Malignant conditions may affect one or more body systems.
Hence, any malignant condition can potentially be assessed by the following methods:
by applying the system-specific tables contained in Chapters 1 to 12. A number of those tables may have to be consulted if the malignant condition causes multiple losses of function;
by applying Chapter 14 which relates specifically to malignancies and which contains both a Functional Loss table and an Other Impairment table. These tables are designed to rate the malignant condition as a whole. The first table relates to loss of function in a general sense. The second table relates to reduced life expectancy which is regarded as an Other Impairment.
If the impairment rating from Chapter 14 is 70 points on the basis of either the malignant disorders functional table (Table 14.1) or the malignant disorders Other Impairment table (Table 14.2), there is no need to follow the steps set out in the following pages. If the rating from Chapter 14 is below 70 points, the steps are to be followed.
Determine the impairment rating for an accepted malignant condition
Follow the steps below to calculate the impairment due to an accepted malignant condition.
(Each of these steps is elaborated in the following pages.)
STEP 1
Establish which body systems are affected by the malignant condition.
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STEP 2
Determine the functional impairment ratings for the affected body systems.
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STEP 3
Determine the total combined impairment rating for the various body system impairments attributable to the malignant condition.
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STEP 4
Determine the impairment rating based on Table 14.1 (Malignant Disorders).
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STEP 5
Determine the impairment rating based on Table 14.2 (Life Expectancy).
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STEP 6
Compare the ratings obtained in Steps 4 and 5. Take the higher rating.
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STEP 7
Compare the ratings obtained in Steps 3 and 6. Take the higher rating.
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STEP 8
If the rating obtained in Step 3 is higher than that obtained in Step 6, separate the components of the rating obtained in Step 3 so that each can be included in the final combining of all ratings.
<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="2" style="width:100.95pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FigureHeading"><span>Functional Loss Table 14.1</span></p></td><td style="width:343.55pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="text-align:right; line-height:14pt"><img src="image.005.png" width="35" height="45" alt=""></p></td></tr><tr><td colspan="3" style="width:455.3pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:6pt; text-align:center; font-size:12pt"><span style="font-weight:bold">MALIGNANT DISORDERS</span></p></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span style="font-weight:bold">Impairment Ratings</span></p></td><td colspan="2" style="width:371.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span style="font-weight:bold">Criteria</span></p></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>NIL</span></p></td><td colspan="2" style="width:371.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>Minor symptoms that are easily tolerated.</span></p></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>TEN</span></p></td><td colspan="2" style="width:371.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>Mild to moderate symptoms that are irritating or unpleasant but rarely prevent completion of any activity. Symptoms may cause loss of efficiency in some activities.</span></p></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>TWENTY</span></p></td><td colspan="2" style="width:371.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>More severe symptoms that are more distressing but prevent few everyday activities. Loss of efficiency is discernible in a good few activities. Self-care is unaffected and independence is retained.</span></p></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>THIRTY-FIVE</span></p></td><td colspan="2" style="width:371.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>Loss of efficiency discernible in many everyday activities. Some elements of self-care are restricted but, in most respects, independence is retained.</span></p></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>FIFTY</span></p></td><td colspan="2" style="width:371.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>Major restrictions in many everyday activities. Capacity for self-care is increasingly restricted, leading to partial dependence on others.</span></p></td></tr><tr><td style="width:72.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>SEVENTY</span></p></td><td colspan="2" style="width:371.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:justify"><span>Most everyday activities are prevented. Dependent on others for most kinds of self-care. Able to be maintained at home with considerable assistance and frequent medical care.</span></p></td></tr><tr style="height:0pt"><td style="width:83.4pt"></td><td style="width:28.35pt"></td><td style="width:354.35pt"></td></tr></tbody></table>
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<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="2" style="width:109.7pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top"><p class="FigureHeading"><span>Functional Loss Table 14.2</span></p></td><td style="width:301.05pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="text-align:right; line-height:14pt"><img src="image.005.png" width="35" height="45" alt=""></p></td></tr><tr><td colspan="3" style="width:421.55pt; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:6pt; text-align:center; font-size:12pt"><span style="font-weight:bold">LIFE EXPECTANCY</span></p></td></tr><tr><td style="width:74.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span style="font-weight:bold">Impairment Ratings</span></p></td><td colspan="2" style="width:336.45pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span style="font-weight:bold">Predicted Survival at the Time of Diagnosis or Staging Procedure</span></p></td></tr><tr><td style="width:74.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span>NIL</span></p></td><td colspan="2" style="width:336.45pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span>Normal, or near-normal, five year survival.</span></p></td></tr><tr><td style="width:74.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span>TEN</span></p></td><td colspan="2" style="width:336.45pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span>Five year survival less than 75% of normal.</span></p></td></tr><tr><td style="width:74.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span>TWENTY</span></p></td><td colspan="2" style="width:336.45pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span>Five year survival less than 50% of normal.</span></p></td></tr><tr><td style="width:74.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span>THIRTY-FIVE</span></p></td><td colspan="2" style="width:336.45pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span>Five year survival less than 25% of normal.</span></p></td></tr><tr><td style="width:74.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span>FIFTY</span></p></td><td colspan="2" style="width:336.45pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span>One year survival less than 50% of normal.</span></p></td></tr><tr><td style="width:74.3pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span>SEVENTY</span></p></td><td colspan="2" style="width:336.45pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:3pt"><span>One year survival less than 25% of normal.</span></p></td></tr><tr style="height:0pt"><td style="width:85.1pt"></td><td style="width:35.4pt"></td><td style="width:311.85pt"></td></tr></tbody></table>
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Step 1: Establish which body systems are affected by the malignant condition.
Before a malignant condition is assessed, information regarding the extent of the condition must be available. Such information includes the site of the primary, the sites of any secondaries, the effects of any surgery and the effects of any radiotherapy or chemotherapy.
From that information the affected body systems can be established and the applicable chapters of this Guide applied.
For example, in the case of an accepted carcinoma of the rectum, there may be surgical resection of the rectum with a colostomy, secondary spread of the cancer to the lungs and spine, and radiotherapy with some resultant digestive disturbances. In such a case, Chapters 1, 3, and 6 of this Guide will have to be applied in Step 1 to arrive at an appropriate functional impairment rating.
Step 2: Determine the functional impairment ratings for the affected body systems.
Depending on the body systems that are affected by the malignant condition and its treatment, each of the relevant chapters of the Guide is to be used and appropriate ratings obtained.
If other accepted or non-accepted conditions also affect any of the same body systems, Chapter 19 (Partially Contributing Impairment) or Chapter 20 (Apportionment) may have to be applied depending upon the circumstances.
Step 3: Determine the total combined impairment rating for the various body system impairments attributable to the malignant condition.
The total combined impairment rating for the various body system impairments associated with the malignant condition is determined by combining the attributable impairment ratings by applying Chapter 18 (Combined Values Chart).
Unless the malignant condition is the only accepted condition, this combined rating is to be regarded as an intermediate rating only.
Step 4: Determine the impairment rating based on Table 14.1 (Malignant Disorders).
Apply Table 14.1 and find the relevant impairment rating for the entire set of effects which have arisen from the malignant disorder treatment, including surgical resection, chemotherapy and radiotherapy.
For the purposes of Table 14.1, “symptoms” encompasses the symptoms of both the malignant condition itself and the symptoms of the effects of its treatment.
If non-accepted conditions or accepted but non-malignant conditions have contributed to the impairment rating obtained from Table 14.1, Chapter 19 (Apportionment) or Chapter 20 (Partially Contributing Impairment) are to be applied depending on the circumstances of the case.
Step 5: Determine the impairment rating based on life expectancy.
If an impairment rating has not been determined on any previous occasion by applying Table 14.2 (Life Expectancy) or its predecessor in an earlier edition of this Guide, a rating is to be obtained from Table 14.2. If a rating has been obtained from Table 14.2 or its predecessor in an earlier edition of this Guide, on a previous occasion, that same rating is to be applied again in all further assessments of the condition.
Whenever possible, the rating from Table 14.2 is to be based on an estimate from an oncologist or other treating specialist of the veteran’s survival. If such information is unavailable, data from standard reference texts is to be applied to provide an estimate. Such an estimate is to be based on malignancies of the same type and degree of spread as that affecting the veteran.
Estimated life expectancy is projected from the time of diagnosis, or from any subsequent major staging procedure or operation. Thus, once a rating from Table 14.2 has been made it is not to be changed, unless subsequent findings indicate that the earlier prognosis was based on incorrect clinical information.
If the assessment is made posthumously, the rating from Table 14.2 is not to be modified to reflect the actual duration for which the veteran survived after diagnosis. The table is only to be used for predicted probability of survival.
Ratings from Table 14.2 are not to be updated to account for the natural progression of the disease. However, it is expected that ratings from Table 14.2 will come to be exceeded by ratings from Table 14.1 during this time.
Ratings from Table 14.2 are not to be reduced because of favourable response to treatment, or because of better than expected survival. However, if the condition is being rated for the first time more than five years after diagnosis, and the disorder is in remission or appears to be cured, the impairment rating from this table is not to exceed ten.
If the veteran has more than one malignant condition accepted, Table 14.2 is to be applied to each condition. Table 14.2 is not to be applied to a recurrence of an old (already diagnosed) condition.
Step 6: Compare the ratings obtained in Steps 4 and 5. Take the higher rating.
The higher of these two ratings will be the rating for the malignant condition on the basis of this chapter.
Step 7: Compare the ratings obtained in Steps 3 and 6. Take the higher rating.
If the rating obtained in Step 3 is higher than that obtained in Step 6, go to Step 8.
If the rating obtained in Step 6 is higher than that obtained in Step 3, then the rating obtained in Step 6 becomes the final rating for the malignant condition and is to be included in the final combining of all ratings.
Step 8: If the rating obtained in Step 3 is higher than the rating obtained in Step 6, separate the components of the rating obtained in Step 3 so that each can be included in the final combining of all impairment ratings.
For example, in the case of an accepted carcinoma of the rectum postulated under Step 1, each of the ratings from Chapters 1, 3, and 6 of the Guide is to be separately included in the final combining of all impairment ratings.