NIOSH OCAS Trip Report 


Discussion with Administrator of Veterans' Administration "Atomic Workers" 


Compensation Program 


Date/Location of Meeting: April3, 2001, Veterans' Administration, Washington, D.C. 

Attendees (Affiliation): 

Larry Elliott, Greg Lotz, Jim Neton, Mary Schubauer-Berigan (NIOSH) 

Neil Otchin, M.D. (VA) 

Claudia Gangi, John Oates (Department ofJustice, RECA program) 

Objective: Learn about administration ofthe VA's "Atomic Veterans" compensation program, 

and the application ofthe probability ofcausation tables and models in the program. 

Meeting summary: We met with Dr. Otchin and the DOJ representatives from 9:00 a.m.-12 

p.m., and were given a demonstration ofthe use ofthe draft NCI/CDC probability ofcausation 

tables. We asked numerous questions about the compensation program operated by the VA, and 

about practical issues related to claims processing, dose assessment and probability ofcausation 

determination for radiation-exposed veterans. The information received will be extremely 

helpful as OCAS drafts regulations for compensation under EEOICP A. 

Specific issues discussed: 

1. 	 Who is eligible for compensation under the VA's presumption of causation (i.e., no 

dose assessment required)? Those currently eligible include veterans who observed or 

otherwise participated in atomic tests while in the military, veterans involved in the 

occupation ofHiroshima and Nagasaki at the end ofWWII, or veterans who worked at a 

DOE gaseous diffusion plant while employed by the military. Veterans who were treated 

with nasopharyngeal applications ofradium are also included. 

2. 	 How many compensation claims are processed per year? The VA receives 250-300 

cancer claims each year. All probability of causation determinations are made by Dr. 

Otchin. 

3. 	 What kind of cancer evidence is required? Do they require physician evidence of 

diagnoses? Do they compensate on the basis of death certificate evidence alone? The 

VA requires extensive medical documentation for the claim. Because ofthe unique 

situation ofthe VA, they can easily obtain VA medical records for diagnostic purposes, and 

examine the individual in conjunction with a claim. Because ofthe need for expert 

judgment in some situations (e.g., pre-cancerous conditions and difficult-to-classify 

cancers), Dr. Otchin recommended that medical officers interpret physician diagnosis. The 

VA rarely has to rely on death certificate information alone, but this would be considered 

acceptable ifno other information on cancer diagnosis is available. Dr. Otchin did note that 

only spouse and parents are considered eligible survivors under the VA program. 

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4. 	 Does the VA compensate based on secondary cancers? Dr. Otchin indicated the VA does 

not determine eligibility for compensation based on metastatic cancer site. Ifthe primary 

site cannot be identified, they use expert judgment to determine the sites most likely to be 

primary, and then determine compensation based on the primary site producing the highest 

probability of causation. However, given their access to medical records through the VA 

hospital system, they are usually able to determine the primary cancer site. 

5. 	 The VA appears to be using the 1985 PC tables from NIB. Do they have a computer 

program established to do this that NIOSB could view? The VA actually determines 

probability of causation from interpolations oftables produced in the 1988 Committee on 

Interagency Radiation Research and Policy Coordination (CIRRPC) report "Use of 

Probability ofCausation by the Veterans Administration in the Adjudication ofClaims of 

Injury Due to Exposure to Ionizing Radiation" (see attachment). These tables give screening 

doses (in rad) associated with the upper 99% credibility limit ofthe 50% probability 

causation estimate, for various cancers and a few background factors (age at exposure, time 

since exposure and smoking). These tables are less detailed than the computational methods 

provided by the 1985 NIH report. 

6. 	 Bow does VA plan to compensate for cancers not modeled in the 2001 NCI tables? 

Bow do they do it now? The VA uses information on relative risk associated with 

radiation exposures, as given in the BEIR V and ATSDR reports and other sources to 

essentially compute a the dose associated with a doubling ofrisk. [Note: This approach 

assumes, among other things, that radiation interacts multiplicatively with all other 

background risk factors for the cancer. Also, it is not clear whether the point estimate or 

upper confidence limit on relative risk is used to estimate doubling dose.]. Literature 

provided by the VA to the NCI/CDC meeting on Radioepidemiological Tables (January 26, 

1999) states that "The VA now recognizes all malignancies as potentially radiogenic as well 

as posterior and subcapsular cataracts, non-malignant thyroid nodules, parathyroid 

adenomas, and tumors ofthe brain and central nervous systems". Although the VA had 

.hoped to obtain radioepidemiological models for all these conditions, these are not available 

in the current NCirevision. 

7. 	 Bow does the VA classify the cancer if it overlaps more than a single modeled cancer 

site (e.g., myeloid leukemia of unspecified chronicity)? The VA is usually able to obtain 

very precise definitions ofcancer, because ofthe extensive use ofVA facilities for diagnosis 

and treatment ofveterans. However, where this situation does occur, the VA selects the 

cancer site producing the probability of causation that is most favorable to the claimant. 

This often does require some iterative interaction with the Defense Threat Reduction 

Agency to produce dose assessments for the proper organ or tissue. 

8. 	 For VA claims, have they classified the compensable cancers by ICD-9, -8, -7 and -6 

revision? Ifso, could we get a copy? (Also need to ask RECA for this) Dr. Otchin 

indicated that the VA has not done this yet, but that it would probably be a good idea to try 

to standardize this process a bit more, since the new NCI PC methods include many more 

cancer sites. 

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9. 	 Lung cancer will be added to the list of Presumptive cancers. Does this include trachea 

and bronchus as well? No, just bronchiolalveolar cancer. Dr. Otchin indicated that the 

basis for the addition ofnew cancers to the presumptive list was primarily politicallymotivated. 

10. 	 Can the VA share an example of a questionnaire given to applicants? The VA doesn't 

have forms that are specific to radiation claims. There is no consistent or generic form at 

this time. 

11. 	 Does the VA have special authority to add diseases to the compensable list? Yes. 

According to Dr. Otchin, because ofprecedent set by other compensation programs, 

Congress delegated responsibility for this to the VA directly. The VA has proposed that five 

cancers (bone, brain, ovary, colon, lung) be added to the compensable list; but these 

regulations are still pending. 

12. 	 What kind of public input does the VA compensation program have? Besides the 

formalized involvement ofthe Veterans' Advisory Committee (NIOSH-OCAS 

representatives attended their last meeting on March 21, 2001), there is a loose network of 

veterans' groups involved to some degree in the program. There is also beginning to be 

more involvement on dosimetry issues, through the recently-established NAS panel. 

13. 	 Does VA recommend that NIOSH-OCAS develop a dialog with the Veterans' Advisory 

Committee? Dr. Otchin recommended this as a possibility to be pursued. Right now the 

Committee is still reviewing the revised tables, and would likely be very interested in 

hearing about the guidance developed byNIOSH-OCAS. The Committee is not yet aware 

that, for many cancers, the revised tables may produce a less favorable result for the 

claimant. 

Other comments: 

Where there is an existing NCI model, the VA appears very reluctant to make modifications 

or expert interpretations on use; however, for cancer sites for which no model exists (e.g., skin, 

male breast), much judgment is applied by the program administrator in determining the 

probability of causation for individual cases. The VA is supposed to take into account other 

exposures the claimant may have had when adjudicating a claim; however, this has proven very 

difficult to do in practice. 

Dr. Otchin indicated that it may be politically very difficult for the VA to recommend use of 

the revised tables for cancers that produce less favorable estimates ofprobability ofcausation 

than the 1985 version; however, this discussion has not yet taken place within either the VA 

program or the Veterans' Advisory Committee. 

The dose distributions were fairly low for most ofthe Atomic Veterans. Fewer than 5% 

received a dose of 5 rem or more. In conducting dose assessments, there is essentially no 

accounting for dosimetry distribution in calculated probability of causation. The VA does not 

appear to have much in-house dose assessment capability, but indicated they would welcome 

guidance from NIOSH on issues such as the variability associated with badge dosimetry readings. 

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