(cell phone 240-506-1556)

To: All veterans

Date: Jan 2015
Topic: Breast Cancer
Independent Veteran Medical Opinion (IMO)
Veteran Medical Nexus Opinion (VMNO)

for Veteran benefits

From:
Craig N. Bash, M.D.
Neuro-Radiologist
www.veteransmedadvisor.com

Pages: 2
NPI or UPIN-1225123318- lic #--D43471
4938 Hampden lane, Bethesda, MD 20814
Phone: (301) 767-9525 Fax: (301) 365-2589
E-Mail: drbash@doctor.com

BREAST CANCER - veteran benefits

Many female and some male veterans have breast masses or breast problems in or following service.
The best first step in the proactive analysis of this problem is the monthly self-breast exam. This is often
followed by mammograms depending on the age and risk profile of the patient. Mammograms have a
large percentage of both false negative/false positive results and add radiation to the patients cancer risk
profile. So this test is imperfect but it still is really the best screening tool available.
A problem I often see involves a patient with a post service breast cancer diagnosis. These cases
require a careful review of the service time medical history/records to determine if the cancer could have
had its inception during service. A careful review of the mammogram imagines is also often helpful to
look for overlooked small masses or calcifications.
The concept of tumor doubling time is important in linking post service tumors to service because some
cancer types have fairly predictable doubling times.
As an example;
A female patient leaves service and then notes a 2 cementer breast cancer nodule one year after
service.
How do we determine service connection?
It is reasonable to back calculate the tumors soze, using doubling times, and state with accuracy that the
cancer was or was not present during service. The Breast Imaging Division at the Massachusetts
General Hospital did a 1991 to 1999 review of 810 breast cancers and found a mean doubling time of
about 130 days for tumors sized 6mm to 41 mm. Tumors of smaller than 6mm had doubling times that
were somewhat shorter with a mean doubling time of 36-94 days (see abstract below).
Estimates of Breast Cancer Growth Rate and Sojourn Time from
Screening Database Information

James Michaelson, PhD,* Sameer Satija, AB, Richard Moore, AB, Griffin Weber, BS, Elkan Halpern,
Andrew Garland, and Daniel B. Kopans, MD#
Journal of Womens Imaging
2003:5:1119
A new method has been developed that can be used
to estimate tumor growth rate from information on the
numbers and sizes of breast cancers found at screening.
With use of this method and information available for the
tumors seen over the last decade at the Breast Imaging
Division at the Massachusetts General Hospital (MGH), it
appears that the median doubling time for invasive
breast cancer is approximately 130 days. From this doubling
time value, together with information on the sizes
at which breast cancers become detectable on clinical
grounds and by screening, it appears that the mean and
median sojourn times for invasive breast cancers in the
MGH population are approximately 1.7 and 1.3 years,
respectively. [Key words: breast cancer, doubling time,
growth rate, sojourn time]
http://www.lifemath.net/quantmed/pdf/Michaelson%20Br%20Ca%20Growth%20Rate.pdf
Post cancer treatments are often secondarily service connected because patients with breast cancers also
often have a series of secondary medical and surgical problems. These should be analyzed for additional
VA medical diagnostic codes once service connection is established by veteran medical nexus opinion. Two
common devastating complications of aggressive treatment are arm edema following mastectomy and postradiation neuro-vascular changes.

Recommendations:
1. Women, especially, should do monthly self-breast exam and have mammograms as per the most current
advice of national cancer society or their physician. These guidelines change frequently.
2. Since often these tumors are found post-service a close review of the patients service history and
medical imaging should be done.
3. All secondary medical/surgical complications should be evaluated and treated and assigned a VA
medical diagnostic code.
4. An effort to back calculate the size of any tumor should be done as a means to determine if the breast
vcancer had its inception during service.
Craig Bash M.D. Associate Professor

drbash@doctor.com cell 240-506-1556

Independent Veteran Medical Opinion (IMO)

Veteran Medical Nexus Opinion (VMNO)
based on Veterans medical records for veteran benefits