Prostate Cancer and the Vietnam Veteran
Jim Strickland on prostate cancer screening and treatment.
It is widely known and accepted that men and women who served in Vietnam were exposed to a chemical that has caused significant health concerns. Whether you refer to it as Agent Orange, a defoliant, an herbicide or dioxin, anyone that served with their boots on the ground of the Republic of Vietnam received some dose of the chemical.
Over the years the Department of Veterans Affairs (the DVA or just "VA") has ceded that there are known health risks that stem from this exposure. During the decades following the end of that war, there has been a list of conditions that are presumed to have been caused, contributed to or aggravated by the exposure to Agent Orange.
The "Presumptive List" http://tinyurl.com/cpmals isn't without its detractors and controversy. If a 63 year old Vietnam veteran is diagnosed with lung cancer this year, was it the long term effects of his pack a day cigarette habit that caused the disease or was it the effect of exposure to dioxin in 1967? While it's impossible to determine an answer to each individual case, the law is clear; The VA must default to a presumption that the tumor is connected to the RVN service and the award of benefits is mostly on autopilot with no proof of cause and effect required.
The same is true of prostate cancer. The veteran who has a history of Vietnam service and who is today diagnosed with prostate cancer will be awarded service connected disability benefits for the condition. Prostate cancer is presumed to be connected to the vet's RVN service and exposure to Agent Orange.
Whether a man is a Vietnam veteran or not, to think about prostate cancer is to accept that many of us are going to get the disease sooner or later. It's almost another rite of passage for men as they age.
Any discussion about the diagnosis and treatment of prostate cancer becomes contentious almost immediately. To screen via the Prostate Specific Antigen (PSA) test or not to screen? Does the Digital Rectal Examination (DRE) of the prostate make for a better diagnosis or is it simply a test designed to make a man cringe? The PSA test tries to identify a trend of a rise in the level of the PSA marker that would indicate that there may be a problem while the DRE allows the examiner to feel hardened lumps that may be tumor.
If either of those tests are positive, the man is usually referred to a urologist who will then take a biopsy of the prostate gland itself. The biopsy process is also an imperfect diagnostic tool. Consider that the surgeon is trying to locate a tumor (or tumors) that may be the size of a BB in an organ that is the size of a walnut. He stabs at it with a needle, more or less blindly, in hopes of retrieving some few cells that can be diagnosed to show cancer or not. If he misses the tumor you may get a clean bill of health but still carry the cancer. If a good specimen is obtained, the tumor hit may be a low grade of cancer while the tumor missed may be a higher grade and much more aggressive.
If you're the Vietnam veteran (or any man) with a suspected or even a confirmed prostate cancer, you have a lot of decisions to make. Those decisions are hard enough but for the RVN vet they get even more convoluted...more on that in a moment.
The New York Times recently published a great article about the most recent international studies about men and their prostates. http://tinyurl.com/d2kc8f
The bottom line, according to columnist Tara Parker-Pope is that, "...two major studies from the United States and Europe found that P.S.A. testing — the annual blood test used to screen men for prostate cancer — saves few, if any, lives while exposing patients to aggressive and unnecessary treatments that can leave them impotent and incontinent."
The very words, "impotent and incontinent" are enough to strike terror into the hearts of the most decorated combat veteran. If the shouts of "incoming" didn't frighten you back then, those words surely will.
Is that what awaits us...erectile dysfunction and a change of diapers 6 times each day?
Maybe, maybe not.
Ms. Parker-Pope's article describes some of the more modern thinking about whether or not a man should even bother with screening. It's easy to accept that a man of age 70 or so who is diagnosed with prostate cancer may easily choose to leave it be. Most prostate cancers are very slow growing and take as long or longer than 10 years to cause a death. In that case, the treatments available...radical surgery and/or intensive radiation therapy may cause his death long before the 10 years has passed.
If you're younger than 70 but you have other health care issues that are likely to cause your demise, again...you may wish to ignore the prostate cancer and avoid the side effects of treatments.
Choosing your treatment, should you decide to be treated, is ultimately one of the most important decisions you'll ever make. My mailbag is peppered weekly with veterans who have made successful recoveries after surgery and they are returning to work and those who are just miserable with a constant leakage they didn't anticipate.
The topics of screening and then treatment are ones you should begin to discuss with your doctor now. Learn about the options that you may have and if you don't care for the sound of that, seek out what other options may be available to you. Ask about fee basis if your local VA Medical Center (VAMC) isn't doing a lot of prostate treatment. Inquire as to what treatments are popular in your VAMC and ask around to speak with others who have received treatment there. If another veteran is happy and doing well, you're more likely to have that result.
One of the topics that I don't believe Ms. Parker-Pope covered very well is the treatment of no treatment at all. The term "Watchful Waiting" http://tinyurl.com/e43ro describes an accepted method of tracking the progress of a known prostate cancer after diagnosis.
I promised a focus on the Vietnam veteran diagnosed with prostate cancer.
Whether or not one accepts that the Vietnam vet's prostate cancer has any connection to exposure to Agent Orange, the rules are well established and that veteran is eligible for disability compensation benefits upon diagnosis and the beginning of treatments. The application for benefits isn't automatic and the veteran should proceed immediately to begin the process of filing for the benefit. Although the award is a foregone conclusion, the Veterans Benefits Administration (VBA) will all too often make hash-work of the application and deny the benefit for various reasons. In that way the application is no different than any other so you're wise to begin ASAP.
Upon the initiation of treatment, the Vietnam veteran is awarded 100% disability dating to the date of the diagnosis. The VA assumes that the treatment will be totally disabling but won't be a permanent condition. If the PSA level and biopsy are used as the markers of having an active cancer, with treatment both of those will return to a normal state.
At that point the treated veteran no longer has prostate cancer. If he doesn't have prostate cancer he can't be awarded a benefit for it. Thus, usually at about the 6 month mark, the veteran is called in for a Compensation and Pension (C&P) examination with a goal to set the rate of compensation to equal the disabling effects of treatments...the "residuals".
Incontinence or "leaking" is the usual residual measured by VA to determine the rate of compensation. The degree of incontinence is measured by how many pads or diapers a man must use each day and the rate is correspondingly higher with the number of pads used.
The veteran may also claim Erectile Dysfunction and receive a Special Monthly Compensation (SMC) benefit known as SMC-K. The SMC-K benefit is on the books as "loss of a creative organ" and although the veteran impaired by erectile dysfunction hasn't lost the organ, he's lost use of it for procreative purposes and is entitled to the SMC-K benefit in addition to the regular rated compensation.
The usual amount of the after-treatment benefits I see range from 30% to 60% plus the SMC-K add-on.
For the Vietnam veteran who chooses watchful waiting as his treatment, this becomes more interesting. Let's do a quick fact check.
Keep in mind that watchful waiting is a treatment. Upon diagnosis and beginning of treatment, the veteran is awarded 100% disability compensation. The 100% is reduced to compensation of residuals of treatment once the condition no longer exists.
For the veteran choosing watchful waiting, there is no end point to the watchful waiting treatment. Until he elects surgical or radiation treatment or dies of either the prostate cancer or another condition, he will remain rated as 100% disabled.
One of the things that our VA does best is screening us for all kinds of problems. VA learned long ago that testing and screening is a cost effective approach to our care. We're often screened for our blood pressure, lipid profiles, colon cancer, hepatitis, diabetes and much more. Our flu shots, pneumonia shots and diabetes medications come to us earlier than almost any other group of patients anywhere.
Now we must decide...to screen for prostate disease or not? If we decide that we want to, do we accept treatment or not? If we accept treatment, what will the treatment be and who do we want to deliver it?
Finally...for the Vietnam veteran who was leaning toward watchful waiting...now you've learned of a financial incentive. I've communicated with a couple of Vietnam veterans who chose watchful waiting years ago. They wrote to me to ask when the 100% payments would end? They were surprised (I was too) that after 5 and 6 years of watchful waiting, nobody at VA had contacted them about their generous benefit. They were doing well and held the same jobs they had when they were diagnosed.
Talk with your primary care provider and review that New York Times piece with him or her. The time to ponder your options is now, while you're feeling well and your prostate is enjoying its own good health. It's the smart thing to do. Waiting until the doc walks into that exam room and tells you, "You have a cancer!" is only going to make all this even more difficult and confusing.
I have my appointment in mid-April. You?