DATE OF ISSUE: 18 JULY 1995
COMPENSATION CLAIMS FOR METASTATIC NEOPLASMS WHERE THE PRIMARY SITE IS "UNKNOWN"
Purpose
The purpose of this DI is to provide the policy and procedures to be applied when a compensation claim for a secondary neoplasm or death from a secondary neoplasm is received.
Background
Metastatic neoplasm can spread to any site of the body. In most cases medical evidence available to the Claims Assessor indicates the primary site from which it developed. However, sometimes claims are received (often recorded as unknown primary) where medical opinion cannot definitely specify the primary site.
Claims Assessors have had some difficulty with these cases and a memo on the subject has previously been issued. Despite this, it has become clear that there is not a consistent application of policy or procedures. This DI is an effort to standardise the approach to these cases.
RMA SOP
The Repatriation Medical Authority has not addressed the question of issuing a SOP for a secondary neoplasm of an unknown primary. It may well be that the RMA will decide not to issue a SOP, taking the view that the determination should be based on the likely primary site.
Standard of proof
In this DI, the phrase, “real possibility” has been used to indicate the standard of proof applicable under the “reasonable hypothesis” regime. This means that the fact can be taken to exist (unless it is disproved beyond reasonable doubt) if there is material in the evidence that points positively to the existence of the fact, and the existence of the fact cannot be said to be obviously fanciful, impossible, incredible or not tenable or too remote or too tenuous. It must be consistent with known facts, and not merely be a possibility left open by the absence of evidence to the contrary. Thus, it must be more than a possibility and it must be positively pointed to by the material before the Claims Assessor, even though it is not proved upon the balance of probabilities.
Similarly, in the DI, the term “more probable than not”, has been used to indicate the standard of proof applicable to findings of fact under the “reasonable satisfaction” standard of proof. This means that the material before the Claims Assessor indicates that it is more likely than not to be true, or it is more probable than not to be true.
Protocol For Processing Cases
Claims Assessors must look at all likelihoods and possibilities and make decisions on the basis of the standard of proof to be applied to the claim. The following protocol should be followed
Confirming the Diagnosis
If a medical report has been received with an unconfirmed or provisional diagnosis on a claimed carcinoma:
check for other evidence on file to see if there is supporting evidence which may allow confirmation of diagnosis—information contained within the diagnostic protocols should be of assistance; and
where you are unable to decide whether the diagnosis can be confirmed refer this evidence to a DMO for advice as to whether confirmation of diagnosis is possible at this stage.
Otherwise, request advice from a DMO upon appropriate action to obtain a confirmed diagnosis—examination, referral, special investigations etc.
Claims received from overseas should be discussed with a DMO to ensure the adequacy of supportive medical evidence.
Where the claim is for metastatic carcinoma or death from metastatic carcinoma
If primary site is known then ICD code on CCPS and consider for a connection with service in accordance with the appropriate RMA SOP.
If medical evidence has not been able to specify a primary site follow the procedure below.
Disability Claims
Identify all other cancer sites suffered by the veteran.
Consider whether it is:
more probable than not (balance of probabilities) that they are primary sites of the metastatic carcinoma;
a real possibility (reasonable hypothesis) that they are primary sites of the metastatic carcinoma.
To do this it will usually be necessary to seek an opinion from a DMO on whether, on the evidence available, any of the identified sites are a real possibility or more probable than not primary sites of the claimed metastatic carcinoma.
The evidence which should be considered by the DMO in giving an opinion should include:
any histology of the secondary neoplasm available which may suggest a primary site
any history of previous cancer treatment which may suggest that this previous cancer could have been a primary site
any history of symptoms that might have been indicative of the primary neoplasm
Only in cases where the DMO is unable to suggest a site as being a real possibility or more probable than not the site for the primary should an opinion from a specialist be needed. This is expected to be an uncommon situation and happen only where there is insufficient evidence available to make an informed opinion as to a primary site. Some realistically possible and likely connections and clinical features associated with realistically possible or likely sites are listed at the end of this DI.
If any of the cancers satisfy the appropriate standard of proof as a primary site, then ICD code on CCPS as subject of claim and consider for a connection with service in accordance with the appropriate RMA SOP. If one can be determined as service related, no further investigation is required. The condition text to be recorded should be amended to read so that metastases are included. For example “Malignant neoplasm of the {site} with metastases”. This way treatment and pension will cover all aspects.
If none can be related to service, all possible and likely sites are to be rejected individually.
Death Claims
If death resulted from metastatic carcinoma:
Consider if any other cancer the veteran suffered from contributed directly to the death.
1.If yes
Each of the other cancers that contributed to death should be ICD coded as causes of death on CCPS and
If one is determined to be service related the death should be accepted.
If none can be related to service follow the procedure below in paragraph 2 for any other cancer that did not contribute directly to death.
2.If no
Then none of the other cancers contributed directly to the death and it should be considered whether they are likely (balance of probabilities) primary sites of the metastatic carcinoma; or real possibilities (reasonable hypothesis) of primary sites of the metastatic carcinoma.
Medical opinion from a DMO should be sought as detailed above.
If any of the cancers satisfy the appropriate standard of proof as a likely or realistically possible site, then ICD code on CCPS as cause of death and consider for a connection with service in accordance with the appropriate RMA SOP. If one can be determined as service related, no further investigation is required. Death should be accepted.
If none can be related they should all be rejected as suggested causes of death not related to service.
Once a decision is made as to the primary site of the neoplasm, Claims Assessors should be conscious of the contentions that would allow the condition to be accepted, especially as there may be different factors in existence apart from those leading to the determination of the primary condition. For example if it is decided under the appropriate standard of proof that the primary site was the lung then any consideration of the smoking history would not be necessary if the claimant was a Vietnam veteran since the SOP includes a contention on Vietnam service.
Some possible connections
It is possible to suggest the realistically possible or most likely site of the primary tumour from the location of the secondary.
Squamous cell carcinoma in a neck gland suggests head and neck cancer,
Carcinoma involving the axillary lymph nodes in a female suggests breast cancer,
Peritoneal carcinomatosis in a female suggests ovarian cancer,
Adenocarcinoma in liver metastases, with elevated CEA [carcinoembryonic antigen] suggests a stomach, biliary or colorectal tumour,
Tumours metastatic to bone include osteolytic or bone destroying lesions in carcinoma of prostate, breast, lung, thyroid, kidney, and bladder,
Tumours metastatic to brain include lung breast, melanoma, renal, colo-rectal, liver, uterus, colon, prostate, melanoma, eye, and sarcoma.
The above list is not, nor is it intended to be, exclusive. It is for guidance only. It is not to be applied as if it is the only links possible.
Clinical features associated with possible or likely site for unknown primary
Smoking history may suggest lung, bladder, pancreas etc,
Alcohol abuse may suggest liver,
Previous anaemia and loss of blood from the bowel may suggest colo-rectal,
Asbestos exposure may suggest mesothelioma,
Prior urinary problems may suggest prostate,
Severe headaches or disturbed vision may suggest brain.
Again the above list is not, nor is it intended to be, exclusive. It is for guidance only. It is not to be applied as if it is the only link possible.
Cases where possible or likely sites cannot be determined.
In rare cases it may be that a decision on a primary site under the appropriate standard of proof cannot be made. In order to assist us in formulating policy in these cases, would you please refer theses cases to Anthony Staunton, Compensation National Operations Policy, National Office.
W R MAXWELL
BRANCH HEAD
COMPENSATION AND REVIEW