by Ken Smith
Attributed to: Dr. Anna Kaplan
This is not a new problem. The Veterans Administration studied military veterans suffering from cancer in the early 1930’s.1 At that time, much less was known about the causes of cancer than what doctors know today. Even so, the VA looked carefully at cancer patients after World War I and the Spanish-American War to try and find the best ways to diagnose and treat them.
What they did not know then was that soldiers exposed to chemical weapons in WWI were definitely at risk for certain cancers.2 Those with full-body exposure to nitrogen or sulfur mustard were more likely to develop cancers of the nasopharynx, larynx, lung, and squamous cell carcinoma of the skin. Those with full body exposure to nitrogen mustard also were at risk of developing acute nonlymphocytic leukemia.
While the last of these veterans has died, those who fought in subsequent wars were also exposed to cancer-inducing agents. These veterans are living with diseases such as mesothelioma caused by exposure to asbestos in third world countries. Exposure to a disease in which there was no place to learn about and veterans are now facing the consequences.
Many of those affected spent years trying to prove that their cancers were service-related, and still continue to do so. For example, veterans exposed to radiation during atomic testing and clean-up were sworn to an “Oath of Secrecy” not to discuss their health and exposure to radiation. This made the recognition of their cancer risks difficult to document. This order was rescinded in 1993.3
All veterans should receive treatment regardless of whether or not there was a relationship between their military service and their illnesses. For those who believed their time in the military resulted in their developing cancer, they believed the government and the VA had a duty to recognize this relationship. It would mean paying special attention to any group of veterans known to be exposed to radiation and chemicals. It also means that they are entitled to disability payments and their spouses may be entitled to survivors’ benefits.
Many hundreds of thousands of veterans were exposed to nuclear radiation. Some 195,000 were exposed during World War II in Japan after the atom bombs were dropped, including soldiers that were part of the Occupation Forces, and also American prisoners of war in camps near Hiroshima and Nagasaki. Many more, estimated at approximately 210,000 were irradiated during the United States’ testing of nuclear weapons through1962.4 Between 1945 and 1962 atmospheric and underwater testing caused exposure. After 1962, nuclear weapons were tested underground and in shafts, and others may have been exposed. The last test was in 1992. There may also be veterans of the Gulf War and Operation Iraqi Freedom who were exposed to depleted Uranium.
There is a list of cancers that are designated presumptively caused by radiation. These cancers, in exposed veterans, are assumed to be caused by radiation. These veterans are eligible for services, disability payments, and other compensations depending on the specifics. Although there are specific forms to fill out and guidelines to follow, the actual filing for these claims is onerous and simple mistakes lead to denial of claims. There are many groups available to help Atomic Veterans.
Included in the list are cancers of:
- Lung, including bronchioloalveolar carcinoma (a rare lung cancer).
- Small intestine
- Bile ducts
- Gall bladder
- Salivary gland
- Urinary tract (kidneys, renal pelvis, ureter, urinary bladder and urethra)
Also included are lymphomas (except Hodgkin’s disease), multiple myeloma, primary liver cancer, and all forms of leukemia except chronic lymphocytic leukemia.5
It took Atomic Veterans many years to get help and recognition of their situation. One reason was that they were sworn to an “Oath of Secrecy” not to discuss their health and exposure to radiation. This made the recognition of their cancer risks difficult to document. The order was rescinded in 1993.3
AGENT ORANGE AND CANCER
The story of veterans and the effects of Agent Orange, or dioxin, an herbicide used extensively during the Vietnam War, is much like the story of the Atomic Veterans. Cancer takes years to develop, and enough data must be collected to be able to make the claim that Agent Orange caused cancer. As of 2003, the list of known cancers considered to be due to this chemical include during the Vietnam War include Non-Hodgkin’s lymphoma, soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma), Hodgkin’s disease, multiple myeloma, respiratory cancers (lung, larynx, trachea and bronchus), prostate cancer; in process of being added – chronic lymphocytic leukemia.5
VHA DIRECTIVE 2003-034: NATIONAL CANCER STRATEGY
This document seems to show the Veterans’ Administration recognition of cancer risks in veterans, and their promise to do what they can for these veterans. It is an example of a change in policy, from a time when Oaths of Secrecy prevented even investigations from going forward, to a time when the VA starts to recognize its responsibilities. It includes directives to let veterans participate in clinical trials, and also to report all the cancers to a Tumor Registry. It should have made it easier in the future to evaluate claims of carcinogenic exposure in veterans.
The document starts with a “background” statement that puts the problem in perspective.
“Cancer is a varied and complex collection of diseases having many causes and clinical characteristics. According to the American Cancer Society, it will claim more than 556,500 American lives in 2003, including a substantial fraction of the Department of Veterans Affairs (VA’s) estimated 175,000 veteran cancer patients. Cancer imposes a severe and in some ways unique burden of illness… Morbidity and mortality from the disease itself are significant, and one’s quality of life may be dramatically reduced by currently available treatment. Arguably, it is the most feared of diseases, and its diagnosis imposes a significant emotional burden on both patients and their families. Approximately 35,000 new cases of cancer occur in VA patients each year; and cancer is the second leading cause of death among veterans… Moreover, the course of the disease is often protracted, and the treatment is quite demanding of resources. As the veteran population ages, this encumbrance will increase. It is necessary that VA formalize its approach to this group of diseases. The purpose of this national VA cancer strategy is to ensure that users of the veterans health care system have easy access to consistently high-quality cancer prevention, detection and treatment services.”5
The numbers allow some comparisons to be made between veterans and the rest of the population. According to the VA, there were approximately 175,000 veterans with cancer in 2003. There were approximately 26.4 million veterans in 2003.6 That would make the incidence of cancer in veterans, the number of veterans at a given time that have cancer approximately 663 per 100,000. According to the American Cancer Society, the incidence of cancer in men in the United States between 1999-2003 was 562.1 per 100,000 men, and 415.3 per 100,000 women.7 So according to the number above supplied from the VA, the rate of cancer in veterans is higher than the general population, which makes sense when all the carcinogenic exposures are taken into consideration.
The VA said that there would be approximately 35,000 new cases of cancer in veterans each year. 35,000 cases in 26.4 million veterans would be 132 cases per 100,000 veterans. According to the ACS, there would be approximately 1,334,100 new cases of cancer in the United States in 2003.8 The population in the United States in 2003 was approximately 290,000,000.9.10 There would be an estimated 460 new cancers per 100,000 Americans in 2003.
Those two sets of figures do not fit together. There are more veterans with cancer. There was exposure to radiation through 1992 for some veterans, and exposure to herbicide throughout the Vietnam War. There should be more new cancers in veterans and not fewer. There also seems to be no attempt by the VA to document how many veterans have cancer that is service related.
Lung cancer is common in the general population. But it is also linked to exposure to radiation and exposure to Agent Orange. There are more smokers among veterans than in the general population. So it is possible that there would be difficulties some of the time in deciding what cancer was service related.
THE VETERANS ADMINISTRATION PROMISES
In VHA Directive 2003-034, the Veterans Administration promised a cancer strategy for veterans. This included many objectives. The VA promised quality care, improved access to care, appropriate cancer expertise, monitoring and improving outcomes, useful screening for cancer, improved quality of life and compassionate care, shared decision making, clinical research, facilitating patient access to promising treatments, contributing to medical care in general by establishing a model for a systematic approach to cancer, and ensure suitable end of life care.5
The Directive also included Strategy Elements, from prevention and education, through early detection, treatment, rehabilitation, research, tumor registry, and end of life care.
The Directive states, “It is VHA policy that all Veterans Integrated Service Networks (VISNs) and medical center Directors implement, as appropriate, the National Cancer Strategy.”5
Each facility was charged with implementing all the recommendations. Each element was more fully discussed in the document. If everything was implemented as stated, every VA or provider of medical care within the VISNs would be giving exemplary care to veterans with cancer. They would have access to the best treatment, be able to participate in research trials, and data would be shared.
Each medical center director is responsible for the following:
- A tumor registry is established, and the data provided is reported the Central Cancer Registry is a timely manner.
- A formal relationship with organizations providing hospice care is established ensuring that hospice services are available to every appropriate VA cancer patient when the need so arises.
- If the facility provides or participates in palliative care, there is a formal, evidence-based protocol for pain management, and that documentation of adequate pain relief is recorded in the patient’s medical record.
- If clinical research in oncology is being conducted at the facility, primacy consideration to NCI-sponsored and VA Cooperative Group research studies must be given consideration over more limited local or regional protocols.
According to the VA policy, all hospitals and treatment centers should have special programs for veterans to insure the quality of their care. Veterans should be involved in clinical oncology research. Cancer should be reported in a timely manner.
It is hard to know how many of these guidelines are being followed. There is information on the VA website about accessing cancer care, and this information is freely available to veterans.
The place to start is the VA website area for healthcare at www1.va.gov/HEALTH/index.asp
From there veterans can find out where the closest VA facility is, they can look at cancer research, find open studies, check benefits and much more.
One thing that is known is that the VA hospitals are not reporting cancer as they promised. Somewhere between 2003 and 2004, many states stopped sharing their cancer data and reporting it. This is a problem for cancer researchers in general, because the data on cancer for those years are incomplete. As many as 70,000 cancers a year may be missing.11 This was first reported in the Lancet Oncology Journal, and confirmed by many investigators.
The VA admits to withholding data. Spokesmen for the VA have discussed privacy concerns, and said that they do not have an obligation to report data to state cancer registries. Each state reaches its own agreement with the VA. Different states have had various levels of success in negotiating a way to obtain data. California is an example of a state in which essentially no reporting of cancer is being done by the VA.
The VA made its policy clear in VHA Directive 2007-023, released August 15, 2007. It states, “It is VHA policy that every VHA health care facility must obtain a Data Transfer Agreement (DTA) (see Att. A) in addition to a signed, written request from the State in order to release or disclose VA cancer registry data to a State cancer registry.”12
This agreement must cite the state law that requires health care providers to report names and data to the state cancer registry and the law that authorizes the state to compel compliance with cancer reporting requirements. The state must use a specific template. There are many other specifics, many of which are difficult if not impossible to comply with. The numbers of cancers not being reported will actually make cancer reporting for the country inaccurate.
At the same time the VA is doing studies to assess the health of Gulf War Veterans, including cancer. The study called, “Estimates of Cancer Prevalence in Gulf Veterans Using State Registries” seems to be a contradiction, because the VA admits to not reporting its cancer data to many state registries.
The War-Related Illness and Injury Study Center (WRIISC-DC) had many ongoing studies including the above and, “Longitudinal Health Study of Gulf War Era Veterans,” “Mortality Follow-Up of U.S. Navy Veterans Who Were Potentially Exposed to Biologic and Chemical Warfare Agents,” “Mortality Follow-Up Study of U.S. Veterans Who Participated in Operations Enduring Freedom and Iraqi Freedom,” “Clinical Surveillance Program for Operations Iraqi Freedom and Enduring Freedom Veterans,” “Antecedents of Fatal Motor Vehicle Crashes in Gulf War and Non-Deployed Veterans, “Health and Communications Study of Veterans, “Study of Health Outcomes & Environmental Surveillance in Bosnia/Kosovo (SHOES),” “Post War Mortality from Neurologic Diseases in Gulf War Veterans, 1991-2004,” “Evaluation of Dr. Stellman’s Herbicide Exposure Reconstruction Model,” and “Environmental Exposures Assessment Tool (EE-Tool) for OIF/OEF Veterans.”
- Matz, PB. Cancer in Army Veterans. Medical Bulletin of the Veteran’s Administration. November/December (abridged), 1931.
- Department of Veterans Affairs, Veterans Health Administration. VHA Directive 2003-034: National Cancer Strategy. June 20, 2003.
- National Association of Atomic Veterans, Inc. The NAAV Mission Purpose. Website accessed August 28, 2008.
- United States Department of Veterans Affairs. Office of Public Health and Environmental Hazards. Atomic Veterans and Radiation-Related issues. Website accessed August 28, 2008.
- Department of Veterans Affairs: Veterans Health Administration. VHA Directive 2003-034: National Cancer Strategy. June 20, 2003.
- Veteran’s Day Press release. November 11, 2003.
- Cancer Facts and Figures 2007. American Cancer Society.
- Cancer Facts and Figures 2003. American Cancer Society.
- Encyclopedia of the Nations :: Americas :: United States
- USA QuickFacts from the US Census Bureau
- VA withholds data for up to 70,000 veteran cases a year from US cancer registries. September 4, 2007.
- VHA Directive 2007-023. Department of Veterans Affairs: Veterans Health Administration. Release of VA Data to State Central Cancer Registries.