Note: Resolve reasonable doubt under in favor of the Veteran when the evidence favoring risk factor(s) in service is equal to the evidence favoring risk factor(s) before or after service. Risk Factor Transmission Information Rating Tips transfusion of blood or blood product before 1992 for HCV, or before 1975 for HBV organ transplant before 1992, or hemodialysis Blood donor screening for HCV was not available until 1989 when HCV was identified. In 1992, more effective screening of blood became possible for HCV. If blood transfusion is a claimed risk factor, obtain the relevant hospital records from service, if possible. Look for evidence of blood transfusions in surgical reports, especially the anesthesia sheet surgical record operative clinical records, or post-operative clinical notes. tattoos body piercing, and acupuncture with needles transmitted through the use of unsterilized equipment Review for indications of tattoos or piercings on induction and separation exams to help determine whether tattooing or piercing took place in service. intravenous drug use transmitted through the use of shared instruments Records of drug treatment may reflect the type of drug high-risk sexual activity Transmission risk is relatively low but increases with multiple sexual partners. Periodic health assessments or records of treatment for sexually transmitted diseases may document a history of high-risk sexual activity or multiple sexual partners. intranasal cocaine use transmitted through the use of shared instruments Records of drug treatment may reflect the type of drug abuse. accidental exposure to blood by percutaneous exposure or on mucous membranes common for the following health care workers combat medics, and corpsmen Consider service department or other records reflecting occupational history.
sharing of toothbrushes, or shaving razors transmitted through direct percutaneous exposure to blood This type of in-service exposure will not generally be documented in service records. Consider statements in the context of the entire evidence picture pertaining to risk factors. immunization with a jet air gun injector one documented case of HBV transmission Despite the lack of any scientific evidence to document transmission of HCV with air gun injectors, it is biologically possible. A medical report linking hepatitis to air gun injectors must include a full discussion of all potential modes of transmission and a rationale as to why the examiner believes the air gun injector was the source for the hepatitis infection. f. Development for Hepatitis Risk Factors As VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, does not inform the claimant to submit evidence of hepatitis risk factors, development for risk factors is required in every hepatitis claim, even when hepatitis is diagnosed in service. Development is necessary to determine if pre- and post-service risk factors are present as well as to ensure that the risk factor is not substance abuse either before or during service. Regardless of what claim form the Veteran submits, development for risk factors is required if the complete risk factor history has not already been provided. If risk factor history is not of record, use the table below to develop to the Veteran. If the Veteran is claiming ... Then generate a risk factors development letter in ... hepatitis C the Veterans Benefits Management System (VBMS). hepatitis A or B, or a non-specific form of hepatitis Modern Award Processing-Development (MAP-D), and alter the letter to specify the type of hepatitis claimed by the Veteran (A, B, or none). References: For more information on SC for hepatitis associated with drug use, see M21-1, Part III, Subpart iv, 4.I.2.g, and
g. Rating Considerations for Prostate Cancer The table below describes common treatments for prostate cancer as well as the side effects and rating considerations associated with the treatment. Type of Treatment Potential Side Effects Rating Considerations watchful waiting also called conservative management observation, or surveillance. No immediate specific therapy is being used, but cancer is active. none, except for the continued presence and potential metastasis of cancer often used when life expectancy is short due to age or other illness since prostate cancer is slow- growing. Review to confirm the continuation of active cancer previously confirmed by biopsy. Evaluate at 100 percent, despite the lack of treatment and possible lack of symptoms. radical prostatectomy surgery which is characterized by removal of prostate gland and seminal vesicles most common treatment for localized cancer can be curative, and nerve-sparing procedure can be performed to improve chances that the patient will retain normal erectile function. impotence, and/or incontinence. In all cases of radical prostatectomy, award SMC (k) for loss of use of a creative organ. Consider SC for ED on a facts-found basis. Cryotherapy, also known as cryosurgery or cryoablation, is a procedure by which the prostate and nearby tissues are frozen with liquid nitrogen via probes in the perineum. impotence incontinence urethral scarring, and rectourethral fistula (rare). Consider SMC (k) on a basis. Radiation can be curative if cancer is confined to the prostate and after external beam radiation impotence, and/or incontinence after brachytherapy After internal HDR the radiation continues only for or days, so a six-month
surrounding tissues and PSA is 15 nanograms (ng)/ml or less is also used as palliative therapy to relieve symptoms of advanced cancer, such as bone pain due to metastasis can be internal radiation therapy, or brachytherapy, in which radioactive seeds are implanted in the prostate. high dose radiation (HDR) are implanted for less than a day and then removed. Radiation is present only while seeds are in place. low dose radiation (LDR) seeds are permanently implanted and give off radiation for weeks to months, depending on the radioisotope used. external radiation therapy, in which radiation is delivered by high-energy eternal radiation for six to eight weeks. impotence incontinence bowel problems, and/or urethral complications. assignment of temporary 100 percent under is appropriate, and consider SMC (k) for impotence on a basis. After internal LDR the effective radiation should be gone by one year assign a 100-percent evaluation for one year, and schedule a review exam six months following the cessation of the treatment period. Note: If radiation is used only as palliative therapy in advanced cancer, the 100-percent evaluation will continue because the cancer will remain active. Therefore review for metastatic disease, and consider permanency. Hormone therapy is primarily for palliation of prostate cancer which is not confined to the prostate for the purpose of testosterone deprivation. Types of hormone therapy include after any hormone therapy hot flashes osteoporosis loss of muscle mass after orchiectomy impotence sterility loss of sex drive Orchiectomy results in anatomical loss of a creative organ; therefore evaluate , and SMC. Hormone therapy may continue for many therefore
orchiectomy, the removal of testes to prevent testosterone production luteinizing hormone releasing hormone agonists (LHRH analogs), which can lower the testosterone as effectively as orchiectomy such as Lupron (leuprolide) Zoladex (goserelin), and busrelin estrogens or drugs, which lower the level of testosterone second-line hormonal drugs, which are used when first-line hormone therapy fails anti-androgens, which block the ability of the body to use androgens, such as Eulexin (flutamide) Casodex (bicalutamide), and Nilandron (nilutamide), and combined hormone therapy, which is an anti-androgen combined with orchiectomy or an LHRH agonist (analog). after anti-androgen therapy gastrointestinal upset breast tenderness gynecomastia decreased libido impotence hot flashes after LHRH analogs impotence hot flashes, and gynecomastia. review treatment records for expected duration of treatment, and consider permanence. chemotherapy Depending on the type of chemotherapy used, there are multiple possible side effects. Chemotherapy is used for palliation as current agents will not eradicate prostate cancer; therefore evaluate as 100 percent consider permanence
actually in remission, or still active and being regularly treated over extended periods of time. Do not schedule a review examination unless the record clearly shows a and stable remission. Important: Consider assigning a permanent and total evaluation when a provision under applies. Reference: For more information when not to schedule a review examination, see M21-1, Part III, Subpart iv, 3.B.2.c. l. Considering Claims for SC of Mycosis Fungoides Mycosis fungoides is a cutaneous T-cell lymphoma which is a type of lymphoma (NHL). For the purposes of determining SC, the disease should be considered the same as NHL and subject to presumptive SC under the provisions of as well as SC under . Mycosis fungoides often manifests as skin symptoms including patches plaques, or tumors. Treatment for mycosis fungoides depends on the involvement and staging and can range from topical therapies such as ultraviolet/light therapy, to the requirement for systemic chemotherapy or radiation in advanced stages. Note: If SC for mycosis fungoides was previously denied, the evidence of record at the time of the prior denial shows a diagnosis of mycosis fungoides and confirms the Veteran’s in Vietnam, review the decision in accordance with and take appropriate action to correct the decision. Reference: For more information on clear and unmistakable error (CUE) determinations, see M21-1, Part III, Subpart iv, 2.B.4, and M21-1, Part IV, Subpart ii, 3.A.2. m. Evaluating Mycosis Fungoides For the purposes of evaluating SC mycosis fungoides, review the medical evidence to identify the manifestations of the disease and/or the treatment required. Mycosis fungoides can potentially be evaluated as skin malignancy under , or NHL under . Use the table below to determine whether to evaluate active mycosis fungoides under or .