered in an asymptomatic individual on rectal examination as a palpable prostatic nodule or by the incidental finding of an elevated PSA. The diagnosis is frequently made coincidentally following transurethral resection for BPH.
Differentiation of prostatic cancer is most commonly based on the Gleason system. The pathologist gives a score of 1-5 to the two most prevalent areas of loss of cell differentiation to give a total score ranging from two to 10. Higher scores correlate with a higher probability of extracapsular spread, nodal involvement and subsequent metastases. The overall Gleason score should be available to the underwriter. A score of less than six is regarded as favourable.
A recently-introduced term is prostatic intraepithelial neoplasia (PIN) which is graded one to three reflecting increasing risks of adjacent or subsequent invasive carcinoma.
Prostatic cancer is associated with elevated serum levels of PSA, but this is a non-specific marker, which is often elevated in benign prostatic disease.
Despite this lack of specificity, PSA is being offered as a screening test for prostatic cancer, often in combination with digital rectal examination, and these procedures are contributing to the more frequent diagnosis of the disease. In general the higher the level the PSA, the more likely is the elevation to be due to cancer. In view of this, it is quite common for insurance companies to obtain a routine PSA blood test on males over 50 particularly if they are assessing CI.
Curative treatment for prostate cancer by total prostatectomy or radiotherapy is only possible if disease is localised to the prostate gland and has not spread to pelvic lymph nodes or beyond. Prior to proceeding with high PSA levels in other words greater than 20, it is usual to perform a staging pelvic lymph node dissection with frozen section pathology, to confirm the absence of nodal spread. In contrast, treatment by radiotherapy does not usually include a staging lymph node dissection and the assessment is made clinically with imaging techniques.
• Life protection ' life ratings will usually assume full staging information, confirmation of radical treatment and no recurrence. Ratings will usually apply for lives over 50 ' younger applicants should be considered on an individual basis by the insurer. When considering life cover for prostate cancer there is a minimum delay period of one year from initial diagnosis and treatment. However, for more severe tumours the decision may range from a postponement period of up to four years to declinature.
If the insurer is able to consider terms following the delay period the extra premium normally consists of an extra cash premium that may be applied to a policy for a limited number of years. This type of loading can possibly revert to standard rates after the rating period.
• Critical illness: terms for CI cover are usually declined although some insurers depending on the grading can offer CI with a full cancer exclusion.
• Total and permanent disability and waiver of premium: following the normal delay period it is unlikely an underwriter would be able to consider any disability benefits.
Precise survival rates for prostate cancers are difficult to describe as there has been a large increase in the numbers diagnosed in recent years due to the increasing use of the PSA blood test. Of all those diagnosed with prostate cancer, about 80 out of every 100 live for more than five years after their diagnosis. 61 out of 100 will live for more than 10 years and 49 out of every 100 will live for more than 15 years.
