Disability Doc

Recurrence/relapse – has been in complete remission or entirely surgically removed but has returned.

Persistent – failure to achieve complete remission.

Progressive – malignancy becomes more extensive after treatment.

In some listings, SSA considers a condition to be disabling for a specified period of time (18 months from the date of diagnosis).

In listings that include a specified time period, that period is the shortest time for which SSA will consider the individual disabled. When the facts in a case warrant it, SSA may establish that the individual is disabled for a longer period.

For example, a case is near the end of the period described in the listing. Evidence shows the claimant is disabled from the effects of therapy and this is expected to continue past the period allowed for in the listing. Or a case where the period described in the listing has ended, and the individual is still disabled due to effects of therapy.

When a listing does not contain a specified period of disability, a condition that meets or equals a listing is considered disabling until at least 3 years after onset of complete remission.

Inoperable – when surgery is of no therapeutic value due to advanced disease or surgery cannot be performed due to risk to the patient.

A caveat - neoadjuvant therapy:

• An attempt to shrink a tumor before surgery.
• Often done to preserve organ function with less radical surgery.
• May improve the rate of cure.
• The fact that neoadjuvant therapy is being used does not automatically make the tumor “inoperable.”

NOTE: If the treating source has determined that the tumor is inoperable, but will reevaluate the situation after the neoadjuvant therapy, then the impairment would meet Listing 13.18A.

If the treating source has not made a determination about whether the tumor is inoperable, then the case should be deferred until the surgery is performed to determine if it was unresectable (unless a fully favorable determination can be made based on the evidence in the case record).

Unresectable –operation was performed but all of the tumor could not be removed.

• If the surgical margins are positive after all the surgeries in the initial treatment plan are completed, the tumor is considered unresectable.
• SSA instructs to consider the individual’s response to the “initial planned treatment regimen.”
• When therapy is a single modality, enough time must pass to allow a determination about whether the therapy will achieve its intended effect.
• SSA opines it cannot make a determination about whether a tumor is unresectable until it can determine the outcome of all surgeries planned in the initial treatment plan.

NOTE: Many times a less invasive procedure may be attempted to preserve organ function. If this fails, then a standard procedure may be performed.

For example, in cases of bladder cancer, an attempt might be made to remove the tumor by transurethral resection in order to preserve bladder function. If this is not successful, a cystectomy (resection of the bladder) may be performed. Then a determination that the tumor is unresectable cannot be made until after the cystectomy.

Type of therapy

• Surgery (surgical excision for treatment and not diagnostic purposes)
• Irradiation
• Chemotherapy
• Hormones
• Immunotherapy
• Bone marrow or stem cell transplant

Multimodal therapy

• Surgery followed by chemotherapy and radiation
• Chemotherapy followed by surgery
• Chemotherapy and concurrent radiation

Other

• Duration of treatment
• Frequency of treatment
• Response to treatment
• Side effects of treatment (short lasting versus permanent)

Categorize the malignancy

• Where the malignancy originated
• If it is a primary tumor
• If it is a recurrent tumor

NOTE: If the primary site cannot be identified, SSA uses the evidence documenting the site(s) of metastasis to evaluate the malignancy under Listing 13.27.

Clarify extent of involvement of the malignancy

• Have the treating source clarify tumor stage if it isn’t clear
• If it is locally advanced
• If it is metastatic
• Local metastasis - tumors that have metastasized to regional tissue or regional lymph nodes
• Distant metastasis - tumors that have metastasized beyond the regional lymph nodes

NOTE: Malignancies that have distant metastases usually meet a listing, with the exception of the following tumors:

• Testicular tumors
• Well-differentiated thyroid carcinoma
• Prostate adenocarcinoma with bone metastasis
• Hodgkin’s lymphoma

These exceptions require at least three months of longitudinal records to decide whether the intended treatment is effective.