The highest incidence of breast cancer is after age 65, and the annual mortality has not changed over past decades, despite all the efforts of medicine, and has remained fairly constant as a cause of death in about 27/100,000 females. There is approximately a 10% cumulative risk for a woman to develop breast cancer during her lifetime. Although principally a cancer of women, breast cancer occurs in men at 1% the frequency it is found in women. Treatment and prognosis in men is similar to that for women.
All forms of breast carcinoma can qualify under the Social Security listing, and there are many possible tumor types. Infiltrating ductal carcinomas are the most frequent, accounting for over half the cases. If the nipple is involved with crust, burning, oozing, or bleeding in association with an underlying carcinoma, then the term Paget’s disease is used. This is not a separate form of cancer and treatment is the same as for other breast cancers. Approximately 6% of breast cancers are medullary carcinomas, which have a better prognosis than intraductal carcinomas. Tubular and mucinous carcinomas of the breast also have a better outcome than infiltrating ductal cancers. Infiltrating lobular carcinomas account for up to 10% of breast cancers. Infiltrating or invasive ductal cancer is the most common breast cancer histologic type, comprising 70% to 80% of all cases.
Until recently, the customary treatment of ductal carcinoma in situ (DCIS) was mastectomy. The rationale for mastectomy included a 30% incidence of multicentric disease (cancer arising in more than one location), a 40% prevalence of residual tumor at mastectomy following wide excision alone, and a 25% to 50% incidence of breast recurrence following limited surgery for palpable tumor, with half of those recurrences being invasive carcinoma. The combined local and distant recurrence rate following mastectomy is 1% to 2%. Due to the success of breast-conserving surgery for invasive carcinoma, this conservative approach was extended to the noninvasive entity (DCIS).
Residual Functional Capacity
Close attention should be given to what the claimant and treating physicians say about the claimant’s symptoms as related both to the cancer and to treatment, bearing in mind that the 12-month duration requirement must be respected. If the treating physician says something vague and useless like, “Ms. X will be sick for a year due to her chemotherapy,” that is a worthless statement without the treatment protocol to demonstrate it will or has lasted 12 months, and why the SSA should believe that the claimant will have debilitating symptoms that long. It is difficult, if not impossible, for any doctor to predict what treatments will be required in the year following the diagnosis of breast cancer, because treatment decisions are based on response to prior courses of treatment. In newly diagnosed cancer, that would require clairvoyant perception. Long-term complications have already been documented over a period of time and there certainly are disability claimants who already have a substantial medical history when they apply for benefits. Limitations from anemia and cardiac toxicity can be considerable if the claimant has received prolonged chemotherapy. Every effort should be made to obtain specific information regarding side effects of treatment from the treating cancer specialist (oncologist), not merely the primary care physician.
If a claimant has a lumpectomy or simple mastectomy, that surgery leaves no residual limitation exertionally or in any other way. However, radical and modified radical mastectomies can reasonably be the basis for an RFC limitation to no more than medium work. In the past, some SSA Federal physicians have insisted that there is no significant residual exertional limitation as a result of removal of chest muscles that is part of these surgeries. The author of this manual disagrees; the chest muscles add significantly to the inward (adductive) force that can be applied with the arms and this capacity is relevant to lifting and carrying. Another consideration is that of arm edema, resulting from disruption of lymphatic drainage when there is extensive axillary lymph node dissection. The SSA should always inquire into the presence and severity of any arm edema a claimant may have, as well as obtain information regarding what the claimant says about resulting functional limitations in their activities of daily living.
Many long-term complications could also be possible, depending on individual circumstances. Reference should be made to the RFC discussion associated with any relevant chronic impairment.
Excerpted from the free eBook Common Medical Issues in Social Security Disability, by Dr. David A. Morton. Download the full eBook for detailed information and 10 medical opinion forms for 4 common areas of disability.
David Morton, a doctor who has made over 50,000 disability determinations for the Social Security Administration, is also the author of Medical Issues in Social Security Disability. The in-depth guide includes over 100 medical opinion forms for a variety of disability areas, to help you efficiently gather persuasive evidence for the SSA.