Case Clinic:
Elevated PSA

^{December 2024}

This series presents individual medical cases that feature challenging conditions, uncommon diseases, or an unusual presentation of symptoms. Below, we summarize a case, explain our research and analysis, and suggest an underwriting recommendation. Munich Re’s team of global medical directors continually track medical research so that primary insurers may benefit from evidence-informed risk assessments. It is our hope that analyses of more challenging cases will foster a greater awareness of medical progress and will help to expand insurability.

The Munich Re medical team investigated the insurability of a 58-year-old male applicant with hypertension who, two years prior to application, was found to have an elevated PSA level of 4.7 ng/ml during a routine medical exam. He had no complaints, his blood pressure was controlled on Losartan, and there was no family history of prostate cancer. On digital rectal exam (DRE) the prostate was reported as symmetrically enlarged, otherwise normal. A repeat PSA eight months prior to application was higher at 5.6 ng/ml.

The applicant was referred to a urologist for evaluation where he was noted to have LUTS (Lower Urinary Tract Symptoms) and an enlarged prostate on digital rectal exam (DRE) (estimated 50cc in volume) that was symmetric and without nodules or induration. A repeat PSA was 5.3 ng/ml and a Prostate Health Index (PHI) value was 32. A multiparametric MRI identified a PIRADS 2 lesion, prostate size of 61 ml, and no other abnormalities. On insurance labs, his PSA was 5.7 ng/ml and all other findings were considered normal. 

The Munich Re medical team recognized the potential of underlying prostate cancer due to the elevated PSA level. The increase in the PSA between visits is of uncertain concern as the PSA velocity of approximately 0.68/yr (5.6-4.7/1.33 yrs) is not particularly high but is certainly not favorable. The PHI result similarly was neither favorable nor within the high risk range. On a positive note, the subsequent MRI noting a PIRADS 2 lesion is associated with a low risk of csPCa, 5% or less.^1-3 In addition, the PSA density of roughly 0.09 (PSA 5.3/61ml volume) is also favorable and supports the notion that the PSA elevations can be explained by BPH. 

Given this favorable MRI finding and a favorable PSA density, and that there were no clearly adverse biomarkers or family history, the risk of important prostate cancer was deemed to be low and within a standard risk classification for mortality.  Morbidity risks can be accepted with an exclusion.